The role of cardiovascular magnetic resonance imaging and computed tomography angiography in suspected non-ST-elevation myocardial infarction patients:Design and rationale of the CARdiovascular Magnetic rEsoNance imaging and computed Tomography Angiography (CARMENTA) trial

BackgroundAlthough high-sensitivity cardiac troponin (hs-cTn) substantially improves the early detection of myocardial injury, it lacks specificity for acute myocardial infarction (MI). In suspected non–ST-elevation MI, invasive coronary angiography (ICA) remains necessary to distinguish between acute MI and noncoronary myocardial disease (eg, myocarditis), unnecessarily subjecting the latter to ICA and associated complications. This trial investigates whether implementing cardiovascular magnetic resonance (CMR) or computed tomography angiography (CTA) early in the diagnostic process may help to differentiate between coronary and noncoronary myocardial disease, thereby preventing unnecessary ICA.Study DesignIn this prospective, single-center, randomized controlled clinical trial, 321 consecutive patients with acute chest pain, elevated hs-cTnT, and nondiagnostic electrocardiogram are randomized to 1 of 3 strategies: (1) CMR, or (2) CTA early in the diagnostic process, or (3) routine clinical management. In the 2 investigational arms of the study, results of CMR or CTA will guide further clinical management. It is expected that noncoronary myocardial disease is detected more frequently after early noninvasive imaging as compared with routine clinical management, and unnecessary ICA will be prevented. The primary end point is the total number of patients undergoing ICA during initial admission. Secondary end points are 30-day and 1-year clinical outcome (major adverse cardiac events and major procedure-related complications), time to final diagnosis, quality of life, and cost-effectiveness.ConclusionThe CARMENTA trial investigates whether implementing CTA or CMR early in the diagnostic process in suspected non–ST-elevation MI based on elevated hs-cTnT can prevent unnecessary ICA as compared with routine clinical management, with no detrimental effect on clinical outcome

Impact of lumbar syndesmophyte on bone health as assessed by bone density (BMD) and bone texture (TBS) in men with axial spondyloarthritis.

Patients with spondyloarthritis (SpA) have an elevated incidence of osteoporosis and are at increased risk of pathological vertebral fracture. Evaluation of bone density by dual energy X-ray absorptiometry (DXA) has its limits in fracture prediction, already known in this population. One hypothesis is that the presence of lumbar syndesmophyte could overestimate the spine bone mineral density (BMD). Trabecular bone score (TBS) is a new texture measurement correlated with bone microarchitecture. Previous studies have shown that TBS is mildly impacted by osteoarthritis and thus could be a predictor of fracture better than spine BMD. We aimed to evaluate a male population of SpA with BMD and TBS measurement and see the impact of lumbar syndesmophytes. Two cohorts of SpA male patients (Lausanne, Sofia) with SpA disease, clinical and bone parameters (femoral neck and total spine BMD+spine TBS) were merged. We compared BMD and TBS results regarding to the presence/absence of syndesmophytes. Our study concerned 51 men [29 with lumbar syndesmophytes (L1 to L4,≥1), 22 without], fulfilling the European Spondyloarthropathy Study Group (ESSG) and the Assessment of SpondyloArthritis international Society (ASAS) criteria. Mean age was 52.18 years old (no difference between the 2 groups) and mean body mass index (BMI) 27.47kg/m <sup>2</sup> (29.12±0.67 with and 25.30±0.81 without, P=0.0006). For the overall population mean BMD T-score at the spine was -0.55±1.54, mean BMD T-score at the femoral neck -1.20±0.95 and mean lumbar spine TBS was 1.26±0.13. Regarding to the presence or the absence of syndesmophytes, mean spine BMD T-score was -0.07±1.63 and -1.18±1.16 (P=0.009 and 0.250 before and after adjustment for BMI), mean femoral neck BMD T-score was -1.37±0.93 and -0.97±0.94 (P=0.14 and 0.03 before and after adjustment for BMI) and mean TBS was 1.21±0.12 and 1.33±0.11 (P=0.001 and 0.06 before and after adjustment for BMI) respectively for SpA men with and without syndesmophytes. Our results showed that SpA men with and without syndesmophytes have lower results compared to the normal population regarding hip BMD, spine TBS and spine BMD except for men with syndesmophytes who have a normal BMD spine T-score. These results suggest that TBS is not influenced by the syndesmophytes in opposite to spine BMD and could be measured in this population in addition to the neck BMD to assess the bone fragility