Coronary Atherosclerosis in Women

Despite numerous studies focused on women’s cardiac health, deaths from cardiovascular disease continue to rise in women. Cardiovascular disease (CVD) continues to be the leading cause of death even in women in many areas of the world. It has been noted that despite higher frequency of chest pain/angina in women compared to men, the incidence of obstructive coronary artery disease (CAD) remains lower in the female population compared with men presenting with similar symptoms. It is critical to have a deep understanding of these topics to ensure a meaningful communication between public, patients, and healthcare professionals. One reason to which this discrepancy has been attributed to is that chest pain in women is less likely to be secondary to obstructive coronary stenosis in comparison to men presenting with similar symptoms. The other issue is that the gold standard for coronary atherosclerosis continues to coronary angiography. This is a key limitation in cardiovascular atherosclerosis management since endothelial dysfunction in addition to a higher risk of atherosclerosis is prevalent in women with hypertension, diabetes, and dyslipidemia. In this chapter, we will focus on the aspects of coronary atherosclerosis that deserve attention with respect to gender-specific considerations, particularly with respect to clinical practice

Advances in Cardiac Computed Tomography

Coronary cardiac computed tomography (CCTA) has seen rapid improvements in technology including hardware and postprocessing techniques that have contributed to its rapid growth and enabled it to remain in the forefront on diagnostic imaging. Important technological advances include wider detectors for greater coverage with less gantry rotation times, dual-source computed tomography (CT) with improved temporal resolution, dual-energy CT where simultaneous imaging at different energies to increase the contrast difference between different tissues enhances diagnostic accuracy, and emergence of spectral CT to enhance atherosclerotic imaging through nanoparticle technology. Software advances include iterative reconstruction methodologies to reduce noise and radiation doses, plaque imaging and quantification tools to assess plaque morphology and stenosis severity. Processing advances using computational fluid dynamics now enables the determination of fractional flow reserve (FFR). Another important advancement in CCTA physiologic imaging is CCTA perfusion imaging to detect ischemia and compares favorably with myocardial perfusion imaging and coronary angiographic stenosis. Finally, large registry studies and single-center studies have now been published assessing the incremental value of coronary calcium score, CT plaque severity of disease and have demonstrated that the CCTA carries strong prognostic value over and above traditional risk assessment in predicting adverse outcomes

Strain Imaging: From Physiology to Practical Applications in Daily Practice

Non-Doppler, 2-dimensional strain imaging is a new echocardiographic technique for obtaining strain and strain rate measurements, which serves as a major advancement in understanding myocardial deformation. It analyzes motion in ultrasound imaging by tracking speckles in 2 dimensions. There are a lot of data emerging with multiple applications of strain imaging in the clinical practice of echocardiography. As incorporation of strain imaging in daily practice has been challenging, we intend to systematically highlight the top 10 applications of speckle-tracking echocardiography, which every cardiologist should be aware of: chemotherapy cardiotoxicity, left ventricular assessment, cardiac amyloidosis, hypertrophic obstructive cardiomyopathy, right ventricular dysfunction, valvular heart diseases (aortic stenosis and mitral regurgitation), cardiac sarcoidosis, athlete heart, left atrial assessment, and cardiac dyssynchrony

Peripheral Arterial Disease - A Practical Approach

""Peripheral Arterial Disease - A Practical Approach"" is an honest effort to provide a clinically relevant approach to the management plan in patients presenting with peripheral vascular symptoms. We have summarized the most pertinent practical aspects of peripheral vascular disease, their clinical implications, diagnostic testing, therapeutic interventions and innovations. We hope this book serves as a reference for basic and advanced peripheral vascular care

Left main coronary artery disease: A review of the spectrum of noninvasive diagnostic modalities

Medically managed significant left main (LM) stem disease has been considered a determinant of increased cardiac mortality approaching 50% at 3-year follow-up. Despite the clinical significance of LM disease, studies comparing the various diagnostic modalities, especially noninvasive, are sparse. Clinicians, particularly imagers, should be aware of the strengths and weaknesses of existing modalities to diagnose LM disease as integrating many clues (history, symptoms, electrocardiogram, and stress hemodynamics are essential to suspect this diagnosis and proceed to the next step). Here we review the existing data on the current role of electrocardiography, nuclear myocardial perfusion imaging (single photon emission computed tomography and positron emission tomography), stress echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging in diagnostic evaluation of LM disease. Wherever applicable we have extended our discussion to multivessel coronary artery disease encompassing scenarios where LMS can present as LM equivalent with or without extensive multivessel coronary artery disease

Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative

OBJECTIVE: The \u27Detroit Cardiogenic Shock Initiative\u27 is a single-arm, multicenter study to assess the feasibility of early mechanical circulatory support (MCS) in patients who present with acute myocardial infarction complicated by cardiogenic shock (AMICS) who undergo percutaneous coronary intervention. METHODS: Between July 2016 and February 2017, 4 metro Detroit sites participated in the study. The centers agreed to treat patients with AMICS using a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those from the \u27SHOCK\u27 trial with an additional exclusion criteria being use of intra-aortic balloon pump counter pulsation prior to MCS. RESULTS: A total of 41 consecutive patients were included. Patients had an average age of 65 ± 14 years, 71% were male and 59% of patients were admitted to the hospital in cardiogenic shock. Prior to receiving MCS, 93% of patients were on vasopressors or inotropes, 15% of patients had a witnessed out of hospital cardiac arrest, 27% of patients had an in-hospital cardiac arrest, and 17% were under active cardiopulmonary resuscitation while MCS was being implanted. In accordance to the protocol recommendation, 66% of patients had a MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 83% of patients. Door to support times averaged 83 ± 58 minutes and 71% of patients were able to reduce the levels of inotropes and vasopressors within the first 24-hours of their index procedure. Pre-procedure cardiac power output (CPO) was 0.57 W and post-procedure CPO was 0.95 W, a 67% increase (p \u3c 0.001). Survival to explant for the entire cohort was 85% a significant improvement from institutional historical controls (85% vs 51% p \u3c 0.001) and survival to discharge was 76%. CONCLUSION: Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study