Lane, Conor M.

Recent advancements in computed tomography have significantly transformed the clinical application of this technique in diagnosing and managing coronary artery disease (CAD). Computed tomography coronary angiography (CTCA) has emerged as a leading non-invasive imaging modality, often serving as the first-line investigation to exclude obstructive CAD in patients with chronic coronary syndrome. Beyond its utility in diagnosing CAD, CTCA has become instrumental in procedural planning for percutaneous coronary intervention (PCI), particularly in complex cases such as left main stem (LMS) interventions, where peri-procedural risks are elevated. This review highlights the evolving role of CTCA in LMS PCI, underscoring its clinical utility in improving procedural precision and, subsequently, patient outcomes. Recent technological advancements, including detailed multiplanar and three-dimensional (3D) reconstructions, CT-derived fractional flow reserve (CTFFR), and the integration of artificial intelligence (AI) algorithms, have expanded the capabilities of CTCA. These innovations allow for comprehensive anatomical and functional assessments, enabling precise plaque morphology, lesion complexity, and bifurcation anatomy evaluations alongside PCI simulations. By offering detailed insights into coronary vasculature and lesion characteristics, CTCA provides critical information for optimising LMS PCI strategies. This review explores the current applications and future potential of CTCA in guiding LMS PCI, highlighting its role in improving procedural planning, risk assessment, and overall management of this challenging patient population.

SummaryBackgroundMedication use has been implicated in the development of microscopic colitis (MC). However, studies have demonstrated inconsistent findings and there exist variations in design.AimTo measure the association between medication use and MC.MethodsPatients who underwent a colonoscopy over a 10‐year period at two academic medical centres (Columbia University Medical Centre and Mayo Clinic) were identified. Cases were patients with biopsy‐proven MC and controls were patients who underwent colonoscopy for evaluation of diarrhoea with biopsies negative for MC. Cases were matched by age, gender and calendar period with up to two controls. Demographics, medication use, smoking history and coeliac disease status were collected. Conditional logistic regression was used with and without adjustment for smoking.ResultsA total of 344 patients with MC were matched to 668 controls. After adjusting for smoking, there was an inverse association between MC and use of proton pump inhibitors (PPIs) (OR 0.64; 95% CI 0.47‐0.87), H2 blockers (OR 0.46; 95% CI 0.24‐0.88) and oral diabetes medications (OR 0.47; 95% CI 0.27‐0.81). There was a positive association with nonsteroidal anti‐inflammatory drug (NSAID) use and MC (OR 1.63; 95% CI 1.12‐2.38).ConclusionsNSAID use was associated with MC, while use of PPIs, H2 blockers and oral diabetes medications were inversely related to MC. Our use of a control group with diarrhoea, as opposed to healthy controls, may have contributed to these inverse associations. Future studies of drug‐induced microscopic colitis should include control groups with diarrhoea, and not only healthy controls.

Abstract Background Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins. Purpose To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation. Methods Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation. Results We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (>6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was >90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or >1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001). Conclusions Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients. Funding Acknowledgement Type of funding sources: None.

OBJECTIVES: Administrative and clinical efforts to improve hospital mortality and intensive care utilization commonly focus on patient rescue, where deteriorating patients are systematically identified and intervened upon. Patient rescue is known to depend on hospital context inclusive of technologic environment, structural features, and hospital organizational behavioral features. With widespread adoption of electronic medical records, early warning score (EWS) systems, which assign points to clinical data elements, are increasingly promoted as a tool for timely patient rescue by referencing their prediction of patient deterioration. We describe the extent to which EWS intervention studies describe the hospital environment of the intervention—details that would be critical for hospital leaders attempting to determine the real-world utility of EWSs in their own hospitals. DATA SOURCES: We searched CINAHL, PubMed, and Scopus databases for English language EWS implementation research published between 2009 and 2021 in adult medical-surgical inpatients. STUDY SELECTION: Studies including pediatric, obstetric, psychiatric, prehospital, outpatient, step-down, or ICU patients were excluded. DATA EXTRACTION: Two investigators independently reviewed titles/abstracts for eligibility based on prespecified exclusion criteria. DATA SYNTHESIS: We identified 1,434 studies for title/abstract screening. In all, 352 studies underwent full-text review and 21 studies were summarized. The 21 studies (18 before-and-after, three randomized trials) detailed 1,107,883 patients across 54 hospitals. Twelve reported the staff composition of an EWS response team. Ten reported the proportion of surgical patients. One reported nursing ratios; none reported intensive care staffing with in-house critical-care physicians. None measured changes in bed utilization or availability. While 16 qualitatively described resources for education/technologic implementation, none estimated costs. None described workforce composition such as team stability or culture of safety in the hospitals. CONCLUSIONS: Despite hundreds of EWS-related publications, most do not report details of hospital context that would inform decisions about real-world EWS adoption. To make informed decisions about whether EWS implementation improves hospital quality, decision-makers may require alternatives such as peer networks and implementation pilots nested within local health systems.

Background: Risk stratification in catecholaminergic polymorphic ventricular tachycardia remains ill defined. Heart rate recovery (HRR) immediately after exercise is regulated by autonomic reflexes, particularly vagal tone, and may be associated with symptoms and ventricular arrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia. Our objective was to evaluate whether HRR after maximal exercise on the exercise stress test (EST) is associated with symptoms and ventricular arrhythmias. Methods: In this retrospective observational study, we included patients ≤65 years of age with an EST without antiarrhythmic drugs who attained at least 80% of their age- and sex-predicted maximal HR. HRR in the recovery phase was calculated as the difference in heart rate (HR) at maximal exercise and at 1 minute in the recovery phase (ΔHRR1′). Results: We included 187 patients (median age, 36 years; 68 [36%] symptomatic before diagnosis). Pre-EST HR and maximal HR were equal among symptomatic and asymptomatic patients. Patients who were symptomatic before diagnosis had a greater ΔHRR1′ after maximal exercise (43 [interquartile range, 25–58] versus 25 [interquartile range, 19–34] beats/min; P <0.001). Corrected for age, sex, and relatedness, patients in the upper tertile for ΔHRR1′ had an odds ratio of 3.4 (95% CI, 1.6–7.4) of being symptomatic before diagnosis ( P <0.001). In addition, ΔHRR1′ was higher in patients with complex ventricular arrhythmias at EST off antiarrhythmic drugs (33 [interquartile range, 22–48] versus 27 [interquartile range, 20–36] beats/min; P =0.01). After diagnosis, patients with a ΔHRR1′ in the upper tertile of its distribution had significantly more arrhythmic events as compared with patients in the other tertiles ( P =0.045). Conclusions: Catecholaminergic polymorphic ventricular tachycardia patients with a larger HRR following exercise are more likely to be symptomatic and have complex ventricular arrhythmias during the first EST off antiarrhythmic drug.

INTRODUCTION: Microscopic colitis (MC) is a common cause of chronic watery diarrhea. Cross-sectional studies have suggested that patients with MC have a lower incidence of colon polyps compared to those without MC. However, existing literature is limited by a lack of longitudinal follow-up and the use of average-risk patients, rather than those with chronic diarrhea as controls. We aimed to further explore the association between MC and colon adenomas. METHODS: This retrospective cohort study included patients that underwent colonoscopy at Mayo Clinic (Rochester, MN) or Columbia University Medical Center (New York, NY) between 7/1/2006 and 12/31/2016. Consecutive cases with MC were identified using pathology databases at each center. Controls had chronic diarrhea, underwent colonoscopy, and did not have MC on biopsy. Cases and controls were matched 1:2 by age (±3 years), sex, and date of index colonoscopy (±6 months). Data was collected on demographics, tobacco and alcohol use, personal and family history of colon neoplasia, and presence of adenomas at the index or follow-up colonoscopies. RESULTS: The study included 376 patients with MC and 752 non-MC patients with chronic diarrhea. The median (range) age of patients was 64 (21, 88) years and 72% were female. Duration of follow-up was not significantly different between the 2 groups (total person years: cases 577, controls 972; P = 0.99) and 51 subjects had a new adenoma on follow-up. There were no significant differences in age, sex, alcohol use, family history of colon neoplasia, and personal history of inflammatory bowel disease between cases and controls. Patients with MC were more likely to be current tobacco users (10% vs. 6%, P = 0.02) and less likely to have a history of prior colon neoplasia (9% vs. 17%, P < 0.001). Patients with MC were significantly less likely to have colon adenomas at the time of their index colonoscopy (5% vs. 12%; odds ratio 0.36; 95% CI 0.21, 0.60; P < 0.001) after adjusting for tobacco use and history of prior lesions. However, when followed over time, there was no significant association between MC and risk of colon adenomas (Figure 1, P = 0.45) after adjusting for tobacco use, history of prior lesions, and presence of adenoma at index colonoscopy. CONCLUSION: Patients with MC are less likely to have colon adenomas at their index colonoscopy compared to those with chronic diarrhea without MC. However, when followed longitudinally, there appears to be no significant association between MC and risk of colon adenomas.

Abstract Aims In patients with catecholaminergic polymorphic ventricular tachycardia (CPVT), implantable cardioverter-defibrillator (ICD) shocks are sometimes ineffective and may even trigger fatal electrical storms. We assessed the efficacy and complications of ICDs placed in patients with CPVT who presented with a sentinel event of sudden cardiac arrest (SCA) while undiagnosed and therefore untreated. Methods and results We analysed 136 patients who presented with SCA and in whom CPVT was diagnosed subsequently, leading to the initiation of guideline-directed therapy, including β-blockers, flecainide, and/or left cardiac sympathetic denervation. An ICD was implanted in 79 patients (58.1%). The primary outcome of the study was sudden cardiac death (SCD). The secondary outcomes were composite outcomes of SCD, SCA, appropriate ICD shocks, and syncope. After a median follow-up of 4.8 years, SCD had occurred in three patients (3.8%) with an ICD and none of the patients without an ICD (P = 0.1). SCD, SCA, or appropriate ICD shocks occurred in 37 patients (46.8%) with an ICD and 9 patients (15.8%) without an ICD (P &lt; 0.0001). Inappropriate ICD shocks occurred in 19 patients (24.7%) and other device-related complications in 22 patients (28.9%). Conclusion In previously undiagnosed patients with CPVT who presented with SCA, an ICD was not associated with improved survival. Instead, the ICD was associated with both a high rate of appropriate ICD shocks and inappropriate ICD shocks along with other device-related complications. Strict adherence to guideline-directed therapy without an ICD may provide adequate protection in these patients without all the potential disadvantages of an ICD.