Aggarwal, Shivani

Purpose: We previously analyzed the 2006 appropriateness criteria for cardiac computed tomography (CT) and found 42% of our patients were not classifiable, suggesting the criteria were difficult to apply clinically. These criteria were revised in 2010. The purpose of our study is to compare the new 2010 appropriate use criteria to the original 2006 criteria to determine if the 2010 criteria were more applicable. Materials and Methods: In a previous study we applied the 2006 appropriateness criteria to 251 patients that underwent cardiac CT from June 1 to December 31, 2007. Each patient was assigned an indication from the 2006 appropriate use criteria by two observers, classifying patients as appropriate, inappropriate, uncertain, or nonclassifiable. A third observer settled disagreements. This process was applied to the same 251 patients using the 2010 criteria. The data from the previous study using the 2006 criteria was compared to the data obtained using the 2010 criteria to determine changes in the number of nonclassifiable, appropriate, inappropriate, and uncertain exams. These results were then analyzed using Bowker's test of symmetry. Observer agreement was calculated using the kappa statistic. Results: 115 patients (46%) were not classifiable using the 2006 criteria. When the 2010 criteria were applied, the number of not classifiable patients decreased to 40 (16%), with the plurality, 41 (16%), of the not classifiable patients moving to inappropriate. In 2006, 69 (27%) were classified as appropriate, 25 (10%) were uncertain, 42 (17%) inappropriate. In 2010, the appropriate increased to 84 (33%), uncertain increased to 40 (16%), and inappropriate increased to 87 (35%). Bowker's test of symmetry demonstrated a statistically significant change with a p<0.001. Agreement between the two observers assigning patients to classification groups also improved with a kappa of 0.55 using the 2010 criteria compared to kappa of 0.31 in 2006. Conclusion: The number of not classifiable patients decreased using the 2010 criteria and the interobserver agreement improved, suggesting they are more applicable and complete than the 2006 criteria. This decrease in not classifiable patients came primarily from an increase in the number of inappropriate indications.

Introduction: Aortic Stenosis (AS) is a common valve disease of the adult, caused by calcification of aortic cusps. The relationship between cusp calcification and severity of AS has been established mostly in men and it is unclear whether the calcification process and its relation to AS severity is similar in women Hypothesis: We hypothesized that the physiologic relation between aortic valve calcification (AVC) load and AS severity is different in men and women and that lower calcification loads may lead to severe AS in women Methods: We prospectively performed high resolution computed tomography (CT) without contrast in 679 patients with AS (Aortic valve area (AVA) <2cm 2 , Mean gradient ≥10 mmHg) at two academic centers (Rochester, MN; Paris, France) to measure AVC scores and compare these to the hemodynamic obstruction measured by Echo-Doppler. Results: Women vs. men were older (76±11 vs 74±11, p<0.0001) with slightly higher ejection fraction (62±12 vs 59±13, p=0.001) but AS severity was similar (AVA/body surface area 0.55±0.2 vs 0.56±0.2 cm 2 /m 2 ; Peak velocity 4±1 vs 3.9±1 m/s; Mean gradient 41±21 vs 38±18 mmHg, all p≥0.1). Yet, AVC load was lower in women vs men, score absolute or normalized for LVOT area (551±383 vs 626±399 all p<0.0001). For those with severe AS (Mean gradient >40 mmHg), AVC scores were 2433±1412 in women vs 3805±1587 in men. Multivariate analysis adjusting for age, BSA, LVOT area and mean gradient, confirmed that severe AS was achieved with lower AVC load in women (all p<0.0001). Conclusions: In this large multicenter AS population, women reached similar AS severity than males for lower calcium loads, even after adjustment for lower body and LVOT size. Hence the relation between valvular calcification process and severity of AS differs in women vs. men. Thus, future studies are needed to determine the differential mechanism of aortic calcification in men and women and diagnostic consideration must be given to gender in the interpretation of AS severity by AVC load.

Background— Aortic valve calcification (AVC) is the intrinsic mechanism of valvular obstruction leading to aortic stenosis (AS) and is measurable by multidetector computed tomography. The link between sex and AS is controversial and that with AVC is unknown. Methods and Results— We prospectively performed multidetector computed tomography in 665 patients with AS (aortic valve area, 1.05±0.35 cm 2 ; mean gradient, 39±19 mm Hg) to measure AVC and to assess the impact of sex on the AVC–AS severity link in men and women. AS severity was comparable between women and men (peak aortic jet velocity: 4.05±0.99 versus 3.93±0.91 m/s, P =0.11; aortic valve area index: 0.55±0.20 versus 0.56±0.18 cm 2 /m 2 ; P =0.46). Conversely, AVC load was lower in women versus men (1703±1321 versus 2694±1628 arbitrary units; P <0.0001) even after adjustment for their smaller body surface area or aortic annular area (both P <0.0001). Thus, odds of high-AVC load were much greater in men than in women (odds ratio, 5.07; P <0.0001). Although AVC showed good associations with hemodynamic AS severity in men and women (all r >0.67; P <0.0001), for any level of AS severity measured by peak aortic jet velocity or aortic valve area index, AVC load, absolute or indexed, was higher in men versus women (all P ≤0.01). Conclusions— In this large AS population, women incurred similar AS severity than men for lower AVC loads, even after indexing for their smaller body size. Hence, the relationship between valvular calcification process and AS severity differs in women and men, warranting further pathophysiological inquiry. For AS severity diagnostic purposes, interpretation of AVC load should be different in men and in women.