Levy, Michael

Introduction: Clinical outcomes of FFR-guided PCI have been superior to those of angiographically guided PCI, with or without prior cardiac stress testing. Based on these findings, we hypothesized that the accuracy of stress testing is inferior to that of FFR in determining the physiologic significance of angiographic coronary artery disease. Method: To that end, we studied 243 consecutive patients who underwent coronary angiography and FFR assessment between September 2010 and April 2013 at Mayo Clinic, Florida. Out of this group, we excluded 143 patients due to absence of stress testing in the preceding 6 months. We assessed demographics, coronary risk factors, symptoms, stress test variables, angiographic data, and FFR measurements. FFR values ≤0.80 were considered to be positive for ischemia. We evaluated the diagnostic performance of stress testing vs. FFR. Result: Out of the 100 patients included in the study, FFR was measured in the Left Main coronary artery in 3(3%), in the Left Anterior Descending artery (LAD) in 67(67%), in the left circumflex territory in 11(11%), in the Right Coronary Artery (RCA) in 18(18%). The diagnostic performance of stress testing vs. FFR is summarized in the table, with regards to presence of ischemia in any vascular territory and with regards to a specific vascular territory. Conclusion: Compared to FFR, cardiac stress testing has reasonable NPV but poor PPV in determining the presence of absence of overall ischemia in a given patient. Most concerning, however, is that stress testing has poor PPV and NPV when used to determine the site of ischemia in a specific vascular territory.

ABSTRACTBackgroundDobutamine stress echocardiography (DSE) is commonly used to risk stratify patients in the cardiac evaluation prior to orthotopic liver transplantation (OLT). Data remain limited regarding the accuracy to predict obstructive coronary artery disease (CAD) using this approach.HypothesisWe hypothesize that DSE may have limitations in the investigation of underlying CAD in patients with end‐stage liver disease.MethodsA retrospective chart review of all patients who underwent OLT at Mayo Clinic in Florida between 1998 and 2010 was performed. Sixty‐six underwent invasive coronary angiography (ICA) within 1 year of DSE and were included in our study. Based on DSE results, patients were stratified into 1 of 3 groups: nonischemic, ischemic, and indeterminate. The relationship between DSE, ICA, and death from all cause and cardiac‐related cause with a minimum 3‐year follow‐up period were analyzed.ResultsA total of 66 patients were included in our cohort. There was no difference in age, gender, severity of liver disease, and echocardiographic findings among the groups. Forty‐three percent of patients (n = 12) with an abnormal result on DSE were found to have moderate or severe obstructive CAD on cardiac catheterization, whereas 49% of patients (n = 17) with a normal finding on DSE had moderate or severe CAD. Of 5 patients who died from a documented cardiac etiology, 3 had normal stress test results, 1 had abnormal findings, and 1 had an indeterminate DSE result. When compared with ICA, our study demonstrated that DSE has a sensitivity of 41.4% (95% confidence interval [CI]: 0.24‐0.61), specificity of 47.1% (95% CI: 0.30‐0.65), positive predictive value of 40.0% (95% CI: 0.23‐0.59), and negative predictive value of 48.0% (95% CI: 0.31‐0.66) in identification of underlying CAD.ConclusionsAlthough widely used, DSE may not always accurately reflect the severity of obstructive CAD in patients undergoing OLT.

Introduction. While patients undergoing orthotopic liver transplantation (OLT) have high cardiovascular event rates, preoperative risk stratification may not necessarily predict those susceptible patients. Troponin T (TnT) may help predict patients at risk for cardiovascular complications.Methods. Consecutive patients undergoing OLT at Mayo Clinic in Florida between 1998 and 2010 who had TnT obtained within 10 days following surgery were included. Three groups were compared based on TnT level: (1) normal (TnT≤0.01 ng/mL), (2) intermediate (TnT 0.02–0.11 ng/mL), and (3) elevated (TnT>0.11 ng/mL). Overall and cardiovascular mortality was assessed.Results. Of the 78 patients included, there was no difference in age, gender, severity of liver disease, and echocardiographic findings. Patients in the normal and intermediate TnT groups had a lower overall mortality rate (14.3% and 0%, resp.) when compared with those with elevated TnT (50%;P=0.001). Patients in the elevated TnT group had a cardiovascular mortality rate of 37.5% compared with 1.4% in the other groups combined (P<0.01). The elevated TnT group had a much higher mortality rate when compared with those in the intermediate group (P<0.0001).Conclusion. TnT may accurately help risk stratify patients in the early postoperative setting to better predict cardiovascular complications.