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Aims: Vascular inflammation inhibits local adipogenesis in pericoronary adipose tissue (PCAT) and this can be detected on coronary computed tomography angiography (CCTA) as an increase in CT attenuation of PCAT surrounding the proximal right coronary artery (RCA). In this cross-sectional study, we assessed the utility of PCAT CT attenuation as an imaging biomarker of coronary inflammation in distinguishing different stages of coronary artery disease (CAD). Methods and Results: Sixty patients with acute myocardial infarction (MI) were prospectively recruited to undergo CCTA within 48 h of admission, prior to invasive angiography. These participants were matched to patients with stable CAD (n = 60) and controls with no CAD (n = 60) by age, gender, BMI, risk factors, medications, and CT tube voltage. PCAT attenuation around the proximal RCA was quantified per-patient using semi-automated software. Patients with MI had a higher PCAT attenuation (-82.3 +/- 5.5 HU) compared with patients with stable CAD (-90.6 +/- 5.7 HU, P < 0.001) and controls (-95.8 +/- 6.2 HU, P < 0.001). PCAT attenuation was significantly increased in stable CAD patients over controls (P = 0.01). The association of PCAT attenuation with stage of CAD was independent of age, gender, cardiovascular risk factors, epicardial adipose tissue volume, and CCTA-derived quantitative plaque burden. No interaction was observed for clinical presentation (MI vs. stable CAD) and plaque burden on PCAT attenuation. Conclusion(s): PCAT CT attenuation as a quantitative measure of global coronary inflammation independently distinguishes patients with MI vs. stable CAD vs. no CAD. Future studies should assess whether this imaging biomarker can track patient responses to therapies in different stages of CAD.Copyright © 2020 Published on behalf of the European Society of Cardiology. All rights reserved.

Aims: Vascular inflammation inhibits local adipogenesis in pericoronary adipose tissue (PCAT) and this can be detected on coronary computed tomography angiography (CCTA) as an increase in CT attenuation of PCAT surrounding the proximal right coronary artery (RCA). In this cross-sectional study, we assessed the utility of PCAT CT attenuation as an imaging biomarker of coronary inflammation in distinguishing different stages of coronary artery disease (CAD). Methods and Results: Sixty patients with acute myocardial infarction (MI) were prospectively recruited to undergo CCTA within 48 h of admission, prior to invasive angiography. These participants were matched to patients with stable CAD (n = 60) and controls with no CAD (n = 60) by age, gender, BMI, risk factors, medications, and CT tube voltage. PCAT attenuation around the proximal RCA was quantified per-patient using semi-automated software. Patients with MI had a higher PCAT attenuation (-82.3 +/- 5.5 HU) compared with patients with stable CAD (-90.6 +/- 5.7 HU, P < 0.001) and controls (-95.8 +/- 6.2 HU, P < 0.001). PCAT attenuation was significantly increased in stable CAD patients over controls (P = 0.01). The association of PCAT attenuation with stage of CAD was independent of age, gender, cardiovascular risk factors, epicardial adipose tissue volume, and CCTA-derived quantitative plaque burden. No interaction was observed for clinical presentation (MI vs. stable CAD) and plaque burden on PCAT attenuation. Conclusion(s): PCAT CT attenuation as a quantitative measure of global coronary inflammation independently distinguishes patients with MI vs. stable CAD vs. no CAD. Future studies should assess whether this imaging biomarker can track patient responses to therapies in different stages of CAD.Copyright © 2020 Published on behalf of the European Society of Cardiology. All rights reserved.

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Background: To compare computed tomography coronary angiography (CTCA) with intravascular ultrasound (IVUS) in quantitative and qualitative plaque assessment. Method(s): Patients who underwent IVUS and CTCA within 3 months for suspected coronary artery disease were retrospectively studied. Plaque volumes on CTCA were quantified manually and with automated-software and were compared to IVUS. High-risk plaque features were compared between CTCA and IVUS. Result(s): There were 769 slices in 32 vessels (27 patients). Manual plaque quantification on CTCA was comparable to IVUS per slice (mean difference of 0.06 +/- 0.07, p = 0.44; Bland-Altman 95% limits of agreement -2.19-2.08 mm3, bias of -0.06 mm3) and per vessel (3.1 mm3 +/- -2.85 mm3, p = 0.92). In contrast, there was significant difference between automated-software and IVUS per slice (2.3 +/- 0.09mm3, p < 0.001; 95% LoA -6.78 to 2.25 mm3, bias of -2.2 mm3) and per vessel (33.04 +/- 10.3 mm3, p < 0.01). The sensitivity, specificity, positive and negative predictive value of CTCA to detect plaques that had features of echo-attenuation on IVUS was 93.3%, 99.6%, 93.3% and 99.6% respectively. The association of >=2 high-risk plaque features on CTCA with echo attenuation (EA) plaque features on IVUS was excellent (86.7%, 99.6%, 92.9% and 99.2%). In comparison, the association of high-risk plaque features on CTCA and plaques with echo-lucency on IVUS was only modest. Conclusion(s): Plaque volume quantification by manual CTCA method is accurate when compared to IVUS. The presence of at least two high-risk plaque features on CTCA is associated with plaque features of echo attenuation on IVUS.Copyright © 2019

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Background: To compare computed tomography coronary angiography (CTCA) with intravascular ultrasound (IVUS) in quantitative and qualitative plaque assessment. Method(s): Patients who underwent IVUS and CTCA within 3 months for suspected coronary artery disease were retrospectively studied. Plaque volumes on CTCA were quantified manually and with automated-software and were compared to IVUS. High-risk plaque features were compared between CTCA and IVUS. Result(s): There were 769 slices in 32 vessels (27 patients). Manual plaque quantification on CTCA was comparable to IVUS per slice (mean difference of 0.06 +/- 0.07, p = 0.44; Bland-Altman 95% limits of agreement -2.19-2.08 mm3, bias of -0.06 mm3) and per vessel (3.1 mm3 +/- -2.85 mm3, p = 0.92). In contrast, there was significant difference between automated-software and IVUS per slice (2.3 +/- 0.09mm3, p < 0.001; 95% LoA -6.78 to 2.25 mm3, bias of -2.2 mm3) and per vessel (33.04 +/- 10.3 mm3, p < 0.01). The sensitivity, specificity, positive and negative predictive value of CTCA to detect plaques that had features of echo-attenuation on IVUS was 93.3%, 99.6%, 93.3% and 99.6% respectively. The association of >=2 high-risk plaque features on CTCA with echo attenuation (EA) plaque features on IVUS was excellent (86.7%, 99.6%, 92.9% and 99.2%). In comparison, the association of high-risk plaque features on CTCA and plaques with echo-lucency on IVUS was only modest. Conclusion(s): Plaque volume quantification by manual CTCA method is accurate when compared to IVUS. The presence of at least two high-risk plaque features on CTCA is associated with plaque features of echo attenuation on IVUS.Copyright © 2019

Background: Off-pump coronary artery bypass grafting (CABG) negates the requirement for extracorporeal circulation used with the traditional on-pump approach. However, off-pump CABG is technically more challenging and may theoretically lead to less complete revascularisation. Recent data suggests a prognostic benefit for traditional on-pump CABG, but the mechanism for this remains unclear. We hypothesised that the inferior outcomes with off-pump CABG could be driven by the need for repeat revascularisation, with this benefit only becoming clear at long-term follow-up. We therefore evaluated short, medium and long-term outcomes of patients undergoing revascularisation with on vs. off-pump CABG. Method(s): Electronic databases were searched to identify suitable randomised controlled trials enrolling >=100 patients in each arm. Clinical outcomes were extracted at 30-days, 12-months or >4 years. The primary outcome was long-term all-cause death, while secondary outcomes included 30-day, 12-month and >4-year cardiac death, stroke, myocardial infarction or revascularisation. Result(s): Thirteen (13) studies comprising 13,234 patients were included. Off-pump CABG was associated with an increased risk of all-cause death (Odds Ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.32, p = 0.01) and repeat bypass surgery (OR 2.57, 95%CI 1.23-5.39, p = 0.01) at long-term follow-up. A significant, increased requirement for revascularisation in off-pump was seen at 12-month follow-up (OR 1.59, 95%CI 1.09-2.33, p = 0.02). No differences were noted between groups at 30-days, 12-months and >4 years for myocardial infarction or stroke. Conclusion(s): Off-pump CABG is associated with significantly higher rates of all-cause mortality rate at long-term follow-up. These outcomes demonstrate a temporal relationship that may be driven by a greater requirement for repeat revascularisation at 1- and 5-year follow-up. Study registration: CRD42018102019 (PROSPERO).Copyright © 2018 Australian an

Background: Off-pump coronary artery bypass grafting (CABG) negates the requirement for extracorporeal circulation used with the traditional on-pump approach. However, off-pump CABG is technically more challenging and may theoretically lead to less complete revascularisation. Recent data suggests a prognostic benefit for traditional on-pump CABG, but the mechanism for this remains unclear. We hypothesised that the inferior outcomes with off-pump CABG could be driven by the need for repeat revascularisation, with this benefit only becoming clear at long-term follow-up. We therefore evaluated short, medium and long-term outcomes of patients undergoing revascularisation with on vs. off-pump CABG. Method(s): Electronic databases were searched to identify suitable randomised controlled trials enrolling >=100 patients in each arm. Clinical outcomes were extracted at 30-days, 12-months or >4 years. The primary outcome was long-term all-cause death, while secondary outcomes included 30-day, 12-month and >4-year cardiac death, stroke, myocardial infarction or revascularisation. Result(s): Thirteen (13) studies comprising 13,234 patients were included. Off-pump CABG was associated with an increased risk of all-cause death (Odds Ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.32, p = 0.01) and repeat bypass surgery (OR 2.57, 95%CI 1.23-5.39, p = 0.01) at long-term follow-up. A significant, increased requirement for revascularisation in off-pump was seen at 12-month follow-up (OR 1.59, 95%CI 1.09-2.33, p = 0.02). No differences were noted between groups at 30-days, 12-months and >4 years for myocardial infarction or stroke. Conclusion(s): Off-pump CABG is associated with significantly higher rates of all-cause mortality rate at long-term follow-up. These outcomes demonstrate a temporal relationship that may be driven by a greater requirement for repeat revascularisation at 1- and 5-year follow-up. Study registration: CRD42018102019 (PROSPERO).Copyright © 2018 Australian an

Background: Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported. Method(s): Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model. Result(s): Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm3 (95% confidence interval: -5.98 to -1.44, P <.001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P =.10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P <.00001). Conclusion(s): The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.Copyright © 2018

Aims To compare the diagnostic performance of a reduced-order computed tomography-derived fractional flow reserve (CT-FFR) technique derived from luminal deformation and static CT stress myocardial perfusion (CTP). Methods and results Forty-six patients (84 vessels) with suspected coronary artery disease from a single institution planned for elective coronary angiography prospectively underwent research indicated invasive fractional flow reserve (FFR) and 320-detector CT coronary angiography (CTA) and static CTP. Analyses were performed in separate blinded core laboratories for CT-FFR and CTP. CT-FFR was derived using a reduced-order model with dedicated software on a standard desktop computer. CTP was assessed visually and quantitatively by transmural perfusion ratio (TPR). Invasive FFR was significant in 33% (28/84) of vessels. Overall per-vessel sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for CT-FFR were 81%, 84%, 71%, 90%, and 83%, respectively, those of visual CTP were 54%, 92%, 79%, 77%, and 78%, respectively, and TPR were 64%, 48%, 42%, 70%, and 54%, respectively. Per-vessel receiver operator curve analysis demonstrated a significantly larger area under the curve (AUC) for CT-FFR (0.89) with that for visual CTP (0.72; P = 0.016), TPR (0.55; P < 0.0001), and CTA (0.76; P = 0.04). The addition of CT-FFR to CTA provided superior improvement in performance (AUC 0.93; P < 0.0001) compared with CTA alone, a combination of CTA with visual CTP (AUC 0.82; P = 0.007) and CTA with TPR (AUC 0.78; P = 0.0006). Conclusion Based on this selected cohort of patients, a reduced-order CT-FFR technique is superior to visual and quantitatively assessed static CTP in detecting haemodynamically significant coronary stenosis as assessed by invasive FFR. All rights reserved.Copyright © The Author(s) 2018.

Background: Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported. Method(s): Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model. Result(s): Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm3 (95% confidence interval: -5.98 to -1.44, P <.001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P =.10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P <.00001). Conclusion(s): The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.Copyright © 2018

Aims To compare the diagnostic performance of a reduced-order computed tomography-derived fractional flow reserve (CT-FFR) technique derived from luminal deformation and static CT stress myocardial perfusion (CTP). Methods and results Forty-six patients (84 vessels) with suspected coronary artery disease from a single institution planned for elective coronary angiography prospectively underwent research indicated invasive fractional flow reserve (FFR) and 320-detector CT coronary angiography (CTA) and static CTP. Analyses were performed in separate blinded core laboratories for CT-FFR and CTP. CT-FFR was derived using a reduced-order model with dedicated software on a standard desktop computer. CTP was assessed visually and quantitatively by transmural perfusion ratio (TPR). Invasive FFR was significant in 33% (28/84) of vessels. Overall per-vessel sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for CT-FFR were 81%, 84%, 71%, 90%, and 83%, respectively, those of visual CTP were 54%, 92%, 79%, 77%, and 78%, respectively, and TPR were 64%, 48%, 42%, 70%, and 54%, respectively. Per-vessel receiver operator curve analysis demonstrated a significantly larger area under the curve (AUC) for CT-FFR (0.89) with that for visual CTP (0.72; P = 0.016), TPR (0.55; P < 0.0001), and CTA (0.76; P = 0.04). The addition of CT-FFR to CTA provided superior improvement in performance (AUC 0.93; P < 0.0001) compared with CTA alone, a combination of CTA with visual CTP (AUC 0.82; P = 0.007) and CTA with TPR (AUC 0.78; P = 0.0006). Conclusion Based on this selected cohort of patients, a reduced-order CT-FFR technique is superior to visual and quantitatively assessed static CTP in detecting haemodynamically significant coronary stenosis as assessed by invasive FFR. All rights reserved.Copyright © The Author(s) 2018.

Background Anticoagulant and antiplatelet therapy are recommended following WATCHMAN implantation (45 days and 6 months) to reduce the risk of embolic events. These patients are often also at high risk of recurrent bleeding complications. We aimed to assess the safety of reduced duration of treatment with anticoagulant and antiplatelet therapy in the early post implant period. Methods This was a retrospective cohort study assessing the duration of antiplatelet and anticoagulant therapy in 47 consecutive patients following WATCHMAN implant. The primary outcome was rate of major bleeding, stroke and systemic embolic complications. The secondary endpoints were rate of device thrombus and peri-device leak >4 mm as assessed by transoesophogeal echocardiography. Results Forty-seven patients were followed up for a mean of 2.4+/-1.7 years (111.4 total patient-years). The rate of stroke was 1.8/100 patient-years (two events) and the rate of major bleeding complication was 8.9/100 patient-years. Three patients had peri-device leak >4 mm and no patients had device thrombus visualised. 70.2% of patients had discontinued anticoagulation at 45 days, 89.4% had discontinued dual antiplatelet therapy at 90 days. Seven patients were not on any form of anticoagulant or antiplatelet at five months. Comparison of probability of survival free from stroke by time of cessation of anticoagulant and antiplatelet therapy demonstrated no significant differences (p-value for log rank test 0.238 and 0.820). Conclusion Following WATCHMAN implant shortened periods of anticoagulants and antiplatelets may be considered, particularly in the context of high bleeding risk.Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Optical coherence tomography (OCT) is an increasingly available intracoronary imaging modality that provides high-resolution imaging of coronary arteries. Its fundamental reliance on the emission and reflection of light enables rapid data acquisition without compromise of image resolution. As such, OCT can inform operators planning percutaneous coronary intervention (PCI) by accurately defining luminal geometry and detailing plaque composition. Following PCI, OCT imaging delivers a thorough assessment of the treated arterial segment and can identify specific features not always visible on alternate imaging modalities, including stent edge-related dissection, plaque tissue prolapse, incomplete stent apposition and the presence of intra-coronary thrombus. Clinical trials highlight that procedural strategy is frequently altered based on OCT findings, while concerns over final stent dimensions have been mitigated through use of a sizing protocol based on external elastic lamina dimensions in the reference arterial segment. Randomised trials are now warranted to definitively ascertain whether OCT-guidance improves clinical outcomes when utilised during PCI.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background Anticoagulant and antiplatelet therapy are recommended following WATCHMAN implantation (45 days and 6 months) to reduce the risk of embolic events. These patients are often also at high risk of recurrent bleeding complications. We aimed to assess the safety of reduced duration of treatment with anticoagulant and antiplatelet therapy in the early post implant period. Methods This was a retrospective cohort study assessing the duration of antiplatelet and anticoagulant therapy in 47 consecutive patients following WATCHMAN implant. The primary outcome was rate of major bleeding, stroke and systemic embolic complications. The secondary endpoints were rate of device thrombus and peri-device leak >4 mm as assessed by transoesophogeal echocardiography. Results Forty-seven patients were followed up for a mean of 2.4+/-1.7 years (111.4 total patient-years). The rate of stroke was 1.8/100 patient-years (two events) and the rate of major bleeding complication was 8.9/100 patient-years. Three patients had peri-device leak >4 mm and no patients had device thrombus visualised. 70.2% of patients had discontinued anticoagulation at 45 days, 89.4% had discontinued dual antiplatelet therapy at 90 days. Seven patients were not on any form of anticoagulant or antiplatelet at five months. Comparison of probability of survival free from stroke by time of cessation of anticoagulant and antiplatelet therapy demonstrated no significant differences (p-value for log rank test 0.238 and 0.820). Conclusion Following WATCHMAN implant shortened periods of anticoagulants and antiplatelets may be considered, particularly in the context of high bleeding risk.Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Optical coherence tomography (OCT) is an increasingly available intracoronary imaging modality that provides high-resolution imaging of coronary arteries. Its fundamental reliance on the emission and reflection of light enables rapid data acquisition without compromise of image resolution. As such, OCT can inform operators planning percutaneous coronary intervention (PCI) by accurately defining luminal geometry and detailing plaque composition. Following PCI, OCT imaging delivers a thorough assessment of the treated arterial segment and can identify specific features not always visible on alternate imaging modalities, including stent edge-related dissection, plaque tissue prolapse, incomplete stent apposition and the presence of intra-coronary thrombus. Clinical trials highlight that procedural strategy is frequently altered based on OCT findings, while concerns over final stent dimensions have been mitigated through use of a sizing protocol based on external elastic lamina dimensions in the reference arterial segment. Randomised trials are now warranted to definitively ascertain whether OCT-guidance improves clinical outcomes when utilised during PCI.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background: Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population. Method(s): Consecutive patients referred for cardiac risk evaluation prior to potential kidney transplantation were evaluated. All patients attempted ESE before pharmacologic testing was considered. Treadmill ESE utilized BRUCE protocol to maximum capacity. THR was defined as >85% of the maximum predicted heart rate (220-age). Functional capacity was assessed by metabolic equivalents (METs) and the rate pressure product (RPP). Result(s): Of 535 patients (349 male, age 56+/-11), 372(70%) reached THR. Mean METs were 10+/-3 with 531(99%) achieving >=4 METs and 87% >=7 METs. Mean RPP was 25 821+/-5820 bpmxmm Hg (83% achieving >20 000 bpmxmm Hg). On multivariate analysis, independent predictors of failure to reach THR were rate-control medication and diabetes; failure to reach 7 METs: females, diabetics, age>=65, and previous cardiac disease; failure to reach RPP>20 000: rate-control medication. There were 97% of ESE completed to physiologic endpoints. Conclusion(s): In unselected potential renal transplant candidates, cardiac assessment by ESE is well tolerated, with 9-in-10 exercising to satisfactory functional capacity. ESE should be considered a feasible alternative to pharmacologic testing in this population.Copyright © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Fractional flow reserve (FFR) is a well-established method of assessing haemodynamically significant coronary artery stenoses that has demonstrated improved outcomes when used to guide revascularization decisions in patients with stable coronary artery disease. However, the role of FFR in the setting of acute coronary syndrome (ACS) remains uncertain. The recently published FAMOUS-NSTEMI trial was a pilot study that demonstrated the safety of routine FFR in ACS patients as well as its impact upon refining management decisions in patients with stenoses of varying severity in nonculprit arteries. The goal of this review is to summarize the current literature of the utility of FFR in the ACS population and highlight the role that the results of FAMOUS-NSTEMI may have on future study and management in this area.Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Background: Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population. Method(s): Consecutive patients referred for cardiac risk evaluation prior to potential kidney transplantation were evaluated. All patients attempted ESE before pharmacologic testing was considered. Treadmill ESE utilized BRUCE protocol to maximum capacity. THR was defined as >85% of the maximum predicted heart rate (220-age). Functional capacity was assessed by metabolic equivalents (METs) and the rate pressure product (RPP). Result(s): Of 535 patients (349 male, age 56+/-11), 372(70%) reached THR. Mean METs were 10+/-3 with 531(99%) achieving >=4 METs and 87% >=7 METs. Mean RPP was 25 821+/-5820 bpmxmm Hg (83% achieving >20 000 bpmxmm Hg). On multivariate analysis, independent predictors of failure to reach THR were rate-control medication and diabetes; failure to reach 7 METs: females, diabetics, age>=65, and previous cardiac disease; failure to reach RPP>20 000: rate-control medication. There were 97% of ESE completed to physiologic endpoints. Conclusion(s): In unselected potential renal transplant candidates, cardiac assessment by ESE is well tolerated, with 9-in-10 exercising to satisfactory functional capacity. ESE should be considered a feasible alternative to pharmacologic testing in this population.Copyright © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Fractional flow reserve (FFR) is a well-established method of assessing haemodynamically significant coronary artery stenoses that has demonstrated improved outcomes when used to guide revascularization decisions in patients with stable coronary artery disease. However, the role of FFR in the setting of acute coronary syndrome (ACS) remains uncertain. The recently published FAMOUS-NSTEMI trial was a pilot study that demonstrated the safety of routine FFR in ACS patients as well as its impact upon refining management decisions in patients with stenoses of varying severity in nonculprit arteries. The goal of this review is to summarize the current literature of the utility of FFR in the ACS population and highlight the role that the results of FAMOUS-NSTEMI may have on future study and management in this area.Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Fractional flow reserve (FFR) is a well-established method of assessing haemodynamically significant coronary artery stenoses that has demonstrated improved outcomes when used to guide revascularization decisions in patients with stable coronary artery disease. However, the role of FFR in the setting of acute coronary syndrome (ACS) remains uncertain. The recently published FAMOUS-NSTEMI trial was a pilot study that demonstrated the safety of routine FFR in ACS patients as well as its impact upon refining management decisions in patients with stenoses of varying severity in nonculprit arteries. The goal of this review is to summarize the current literature of the utility of FFR in the ACS population and highlight the role that the results of FAMOUS-NSTEMI may have on future study and management in this area.