Netherlands Heart Journal最新文献

Background: This study investigates the effects of spondylodiscitis on the inflammation burden in infective endocarditis patients.

Methods: A prospective, observational study was conducted between September 2018 and October 2022 in a non-surgical teaching hospital. Patients with a definite or possible and treated as infective endocarditis were recruited from the Alkmaar Endocarditis Team meetings. Spondylodiscitis was diagnosed based on symptoms and radiological findings. The inflammation burden was defined as the area under the C‑reactive protein (CRP) curve.

Results: 174 consecutive patients with infective endocarditis were included (mean age 73 years, 34.5% female). Concomitant spondylodiscitis was present in 32 patients (18%), frequently associated with Streptococcus species (38%). At admission, the mean level of CRP was significantly higher in patients with concomitant spondylodiscitis (p = 0.004). The median CRP area under the curve was significantly higher in spondylodiscitis patients (4.2 × 10⁶ min.mg/l [1.2 × 10⁵ - 1.6 × 10⁷ min.mg/l] vs 2.0 × 10⁶ min.mg/l [8.7 × 10⁴ - 1.6 × 10⁷ min.mg/l], p < 0.001). This difference remained during the whole treatment period. At 6 months of follow-up, rates of mortality and relapse of infective endocarditis were not significantly different.

Conclusion: The prevalence of spondylodiscitis in non-referred patients with infective endocarditis was 18%. Endocarditis patients with spondylodiscitis had an increased inflammation burden at and during admission. This difference in normalisation of CRP levels was particularly apparent in the final phase of antibiotic treatment but not related to infectious complications. Despite an augmented inflammation burden, spondylodiscitis was not associated with mortality, cardiac surgery or infectious relapse.

The maximum aortic diameter is the main risk predictor for type A acute aortic syndromes and understanding the growth rate of ascending thoracic aortic aneurysms (aTAAs) is pivotal for risk assessment and stratification for pre-emptive aortic surgery. Prevailing guidelines recommend serial imaging of aTAA patients until the thresholds for prophylactic surgery are met. Based on early landmark studies, it was thought that the growth rate of aTAAs is substantially higher than that of the normal-sized aorta. However, more recent studies have reported that aTAA growth is generally slow, questioning the need for frequent imaging during follow-up. The current systematic review provides an overview of studies reporting annual diameter growth rates of non-syndromic aTAAs and explains differences in findings between early and recent studies.

Background: Patients with stable chest pain suspected of coronary artery disease (CAD) usually undergo multiple diagnostic tests to confirm or rule out obstructive CAD. Some tests may not effectively assess the presence of CAD, precluding optimal treatment. A diagnostic strategy of upfront computed tomography coronary angiography (CTCA) combined with optimal medical therapy (OMT) tailored to the extent of CAD may be superior to standard care in preventing major adverse cardiac events.

Study design: The CLEAR-CAD trial is a prospective, open-label, multicentre, randomised, superiority trial of an upfront CTCA-guided strategy in 6444 patients presenting in an outpatient setting with suspected CAD compared with standard care, in approximately 30 participating centres in the Netherlands. The upfront CTCA-guided strategy consists of an initial CTCA which is assessed using the Coronary Artery Disease-Reporting and Data System (CAD-RADS 2.0). In patients without CAD (CAD-RADS 0) no specific cardiac medication is mandated. Patients with non-obstructive CAD (CAD-RADS 1-2) are treated with preventive OMT. Patients with obstructive CAD (CAD-RADS ≥ 3) are treated with preventive and anti-anginal OMT; in the presence of pharmacologically refractory symptoms patients undergo selective revascularisation after non-invasive functional imaging for myocardial ischaemia (≥ 10%). Patients with significant left main or proximal left anterior descending coronary artery stenosis on CTCA undergo direct invasive coronary angiography and subsequent revascularisation. The primary endpoint is the composite of all-cause death and myocardial infarction.

Conclusion: The CLEAR-CAD trial is the first randomised study to investigate the efficacy of a combined upfront CTCA-guided medical and selective revascularisation strategy in an outpatient setting with suspected CAD compared with standard care.

Computed tomography-derived fractional flow reserve (CT-FFR) enhances the specificity of coronary computed tomography angiography (CCTA) to that of the most specific non-invasive imaging techniques, while maintaining high sensitivity in stable coronary artery disease (CAD). As gatekeeper for invasive coronary angiography (ICA), use of CT-FFR results in a significant reduction of negative ICA procedures and associated costs and complications, without increasing cardiovascular events. It is expected that CT-FFR algorithms will continue to improve, regarding accuracy and generalisability, and that introduction of new features will allow further treatment guidance and reduced invasive diagnostic testing. Advancements in CCTA quality and artificial intelligence (AI) are starting to unfold the incremental diagnostic and prognostic capabilities of CCTA's attenuation-based images in CAD, with future perspectives promising additional CCTA parameters which will enable non-invasive assessment of myocardial ischaemia as well as CAD activity and future cardiovascular risk. This review discusses practical application, interpretation and impact of CT-FFR on patient care, and how this ties into the CCTA 'one stop shop' for coronary assessment and patient prognosis. In this light, selective adoption of the most promising, objective and reproducible techniques and algorithms will yield maximal diagnostic value of CCTA without overcomplicating patient management and guideline recommendations.

Several risk prediction models exist to predict atherosclerotic cardiovascular disease in asymptomatic individuals, but systematic reviews have generally found these models to be of limited utility. The coronary artery calcium score (CACS) offers an improvement in risk prediction, yet its role remains contentious. Notably, its negative predictive value has a high ability to rule out clinically relevant atherosclerotic cardiovascular disease. Nonetheless, CACS 0 does not permanently reclassify to a lower cardiovascular risk and periodic reassessment every 5 to 10 years remains necessary. Conversely, elevated CACS (> 100 or > 75th percentile adjusted for age, sex and ethnicity) can reclassify intermediate-risk individuals to a high risk, benefiting from preventive medication. The forthcoming update to the Dutch cardiovascular risk management guideline intends to re-position CACS for cardiovascular risk assessment as such in asymptomatic individuals. Beyond CACS as a single number, several guidelines recommend coronary CT angiography (CCTA), which provides additional information about luminal stenosis and (high-risk) plaque composition, as the first choice of test in symptomatic patients and high-risk patients. Ongoing randomised studies will have to determine the value of atherosclerosis evaluation with CCTA for primary prevention in asymptomatic individuals.

Photon-counting detector computed tomography (PCD-CT) has emerged as a revolutionary technology in CT imaging. PCD-CT offers significant advancements over conventional energy-integrating detector CT, including increased spatial resolution, artefact reduction and inherent spectral imaging capabilities. In cardiac imaging, PCD-CT can offer a more accurate assessment of coronary artery disease, plaque characterisation and the in-stent lumen. Additionally, it might improve the visualisation of myocardial fibrosis through qualitative late enhancement imaging and quantitative extracellular volume measurements. The use of PCD-CT in cardiac imaging holds significant potential, positioning itself as a valuable modality that could serve as a one-stop-shop by integrating both angiography and tissue characterisation into a single examination. Despite its potential, large-scale clinical trials, standardisation of protocols and cost-effectiveness considerations are required for its broader integration into clinical practice. This narrative review provides an overview of the current literature on PCD-CT regarding the possibilities and limitations of cardiac imaging.

The Coronary Artery Disease-Reporting and Data System (CAD-RADS) is a standardised reporting method which was created in order to improve communication with referring physicians as well as for management considerations. The CAD-RADS score denotes the absence or presence of stenosis, while plaque burden and potential modifiers provide insight into plaque extent and characteristics. The modifier ischaemia enables the incorporation of fractional flow reserve CT and CT perfusion, while the modifier exception is used to denote potential coronary abnormalities. Higher CAD-RADS categories demonstrate incremental prognostic value, with further improvement when taking plaque burden into account. CAD-RADS improves communication with the referring clinician as well as guiding therapeutic management and as such is relevant to uniform patient care in the Netherlands.