In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk-stratification and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. CT is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose, however contrast computed tomography techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance and computed tomography will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.
Ticagrelor is a potent and orally active P2Y12 inhibitor. Ticagrelor has been extensively tested in Phase II and Phase III trials in patients with coronary artery disease. The pharmacokinetics and pharmacodynamics of Ticagrelor result in more rapid and effective inhibition of platelet activation compared with other P2Y12 inhibitors. This has resulted in a reduction in recurrent major cardiovascular events in initial randomized controls trials comparing Ticagrelor with clopidogrel. More recently, clinical trials have investigated the use of Ticagrelor in patients with stable coronary artery disease and a high residual risk of coronary thrombotic events. In patients with stable coronary artery disease, the potent antiplatelet effect of Ticagrelor is counterbalanced by an increased risk of major bleeding. Further research is ongoing to determine the optimal duration of Ticagrelor therapy.
Despite recent advances, cardiovascular disease remains the leading cause of death globally. As such, there is a need to optimise our current diagnostic and risk stratification pathways in order to better deliver individualised preventative therapies. Non-invasive imaging of coronary artery plaque can interrogate multiple aspects of coronary atherosclerotic disease, including plaque morphology, anatomy and flow. More recently, disease activity is being assessed to provide mechanistic insights into in vivo atherosclerosis biology. Molecular imaging using positron emission tomography is unique in this field, with the potential to identify specific biological processes using either bespoke or re-purposed radiotracers. This review provides an overview of non-invasive vulnerable plaque detection and molecular imaging of coronary atherosclerosis.
Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): NA Background Endocarditis is a complex condition with high rates of morbidity and mortality. The clinical presentation is highly variable and diagnosis may be difficult. ESC guidelines include modified diagnostic criteria utilising both Duke criteria and multimodality imaging techniques in order to improve sensitivity. A Multidisciplinary Endocarditis Team (MDT) is recommended to improve patient care and has been shown to reduce 1 year mortality. We have established a local endocarditis team, with remote input from our regional cardiothoracic centre. During weekly virtual multidisciplinary meetings (MDM), all patients with suspected endocarditis are discussed, with recommendations on investigations, antimicrobial therapy and management. Purpose We audited the use of multimodality imaging in the diagnosis of endocarditis before and after the implementation of the MDM to compare management strategies. Methods Inpatients who were clinically diagnosed and treated for endocarditis in the first 6 months of 2019 (pre MDT – Group 1, n = 30) and 2021 (with MDT input - Group 2, n = 21) were included. Likelihood of endocarditis was calculated using the modified Duke score and multimodality imaging, resulting in categories of definite IE, possible IE and rejected IE. Imaging specifically requested for the diagnosis of endocarditis (or infection/embolic source) was recorded. Where imaging criteria were demonstrated, the modality making this diagnosis was recorded. Results In both groups all patients had a transthoracic echocardiogram (TTE) with a similar diagnostic yield: (20%) in group 1 and 6(29%) in group 2, p = 0.481. In group 1, 13 patients without diagnostic criteria on TTE had a second investigation, with a further 4 meeting imaging criteria. 1 patient had a third test. In group 2, 13 had a second test with a further 8 meeting imaging criteria. 3 patients had a third test with 1 further positive result (Figure 1). There was increased usage of additional testing after a normal TTE in group 2 (87%) compared to group 1 (54%), p = 0.036. Overall, in group 1, 10(33%) patients demonstrated imaging criteria for endocarditis. In group 2, this increased to 15(71%), p = 0.008. A wider spread of imaging techniques was used in group 2 (Figure 1). In group 1, diagnostic criteria were found on TTE (60%) or TOE (40%). In group 2, they were seen from all four modalities: TTE (40%), TOE (33%), FDG-PET (20%) and CT (7%). In group 1, the spread of diagnostic classification was: • Definite endocarditis - 6(20%) • Possible endocarditis - 13(43%) • Rejected endocarditis - 11(37%) In group 2, this was: • Definite endocarditis - 12(57%) • Possible endocarditis - 9(43%) Conclusion Creation of endocarditis MDT resulted in increased use of multimodality imaging in patients with suspected endocarditis, resulting in a higher diagnostic yield and an increase in diagnostic certainty. Abstract Figure.
ObjectiveWe sought to evaluate the potential impact of racial difference (Asians vs Caucasians) on the clinical usefulness of pressure recovery (PR) adjustment for preventing discordant aortic stenosis (AS) grading in patients with severe AS.MethodsData from 1450 patients (mean age, 70.2±10.6 years; 290 (20%) Caucasians; aortic valve area (AVA), 0.77±0.26 cm2) were retrospectively analysed. PR-adjusted AVA was calculated using a validated equation. Discordant grading of severe AS was defined as AVA of <1.0 cm2and mean gradient of <40 mm Hg. The frequency of discordant grading was assessed in the overall cohort and the propensity score-matched cohort.ResultsBefore PR adjustment, 1186 patients showed AVA values of <1.0 cm2; after PR adjustment, 170 (14.3%) were reclassified as having moderate AS. PR adjustment decreased the frequency of discordant grading from 31.4% to 14.1% in Caucasians and from 13.8% to 7.9% in Asians. Patients with reclassification to moderate AS after PR adjustment had a significantly lower risk of a composite of aortic valve replacement or all-cause death than did those with severe AS after PR adjustment (HR 0.38; 95% CI 0.31–0.46; p<0.001). In propensity score-matched cohorts (173 pairs), the frequency of discordant grading before PR adjustment was 42.2% and 43.9% in the Caucasian and Asian patients, respectively, which decreased to 21.4% and 20.2%, respectively, after PR adjustment.ConclusionsClinically relevant PR occurred, regardless of race in patients with moderate to severe AS. Routine PR adjustment may be useful for reconciling discordant AS grading.
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