In symptomatic patients with a CAC score of 0, obstructive CAD is possible and is associated with increased cardiovascular events. CAC scoring did not add incremental prognostic information to CCTA.
We sought to assess the prognostic value of coronary computed tomography angiography (CCTA) among military health care system beneficiaries. We identified 1,125 consecutive symptomatic patients without known coronary artery disease (CAD) referred for 64-slice CCTA (2006-2010) at a single center. CAD was assessed as none, < 50%, or > or = 50% (obstructive) coronary stenosis. A combined endpoint of major adverse events (death, myocardial infarction [MI], coronary revascularization > 90 days after CCTA) was assessed by Kaplan-Meier and Cox proportional hazards. The mean age was 50 +/- 12 years, 59% were male, and 617 (55%) had no CAD, 411 (37%) nonobstructive CAD, and 97 (9%) obstructive CAD on CCTA. During 2.0 +/- 1.1-year follow-up, there were 6 deaths, 3 MIs, and 6 revascularizations. There was 1 event in the no-CAD group (0.08%/year), 4 events in the nonobstructive group (0.5%/year), and 9 events in patients with obstructive CAD (4.5%/year) (p < 0.001). Patients with obstructive CAD had significantly increased combined adverse events. Increasing angina typicality and risk factors (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.05-1.46; p = 0.01) and obstructive CAD (HR 12.1, 95% CI 3.99-36.9; p < 0.001) were independently predictive of events. Absence of CAD was associated with very low event rates, providing military health care system patients and providers confidence in regards to cardiovascular risk, future deployments, and occupational assignments.
Electrical alternans is an electrocardiographic phenomenon defined as an alternating amplitude or axis of the QRS complexes in any or all leads. It is most commonly associated with a large pericardial effusion and impending threat of cardiac tamponade; however, a literature review showed that this electrocardiographic finding can be seen in a variety of other clinical scenarios with varying etiologies and prognoses. Several electrocardiogram examples are presented with a brief review of the potential mechanisms and clinical significance and demonstrate that electrical alternans is more correctly considered an electrocardiographic sign, rather than a diagnosis, with a broad differential for potential etiologies. For some causes, the clinical significance is well known, but for others, further research is needed.
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