Introduction
Diagnostic and interventional procedures for coronary artery disease: implications for selection of contrast media
Instituto de Ciencias del Corazón (ICICOR), University Hospital—School of Medicine, Valladolid, Spain, E-mail address: faviles{at}secardiologia.es
Cardiovascular disease (CVD) is the leading cause of death in the North American population and in most European countries.1,2 On average, CVD [including coronary heart disease (CHD) and stroke] accounts for about half of all mortality in Europe and for 30% of all deaths before the age of 65 years.2 There is a two- to five-fold difference in premature CVD mortality between western Europe and countries of central and eastern Europe (CCEE), with the approximate rates of CVD mortality per 100 000 population under the age of 65 years being 50 in western Europe, 120 in the CCEE, and 230 in the newly independent states of the former USSR (NIS).3 In addition, nearly 2600 Americans die of CVD every day, which is more than the next five leading causes of death combined. However, as methods for detecting and treating heart disease improve, many of these patients can be treated to improve the duration and/or quality of their lives.
Techniques commonly used to either detect the presence of coronary artery disease (angiography) or treat coronary artery disease (percutaneous coronary interventions,PCI) are invasive. Although the safety of these procedures has improved over the years, patients may still experience in-hospital complications such as death, myocardial infarction, emergency coronary artery bypass grafting, stroke, and contrast-induced nephropathy.4 These complications are more common in patients with identifiable risk factors including advanced age, diabetes mellitus, hypertension, and renal insufficiency.
It is anticipated that the incidence of complications associated with angiography and PCI will increase as more patients with risk factors such as advanced age, diabetes, hypertension, and end-stage renal disease (ESRD) are treated. By 2010, it is estimated that 40 million Americans will be aged 65 or older. Europe has the oldest population in the world and one in three Europeans is projected to be aged 65 and older by 2050.2 The prevalence of diabetes is projected to increase considerably worldwide to 5.4% or 300 million people by 2025.5 Currently, 17 million Americans have diabetes mellitus, almost 15 million classified as pre-diabetic, and diabetes affects about 23 million adults in the European region.3 The EUROASPIRE II survey, carried out during 1999–2000 in 15 European countries in patients with established CHD,6 demonstrated that 29% of these patients were diabetic, including 9% with undetected diabetes mellitus, and 23% were pre-diabetic, defined as impaired glucose tolerance. Twenty-eight per cent of Americans have high blood pressure, but the prevalence of hypertension in European countries is even higher, with 44% of the population affected at the 140/90 mmHg threshold.7 There is also an alarming increase in the incidence of renal insufficiency, which affects almost four million adult Americans. In the United States, the incidence of ESRD is projected to be more than two million by 2030.8 Worldwide about 1.5 million people were undergoing treatment for ESRD at the end of 2001, an increase of 7% compared with year-end 2000.9 Although lower in Japan and the United States, the prevalence of ESRD in Europe is highest in certain areas of Spain, followed by Germany, Belgium, and Greece.10
On the basis of these demographics, interventional cardiologists will see an increasing number of patients who are at high risk for experiencing adverse outcomes during or after angiography and PCI. Thus, physicians need to be familiar with the latest approaches for preventing complications in high-risk patients. Identifying patients at risk and using appropriate therapies are essential to minimize the morbidity and mortality of patients with coronary artery disease.
As a result of active research worldwide, improvements in detection and treatment of CVD are making procedures safer for high-risk patients. The papers in this supplement will review non-invasive assessment of the coronary arteries, and procedures for minimizing in-hospital complications of PCI.
Non-invasive imaging of coronary arteries with MDCT
Coronary angiography provides essential information about the location and extent of coronary stenoses, and stenoses can be treated with PCI in the same procedure. However, 20% of angiography procedures do not result in performance of interventional procedures1 and adverse events (bleeding) may occur. Over the past few decades, non-invasive imaging technology has improved dramatically with the development of magnetic resonance imaging and multidetector-row computer tomography (MDCT).11
MDCT allows the three-dimensional visualization of bodily organs and is routinely used to diagnose structural pathologies in the chest, abdomen, and head. MDCT, especially in the newer 16–64-slice MDCT scanners, is capable of producing high-resolution three-dimensional images of the heart for visualization of the coronary arteries.12,13 It can provide information not available from traditional angiography, such as characterization of plaques based on their content of lipid or fibrous material. Furthermore, data from a single MDCT scan can simultaneously provide information on the condition of the coronary arteries, aorta, and pulmonary arteries, rapidly investigating important causes of chest pain.14
Optimizing MDCT for examination of the coronary arteries has been a particular challenge because of the non-linear motion of the arteries, their small size, and their positioning. However, many technical difficulties have been overcome, and MDCT is emerging as a viable alternative for assessing coronary artery disease, particularly in patients at risk for complications.
The first article in this supplement presents the latest advances in MDCT technology for imaging coronary arteries. The purpose of this review is to describe the theory behind MDCT, its strengths and limitations, and approaches to optimizing image quality, which include regulation of heart rate and appropriate use of contrast media.
Reducing in-hospital complications associated with PCI
During the past few decades, the technologies used in interventional cardiology have advanced rapidly. Now, balloon angioplasty is rarely performed and a wide variety of stents, including drug-eluting stents, have been shown to improve patient outcomes. The recent introduction of drug-eluting stents has the potential to increase the durability of our procedural results, markedly reducing the need for re-intervention and possibly reducing the need for coronary artery bypass grafting.15–17
Because PCI now provides long-lasting results and presents minimal risk to many patients, it is considered to be an option for patients with risk factors such as very advanced age, compromised ventricular function, diabetes, or renal disease. Indeed, accumulating clinical evidence supports the efficacy of PCI in high-risk patients, including patients with acute coronary syndrome and chronic kidney failure.18
Although PCI is often technically successful in patients with risk factors, it can be associated with a higher incidence of acute cardiac and/or renal complications and requires special management.4 Recent clinical studies have established the efficacy of specific treatment strategies in high-risk patient populations (see Brinker et al., in this supplement, pp. G13–G24).
The purpose of the second review is to present the latest evidence on identifying patients at risk for in-hospital cardiac and renal complications of PCI and to review contemporary practical strategies that reduce the incidences of these complications.
At the same time that the population is ageing and more patients are presenting with coronary artery disease and with risk factors such as advanced age, diabetes, and renal failure, strategies to more safely diagnose and treat patients with CHD are emerging. Non-invasive detection and monitoring of coronary artery disease with MDCT followed by interventions using procedures that minimize cardiac and renal complications should be considered to improve the safety of treatment for patients with known risk factors.
References
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- De Backer G, Ambrosioni E, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2003;10(Suppl. 1):S1–S78.[CrossRef][Web of Science][Medline]
- World Health Organization. The European Health Report 2002. WHO Regional Publications, European Series, No. 97. http://www.euro.who.int/europeanhealthreport (13 January 2005).
- Smith SC Jr, Dove JT, Jacobs AK et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)-executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions. Circulation 2001;103:3019–3041.
[Free Full Text] - King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414–1431.[Abstract]
- Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001;22:554–572.
[Abstract/Free Full Text] - Wolf-Maier K, Cooper RS, Banegas JR et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003;289:2363–2369.
[Abstract/Free Full Text] - Szczech L, Lazar I. Projecting the United States ESRD population: issues regarding treatment of patients with ESRD. Kidney Int 2004;66:S3–S7.
- Moeller S, Gioberge S, Brown G. ESRD patients in 2001: global overview of patients, treatment modalities and development trends. Nephrol Dial Transplant 2002;17:2071–2076.
[Free Full Text] - USRDS. United States Renal Data System. http://www.usrds.org (13 January 2005).
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- Heuser R, Houser F, Culler SD et al. A retrospective study of 6,671 patients comparing coronary stenting and balloon angioplasty. J Invasive Cardiol 2000;12:354–362.[Web of Science][Medline]
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[Abstract/Free Full Text] - Watanabe CT, Maynard C, Ritchie JL. Short-term outcomes after percutaneous coronary intervention: effects of stenting and institutional volume shifts. Am Heart J 2002;144:310–314.[Medline]
- Keeley EC, Kadakia R, Soman S et al. Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with acute coronary syndromes. Am J Cardiol 2003;92:509–514.[CrossRef][Web of Science][Medline]
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