August 2018 Issue
ISSN 2689-291X
ISSN 2689-291X
Topic Review
Psychocardiology: The Mysterious
Brain-Heart Interaction Discipline!
Introduction
It is often said that “The heart is the seat of emotions”, in reference to the mystifying interaction between the mind and the heart. Many psychiatric illnesses have been clearly demonstrated to directly or indirectly affect the cardiovascular system. Cardiovascular disease in general can also cause or exacerbate many psychiatric conditions. An increasing amount of literature has been published in Pubmed under the search term “cardiovascular psychiatry” over the past few decades, reflecting the better understanding and recognition of this complex Brain-Heart interaction. (1)
Psychiatric conditions shown to be associated with heart disease include anger, hostility, anxiety, depression, delirium and neurocognitive disorders, psychotic disorders, and post-traumatic stress disorder; all of which impact and are impacted by cardiac critical care. Depression is quite common in patients with coronary heart disease and congestive heart failure, and is associated with increased morbidity and mortality. (2)
The Clinical Commission of the German Heart Society (DGK) recently updated their “state of the art” paper on the current empirical evidence in psychocardiology in 2015. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiology practice and highlights areas of high priority. (3)
Depression and Anxiety
In a scientific statement, the American Heart Association (AHA) elevated depression to the status of a risk factor for patients with acute coronary syndromes: “depression after acute coronary syndrome is a risk factor for all-cause and cardiac mortality, as well as for composite outcomes including mortality or nonfatal cardiac events. As such, depression should be elevated to the level of a risk factor for poor prognosis after acute coronary syndrome.” (4)
Depression and anxiety in heart patients are associated with cardiac risk behaviors such as smoking, obesity, excess alcohol consumption and medication non-compliance, which elevate the risk associated with mortality to the level of other well-known risk factors such as smoking, according to the Danish national DenHeart survey. (6)
The effect of mood disorders on vascular function, the plausible biological pathways and the potential role played by inflammation and the effect of treatment have been reviewed by Fiedorowicz. (7)
Treatment of depression has been shown to have a positive effect on outcomes in coronary artery disease patients. The ENRICHD study showed that use of selective serotonin reuptake inhibitors in depressed patients who experience an acute myocardial infarction might reduce subsequent cardiovascular morbidity and mortality (8). Whether such benefit is related to a direct pharmacologic action of the medications on the inhibition of platelet activation and the lowering of heart rate, or a secondary effect due to enhanced compliance with medications and lifestyle changes after treating depression, is debatable (9). A cognitive-behavioral therapy intervention program was shown to decrease the risk of recurrent cardiovascular disease and recurrent acute myocardial infarctions (10).
Conclusion
There is increasing evidence demonstrating an unequivocal interaction between the heart and the brain at the chemical level and at the behavioral level. Cardiovascular disease remains the number one killer globally according to the World Health Organization (WHO). Primary and secondary prevention of cardiac disease incorporate to a large extent behavioral changes which are often challenging to implement without adequate medical provider training, and remain an impediment to cardiovascular disease prevention. Psychocardiology is a rapidly emerging discipline with the potential of helping train medical providers in the proper evaluation and treatment of behavioral challenges in cardiac patients; this is infrequently included in medical training curricula. With its mounting importance, whether psychocardiology will one day become a new medical specialty, or a subspecialty of either cardiology or psychiatry training, is an intriguing thought and remains to be seen.
References
Authors
Mazen Omar, B.S.
Medical Student
University of South Alabama
Mobile, AL
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
It is often said that “The heart is the seat of emotions”, in reference to the mystifying interaction between the mind and the heart. Many psychiatric illnesses have been clearly demonstrated to directly or indirectly affect the cardiovascular system. Cardiovascular disease in general can also cause or exacerbate many psychiatric conditions. An increasing amount of literature has been published in Pubmed under the search term “cardiovascular psychiatry” over the past few decades, reflecting the better understanding and recognition of this complex Brain-Heart interaction. (1)
Psychiatric conditions shown to be associated with heart disease include anger, hostility, anxiety, depression, delirium and neurocognitive disorders, psychotic disorders, and post-traumatic stress disorder; all of which impact and are impacted by cardiac critical care. Depression is quite common in patients with coronary heart disease and congestive heart failure, and is associated with increased morbidity and mortality. (2)
The Clinical Commission of the German Heart Society (DGK) recently updated their “state of the art” paper on the current empirical evidence in psychocardiology in 2015. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiology practice and highlights areas of high priority. (3)
Depression and Anxiety
In a scientific statement, the American Heart Association (AHA) elevated depression to the status of a risk factor for patients with acute coronary syndromes: “depression after acute coronary syndrome is a risk factor for all-cause and cardiac mortality, as well as for composite outcomes including mortality or nonfatal cardiac events. As such, depression should be elevated to the level of a risk factor for poor prognosis after acute coronary syndrome.” (4)
Depression and anxiety in heart patients are associated with cardiac risk behaviors such as smoking, obesity, excess alcohol consumption and medication non-compliance, which elevate the risk associated with mortality to the level of other well-known risk factors such as smoking, according to the Danish national DenHeart survey. (6)
The effect of mood disorders on vascular function, the plausible biological pathways and the potential role played by inflammation and the effect of treatment have been reviewed by Fiedorowicz. (7)
Treatment of depression has been shown to have a positive effect on outcomes in coronary artery disease patients. The ENRICHD study showed that use of selective serotonin reuptake inhibitors in depressed patients who experience an acute myocardial infarction might reduce subsequent cardiovascular morbidity and mortality (8). Whether such benefit is related to a direct pharmacologic action of the medications on the inhibition of platelet activation and the lowering of heart rate, or a secondary effect due to enhanced compliance with medications and lifestyle changes after treating depression, is debatable (9). A cognitive-behavioral therapy intervention program was shown to decrease the risk of recurrent cardiovascular disease and recurrent acute myocardial infarctions (10).
Conclusion
There is increasing evidence demonstrating an unequivocal interaction between the heart and the brain at the chemical level and at the behavioral level. Cardiovascular disease remains the number one killer globally according to the World Health Organization (WHO). Primary and secondary prevention of cardiac disease incorporate to a large extent behavioral changes which are often challenging to implement without adequate medical provider training, and remain an impediment to cardiovascular disease prevention. Psychocardiology is a rapidly emerging discipline with the potential of helping train medical providers in the proper evaluation and treatment of behavioral challenges in cardiac patients; this is infrequently included in medical training curricula. With its mounting importance, whether psychocardiology will one day become a new medical specialty, or a subspecialty of either cardiology or psychiatry training, is an intriguing thought and remains to be seen.
References
- Manev H. The Heart-Brain Connection Begets Cardiovascular Psychiatry and Neurology. Cardiovasc Psychiatry Neurol. 2009;2009:546737
- Shapiro PA. Crit Care Clin. 2017 Jul;33(3):619-634.
- Karl-Heinz Ladwig, Florian Lederbogen, Christian Albus, et al. Ger Med Sci. 2014; 12: Doc09.
- Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the american heart association. Circulation. 2014; 129(12):1350–69.
- Jess G. Fiedorowicz. Curr Psychiatry Rep. 2014 Oct; 16(10): 492.
- R.K. Saran, Aniket Puri, Manu Agarwal. Indian Heart J. 2012 Jul; 64(4): 397–401.
- Berg SK, Rasmussen TB, Thrysoee L, et al. Mental health is a risk factor for poor outcomes in cardiac patients: Findings from the national DenHeart survey. J Psychosom Res. 2018 Sep;112:66-72.
- Taylor CB, Youngblood ME, Catellier D, et al; ENRICHD Investigators. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry. 2005 Jul;62(7):792-8.
- Vieweg WV, Julius DA, Fernandez A, et al. of in with . Am J Med. 2006 Jul;119(7):567-73.
- Gulliksson M, Burell G, Vessby B. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch Intern Med. 2011 Jan 24;171(2):134-40.
Authors
Mazen Omar, B.S.
Medical Student
University of South Alabama
Mobile, AL
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Journal Review
Oral Antibiotics for Endocarditis!
Long-Awaited Novel Approach for an Old Diagnosis
Abstract:
Endocarditis has traditionally been treated with intravenous (IV) antibiotic therapy for up to six weeks (1). This creates the burden of long term IV access in patients, financial cost and time-consuming IV medication administration. Iversen and colleagues (2) published in the August 28th 2018 issue of the New England Journal of Medicine findings of the POET study (Partial Oral vs. Intravenous Antibiotic Treatment of Endocarditis), a multicenter, unblinded, noninferiority study that compared IV treatment of endocarditis with changing to oral antibiotic treatment. The end point was a composite of all-cause mortality, cardiac surgery, embolic events, or relapse of bacteremia at 6 months after treatment ended. Out of the 400 adults with left-sided endocarditis, 199 received continuous IV antibiotic treatment, and 201 patients were changed to oral antibiotic therapy. Both groups received IV antibiotics for 10 days initially. The IV therapy group continued to receive treatment for 19 days, whereas the oral therapy group continued to receive therapy for 17 days.
The inclusion criteria were:
Of note, 4 patients crossed over from the oral treatment group to the IV treatment group (1 patient due to nausea, 1 due to bacteremia with a new pathogen, and 2 due to patient choice); 22% of the IV treatment group were changed to a different IV regimen, and 12% of the oral treatment group were changed to a different oral regimen.
Results:
The primary outcome (composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed) occurred in 12.1% of the IV treatment group (24 patients), and in 9% (18 patients) of the oral treatment group, making the change from IV to oral treatment a noninferior option to the traditional continuation of IV antibiotic treatment.
The median length of hospital stay after randomization was 19 days in the intravenous treatment group and only 3 days in the oral treatment group (P<0.001).
Adverse effects were reported in 12 patients (6%) in the intravenous treatment group and 10 patients (5%) in the oral treatment group (P = 0.66); these included allergy (50%), bone marrow suppression (27%), and gastrointestinal effects (14%), with no significant differences between groups.
Discussion:
In the hemodynamically stable patient without high risk features of endocarditis, the switch to oral antibiotic treatment is an attractive option. This potentially allows for a shorter hospital stay, less complications and more patient comfort compared with long-term IV antibiotic therapy. The absence of IV line in outpatient therapy may also decrease the risk of relapse of IV drug use (albeit, IV drug use population may have right-sided rather than left-sided endocarditis). Careful consideration must be taken prior to changing to oral therapy; these patients require close follow up (since 12% had to change their regimen) and they must have intact gastrointestinal function so as to guarantee successful treatment. Nevertheless, POET shows a promising step forward in the treatment of a devastating disease that historically required prolonged course of IV therapy with antibiotics.
References:
Authors:
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Mustafa Awan, M.D.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Endocarditis has traditionally been treated with intravenous (IV) antibiotic therapy for up to six weeks (1). This creates the burden of long term IV access in patients, financial cost and time-consuming IV medication administration. Iversen and colleagues (2) published in the August 28th 2018 issue of the New England Journal of Medicine findings of the POET study (Partial Oral vs. Intravenous Antibiotic Treatment of Endocarditis), a multicenter, unblinded, noninferiority study that compared IV treatment of endocarditis with changing to oral antibiotic treatment. The end point was a composite of all-cause mortality, cardiac surgery, embolic events, or relapse of bacteremia at 6 months after treatment ended. Out of the 400 adults with left-sided endocarditis, 199 received continuous IV antibiotic treatment, and 201 patients were changed to oral antibiotic therapy. Both groups received IV antibiotics for 10 days initially. The IV therapy group continued to receive treatment for 19 days, whereas the oral therapy group continued to receive therapy for 17 days.
The inclusion criteria were:
- At least 18 years of age
- Hemodynamically stable
- Endocarditis of left sided native or prosthetic valves
- Blood cultures positive for streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci
- No abscess or valve abnormalities that would require surgery
Of note, 4 patients crossed over from the oral treatment group to the IV treatment group (1 patient due to nausea, 1 due to bacteremia with a new pathogen, and 2 due to patient choice); 22% of the IV treatment group were changed to a different IV regimen, and 12% of the oral treatment group were changed to a different oral regimen.
Results:
The primary outcome (composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed) occurred in 12.1% of the IV treatment group (24 patients), and in 9% (18 patients) of the oral treatment group, making the change from IV to oral treatment a noninferior option to the traditional continuation of IV antibiotic treatment.
The median length of hospital stay after randomization was 19 days in the intravenous treatment group and only 3 days in the oral treatment group (P<0.001).
Adverse effects were reported in 12 patients (6%) in the intravenous treatment group and 10 patients (5%) in the oral treatment group (P = 0.66); these included allergy (50%), bone marrow suppression (27%), and gastrointestinal effects (14%), with no significant differences between groups.
Discussion:
In the hemodynamically stable patient without high risk features of endocarditis, the switch to oral antibiotic treatment is an attractive option. This potentially allows for a shorter hospital stay, less complications and more patient comfort compared with long-term IV antibiotic therapy. The absence of IV line in outpatient therapy may also decrease the risk of relapse of IV drug use (albeit, IV drug use population may have right-sided rather than left-sided endocarditis). Careful consideration must be taken prior to changing to oral therapy; these patients require close follow up (since 12% had to change their regimen) and they must have intact gastrointestinal function so as to guarantee successful treatment. Nevertheless, POET shows a promising step forward in the treatment of a devastating disease that historically required prolonged course of IV therapy with antibiotics.
References:
- Gould FK, Denning DW, Elliott TS, et al. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2012 Feb;67(2):269-89.
- Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2018 Aug 28.
Authors:
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Mustafa Awan, M.D.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Journal Review
“Seeing is Believing”: Reduction of Coronary Events by CT Angiography Compared to Conventional Risk Stratification
Abstract:
The PROMISE study of symptomatic patient with suspected coronary artery disease (CAD) did not demonstrate superiority of CT angiography (CTA) in 2-year clinical outcomes compared to stress testing, despite the overall increase in radiation exposure, casting doubt on the utility of this modality in the diagnosis of coronary artery disease (1). In a recent issue of the New England Journal of Medicine, Newby et al (2) published the findings of the SCOT-HEART (Scottish COmputed Tomography of the HEART) trial. This was an open-label, multicenter, parallel-group trial, which randomly assigned 4146 patients referred for evaluation of stable chest pain to standard care plus CTA (2073 patients) or standard care alone (2073 patients). The primary end point, death from coronary disease or nonfatal myocardial infarction (MI) at 5 years, was assessed over 3 to 7 years of follow-up.
The inclusion criteria were:
Patients underwent clinical evaluation, including, if indicated, symptom-limited exercise stress test. Patients were randomly assigned in a 1:1 ratio to standard care plus CTA or standard care alone. Patient management according to available data was at the discretion of the treating provider. Providers caring for patients in the CTA group were urged to incorporate the results of the CTA in their management decisions. Providers caring for patients in the standard-care group were prompted to consider a prespecified cardiovascular risk score in their management decisions. When there was evidence of nonobstructive or obstructive coronary artery disease on the CTA, or when a patient had a high risk on a prespecified cardiovascular risk score, the providers were encouraged by the trial coordinating center to prescribe preventative therapies such as aspirin and statin medications.
Results:
The primary end point (death from coronary artery disease or nonfatal myocardial infarction) was 2.3% (48 patients) in the CTA group compared to 3.9% (81 patients) in the standard-care group (P = 0.004). The difference was driven mostly by a lower rate of nonfatal MI in the CTA group compared with the standard-care group. At 5 years, there was no difference in the frequency of coronary angiography (23.6% versus 24.2%) or revascularization (13.5% versus 12.9%) between the groups.
The 5-year event rates were higher in patients with possible angina (3.1%) compared with those with nonanginal chest pain (1.8%). However, the absolute difference in the primary end point at 5 years between the CTA group and the standard-care group was similar in these two patient subsets (1.5 percentage points in patients with possible angina and 1.3 percentage points in patients with nonanginal chest pain).
Discussion:
SCOT-HEART trial demonstrated that CT angiography, with resultant changes in treatment, caused a significantly lower rate of death from coronary disease or nonfatal MI than standard care alone. Although invasive angiography and coronary revascularization use were higher in the CTA group in the first few months of follow-up, there were no differences in the overall use of invasive angiography and coronary revascularization at 5 years. These findings suggest that the CTA resulted in more correct diagnoses of coronary artery disease than standard care alone, which, in turn, resulted in the increased use of preventative therapies, causing fewer clinical events in the CTA group than in the standard-care group.
Clinical Perspective:
The findings of SCOT-HEART clinic trial are intriguing. The anatomic delineation of coronary disease using CT angiography in patients suspected of having coronary disease had a greater impact on implementation of preventative therapies, resulting in better cardiovascular outcomes, compared to incorporating a prespecified cardiovascular risk score. It leaves one to ponder whether providers would rather “see” the coronary disease using CT angiography before they “believe” in applying life-saving preventative therapies, rather than use the more abstract risk scoring, or whether the particular risk scoring system employed in this study (The ASSIGN risk score) fell short of protecting at risk patients. Further studies, possibly with comparison of other risk scoring schemes to CT angiography, may help shed some light on this point. Meanwhile, the significant findings of this study seem to have added a prognostic qualification to the use of CT angiography which may help offset some of the negative publicity surrounding its implementation.
References:
1. Douglas PS, Hoffmann U, Patel MR, et al; PROMISE Investigators. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015 Apr 2;372(14):1291-300.
2. Newby DE, Adamson PD, Berry C, et al; SCOT-HEART Investigators. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. 2018 Sep 6;379(10):924-933.
Authors:
Joseph Heron, B.S.
Medical Student
University of South Alabama
Mobile, AL
Sajjad Ahmad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Muhammad Umer Awan, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, A
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
The PROMISE study of symptomatic patient with suspected coronary artery disease (CAD) did not demonstrate superiority of CT angiography (CTA) in 2-year clinical outcomes compared to stress testing, despite the overall increase in radiation exposure, casting doubt on the utility of this modality in the diagnosis of coronary artery disease (1). In a recent issue of the New England Journal of Medicine, Newby et al (2) published the findings of the SCOT-HEART (Scottish COmputed Tomography of the HEART) trial. This was an open-label, multicenter, parallel-group trial, which randomly assigned 4146 patients referred for evaluation of stable chest pain to standard care plus CTA (2073 patients) or standard care alone (2073 patients). The primary end point, death from coronary disease or nonfatal myocardial infarction (MI) at 5 years, was assessed over 3 to 7 years of follow-up.
The inclusion criteria were:
- Patients 18 to 75 years of age
- Stable chest pain
- Referral by a primary care physician to a cardiology clinic
Patients underwent clinical evaluation, including, if indicated, symptom-limited exercise stress test. Patients were randomly assigned in a 1:1 ratio to standard care plus CTA or standard care alone. Patient management according to available data was at the discretion of the treating provider. Providers caring for patients in the CTA group were urged to incorporate the results of the CTA in their management decisions. Providers caring for patients in the standard-care group were prompted to consider a prespecified cardiovascular risk score in their management decisions. When there was evidence of nonobstructive or obstructive coronary artery disease on the CTA, or when a patient had a high risk on a prespecified cardiovascular risk score, the providers were encouraged by the trial coordinating center to prescribe preventative therapies such as aspirin and statin medications.
Results:
The primary end point (death from coronary artery disease or nonfatal myocardial infarction) was 2.3% (48 patients) in the CTA group compared to 3.9% (81 patients) in the standard-care group (P = 0.004). The difference was driven mostly by a lower rate of nonfatal MI in the CTA group compared with the standard-care group. At 5 years, there was no difference in the frequency of coronary angiography (23.6% versus 24.2%) or revascularization (13.5% versus 12.9%) between the groups.
The 5-year event rates were higher in patients with possible angina (3.1%) compared with those with nonanginal chest pain (1.8%). However, the absolute difference in the primary end point at 5 years between the CTA group and the standard-care group was similar in these two patient subsets (1.5 percentage points in patients with possible angina and 1.3 percentage points in patients with nonanginal chest pain).
Discussion:
SCOT-HEART trial demonstrated that CT angiography, with resultant changes in treatment, caused a significantly lower rate of death from coronary disease or nonfatal MI than standard care alone. Although invasive angiography and coronary revascularization use were higher in the CTA group in the first few months of follow-up, there were no differences in the overall use of invasive angiography and coronary revascularization at 5 years. These findings suggest that the CTA resulted in more correct diagnoses of coronary artery disease than standard care alone, which, in turn, resulted in the increased use of preventative therapies, causing fewer clinical events in the CTA group than in the standard-care group.
Clinical Perspective:
The findings of SCOT-HEART clinic trial are intriguing. The anatomic delineation of coronary disease using CT angiography in patients suspected of having coronary disease had a greater impact on implementation of preventative therapies, resulting in better cardiovascular outcomes, compared to incorporating a prespecified cardiovascular risk score. It leaves one to ponder whether providers would rather “see” the coronary disease using CT angiography before they “believe” in applying life-saving preventative therapies, rather than use the more abstract risk scoring, or whether the particular risk scoring system employed in this study (The ASSIGN risk score) fell short of protecting at risk patients. Further studies, possibly with comparison of other risk scoring schemes to CT angiography, may help shed some light on this point. Meanwhile, the significant findings of this study seem to have added a prognostic qualification to the use of CT angiography which may help offset some of the negative publicity surrounding its implementation.
References:
1. Douglas PS, Hoffmann U, Patel MR, et al; PROMISE Investigators. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015 Apr 2;372(14):1291-300.
2. Newby DE, Adamson PD, Berry C, et al; SCOT-HEART Investigators. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. 2018 Sep 6;379(10):924-933.
Authors:
Joseph Heron, B.S.
Medical Student
University of South Alabama
Mobile, AL
Sajjad Ahmad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Muhammad Umer Awan, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, A
Christopher Malozzi, D.O.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL