Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology

Prevalence of emerging cardiovascular risk factors in younger individuals with a family history of premature coronary heart disease and low Framingham risk score

INTRODUCTION

The purpose of this study was to assess the prevalence of emerging cardiac risk factors in individuals with a family history of premature coronary heart disease (CHD) and who were predicted to be low-risk for cardiovascular (CV) disease based on their Framingham risk score.

METHODS

We prospectively evaluated 89 younger men and women with a family history of premature CHD and who had a low Framingham risk score. Patients with CHD or CHD equivalents were excluded. All patients were screened for emerging clinical and lipid risk factors.

RESULTS

Coronary calcium was present in 38% of patients and C-reactive protein > 3 mg/dl was present in 24% of patients. Low levels of high-density lipoprotein (HDL2) cholesterol were the most prevalent emerging lipid risk factor and was present in 72% of the study group. More individuals had low levels of HDL2 than total HDL (34% versus 71%; p-value =0.001). Triglyceride- (TG)-rich remnant lipoproteins were present in 49% of patients.

CONCLUSIONS

The Framingham risk score poorly predicts CV risk in younger healthy persons with a family history of premature CHD. The prevalence of subclinical CHD and emerging clinical and lipid risk factors is high in these patients. The most prevalent lipid risk factor was low levels of HDL2. Individuals with a family history of premature CHD may benefit from screening for emerging risk factors to better assess their CV risk.

Coronary calcium predicts events better with absolute calcium scores than age-sex-race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis)

OBJECTIVES

In this study, we aimed to establish whether age-sex-specific percentiles of coronary artery calcium (CAC) predict cardiovascular outcomes better than the actual (absolute) CAC score.

BACKGROUND

The presence and extent of CAC correlates with the overall magnitude of coronary atherosclerotic plaque burden and with the development of subsequent coronary events.

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) is a prospective cohort study of 6,814 asymptomatic participants followed for coronary heart disease (CHD) events including myocardial infarction, angina, resuscitated cardiac arrest, or CHD death. Time to incident CHD was modeled with Cox regression, and we compared models with percentiles based on age, sex, and/or race/ethnicity to categories commonly used (0, 1 to 100, 101 to 400, 400+ Agatston units).

RESULTS

There were 163 (2.4%) incident CHD events (median follow-up 3.75 years). Expressing CAC in terms of age- and sex-specific percentiles had significantly lower area under the receiver-operating characteristic curve (AUC) than when using absolute scores (women: AUC 0.73 versus 0.76, p = 0.044; men: AUC 0.73 versus 0.77, p < 0.001). Akaike's information criterion indicated better model fit with the overall score. Both methods robustly predicted events (>90th percentile associated with a hazard ratio [HR] of 16.4, 95% confidence interval [CI]: 9.30 to 28.9, and score >400 associated with HR of 20.6, 95% CI: 11.8 to 36.0). Within groups based on age-, sex-, and race/ethnicity-specific percentiles there remains a clear trend of increasing risk across levels of the absolute CAC groups. In contrast, once absolute CAC category is fixed, there is no increasing trend across levels of age-, sex-, and race/ethnicity-specific categories. Patients with low absolute scores are low-risk, regardless of age-, sex-, and race/ethnicity-specific percentile rank. Persons with an absolute CAC score of >400 are high risk, regardless of percentile rank.

CONCLUSIONS

Using absolute CAC in standard groups performed better than age-, sex-, and race/ethnicity-specific percentiles in terms of model fit and discrimination. We recommend using cut points based on the absolute CAC amount, and the common CAC cut points of 100 and 400 seem to perform well.

Progression of coronary artery calcification in renal transplantation and the role of secondary hyperparathyroidism and inflammation

BACKGROUND AND OBJECTIVES

Transplantation should favorably affect coronary calcification (CAC) progression in dialysis; however, changes in CAC score in the individual patient are not reliably evaluated.

DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS

The authors used special tables of reproducibility limits for each score level to study, by multislice computed tomography and biochemistries, the 2-year changes in CAC in 41 transplant patients (age 48 +/- 13 yr, 25 men, dialysis vintage 4.8 +/- 4.3 yr, underwent transplant 6.2 +/- 5.5 yr prior). Thirty balanced dialysis patients served as controls.

RESULTS

In the study group, Agatston score was stable, and C-reactive protein decreased, whereas fetuin and osteoprotegerin increased. In the control group, Agatston score increased, parathyroid hormone and phosphate decreased, and inflammation markers were persistently twice as high as in the study group. With regard to individual changes, 12.2% transplant patients worsened, compared with 56.6% of patients in dialysis (P < 0.0001). Patients without calcification at entry showed slower progression in transplantation (8.3%) than in dialysis (44.4%; P < 0.034), and the difference was similar to that observed in cases with CAC (17.6% versus 61.9%; P < 0.007). Discriminant analysis indicated parathyroid hormone, the modality of therapy (dialysis or transplantation), and erythrocyte sedimentation rate as the variables most associated with worsening.

CONCLUSIONS

Renal transplantation lowers but does not halt CAC progression. Inflammation and hyperparathyroidism are associated with progression in the populations studied.

Traditional clinical risk assessment tools do not accurately predict coronary atherosclerotic plaque burden: a CT angiography study

OBJECTIVE

The objective of our study was to determine the degree to which Framingham risk estimates and the National Cholesterol Education Program (NCEP) Adult Treatment Panel III core risk categories correlate with total coronary atherosclerotic plaque burden (calcified and noncalcified) as estimated on coronary CT angiograms.

MATERIALS AND METHODS

Coronary CT angiography was performed in 1,653 patients (1,089 men, 564 women) without a history of coronary heart disease (mean age+/-SD: men, 51.6+/-9.7 years; women, 56.9+/-10.5 years). The most common reasons for the examination were hypercholesterolemia, family history, hypertension, smoking, and atypical chest pain. The coronary tree was divided into 16 segments; four different methods were used to quantify the amount of atherosclerotic plaque or the degree of stenosis in each segment, and segment scores were combined to give total scores. Framingham risk estimates and NCEP risk categories were calculated for each patient.

RESULTS

Correlation of plaque scores with the Framingham 10-year risk estimates were modest: Spearman's rho was 0.49-0.55. For all comparisons of NCEP risk categories to plaque score categories, the proportion of raw agreement, p(0), was less than 0.50. Cohen's kappa ranged from 0.18 to 0.20. Overall, 21% of the patients would have their perceived need for statins changed by using the coronary CTA plaque estimates in place of the NCEP core risk categories; 26% of the patients on statins had no detectable plaque.

CONCLUSION

Coronary risk stratification using a risk factor only-based scheme is a weak discriminator of the overall atherosclerotic plaque burden in individual patients. Patients with little or no plaque might be subjected to lifelong drug therapy, whereas many others with substantial plaque might be undertreated or not treated at all.

Association of impaired fasting glucose and coronary artery calcification as a marker of subclinical atherosclerosis in a population-based cohort--results of the Heinz Nixdorf Recall Study

AIMS/HYPOTHESIS

Atherosclerosis and cardiovascular diseases are often present at the time of diagnosis of type 2 diabetes mellitus. Whether subclinical atherosclerosis can be detected in the pre-diabetic (borderline fasting hyperglycemia) state is not clear. This study investigated the association of impaired fasting glucose (IFG) and coronary artery calcification (CAC), a marker of subclinical atherosclerosis, among participants without a history of coronary heart disease or manifest diabetes mellitus.

METHODS

Study participants (aged 45-75 years) of the population-based Heinz Nixdorf Recall Study were categorised into those with normal fasting glucose (glucose <6.1 mmol/l) and those with IFG (glucose >or=6.1 to <7.0 mmol/l), excluding participants with a history of CHD or diabetes mellitus. CAC was assessed by electron-beam computed tomography, and risk factors were assessed by extended interviews, anthropometric measurements and laboratory tests. Various CAC cut-off points were used in multiple logistic and ordinal logistic regression models to estimate ORs and 95% CIs.

RESULTS

Of the 2,184 participants, more men had IFG than did women (37% vs 22%). Participants with IFG showed a higher prevalence of CAC > 0 (men OR 1.90, 95% CI 1.33-2.70; women 1.63, 1.23-2.15). Risk factor adjustment weakened this association in both sexes (men 1.63, 1.12-1.36; women 1.26, 0.93-1.70). When the age- and sex-specific 75th percentile was used as the cut-off point for CAC, the association further decreased in men (1.10, 0.81-1.50), but became stronger in women (1.41, 1.02-1.94).

CONCLUSIONS/INTERPRETATION

These data support the hypothesis that CAC is already present in the pre-diabetic state and that IFG has a modest and independent impact on the atherosclerotic process. Biological sex appears to modify the association between IFG and CAC.

Update on integrated biomarkers for assessment of long-term risk of cardiovascular complications in initially healthy subjects and patients with manifest atherosclerosis

Risk stratification for cardiovascular diseases (CVD) remains suboptimal even after the introduction of global risk assessment by various scores. This has prompted the search for additional biomarkers which might help to improve risk stratification. Basically, there are blood biomarkers representing various pathophysiological pathways of atherosclerosis, and markers of subclinical disease. Since inflammatory processes accompany all stages of atherosclerosis, measurement of plasma/serum concentrations of circulating inflammatory biomarkers have received great attention. Such biomarkers can be measured systemically by sensitive assays, and elevated concentrations in the circulation have been shown to be associated with future CVD events. Thus, they might add to the predictive value of the atherogenic lipoprotein phenotype to further improve CVD risk assessment. In addition, several non-invasive imaging techniques are available for which also a predictive value for CVD could be established. However, for most of these biomarkers the clinical utility has not yet been firmly established. This review attempts to give an update on the potential use of biomarkers for risk stratification in initially healthy subjects and patients with manifest, chronic atherosclerosis, particularly focusing on the integrated value of the combination of these markers.

Coronary artery aneurysm with thrombus evaluated by multi-detector row computed tomography

This is a case report of a 60-year-old woman with acute myocardial infarction (AMI) who had coronary aneurysms and thrombus in the right coronary artery detected by multi-detector row computed tomography (MDCT). In this case, MDCT was useful for clarifying the thrombus complicated with coronary aneurysms, which was considered to be the cause of AMI. Thus, warfarin was started as an anticoagulant therapy for thrombus.

Comparison of Methods for Magnetic Resonance-Guided [18-F]Fluorodeoxyglucose Positron Emission Tomography in Human Carotid Arteries

Background and Purpose— Inflammation is a major risk factor for atherosclerotic plaque rupture and clinical events. Previous studies have shown that plaque [ 18 F]fluorodeoxyglucose (FDG) uptake correlates with macrophage content. In this study we examined the reproducibility of 3 methods of quantifying plaque FDG uptake in the carotid arteries using positron emission tomography (PET). The correlation between 2 simplified uptake parameters (standardized uptake value [SUV], vessel wall-to-blood ratio [VBR]) and a gold standard technique (influx rate [K i ]) was also determined. We used MRI to correct carotid plaque FDG uptake for partial volume error.

Methods— Seven patients with a recent carotid territory transient ischemic attack underwent imaging twice within 8 days using MR and FDG-PET. MR coregistered to PET was used to delineate regions of interest, and to facilitate partial volume correction (PVC).

Results— SUV was the most reproducible parameter irrespective of whether it was normalized by body surface area (BSA), lean body mass, or weight (intraclass correlation coefficient=0.85, 0.88, and 0.90, respectively). VBR correlated better to K i than SUV ( r =0.58 VBR, r =0.46 SUV BSA ). PVC improved these correlations to r =0.81 VBR and r =0.76 SUV BSA , and only slightly degraded the reproducibility of SUV (intraclass correlation coefficient=0.83–0.85).

Conclusions— MR-guided FDG-PET is a highly reproducible technique in the carotid artery and the excellent anatomic detail provided by MR facilitates PVC. Of the methods examined, SUV BSA PVC appears to represent the best compromise between reproducible and accurate determination of FDG metabolism in carotid artery vessel wall.

Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial

OBJECTIVES

The purpose of this study was to evaluate the diagnostic accuracy of electrocardiographically gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals without known coronary artery disease (CAD).

BACKGROUND

CCTA is a promising method for detection and exclusion of obstructive coronary artery stenosis. To date, no prospective multicenter trial has evaluated the diagnostic accuracy of 64-multidetector row CCTA in populations with intermediate prevalence of CAD.

METHODS

We prospectively evaluated subjects with chest pain at 16 sites who were clinically referred for invasive coronary angiography (ICA). CCTAs were scored by consensus of 3 independent blinded readers. The ICAs were evaluated for coronary stenosis based on quantitative coronary angiography (QCA). No subjects were excluded for baseline coronary artery calcium score or body mass index.

RESULTS

A total of 230 subjects underwent both CCTA and ICA (59.1% male; mean age: 57 +/- 10 years). On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect > or =50% or > or =70% stenosis were 95%, 83%, 64%, and 99%, respectively, and 94%, 83%, 48%, 99%, respectively. No differences in sensitivity and specificity were noted for nonobese compared with obese subjects or for heart rates < or =65 beats/min compared with >65 beats/min, whereas calcium scores >400 reduced specificity significantly.

CONCLUSIONS

In this prospective multicenter trial of chest pain patients without known CAD, 64-multidetector row CCTA possesses high diagnostic accuracy for detection of obstructive coronary stenosis at both thresholds of 50% and 70% stenosis. Importantly, the 99% negative predictive value at the patient and vessel level establishes CCTA as an effective noninvasive alternative to ICA to rule out obstructive coronary artery stenosis. (A Study of Computed Tomography [CT] for Evaluation of Coronary Artery Blockages in Typical or Atypical Chest Pain; NCT00348569).

The unresolved issues with risk stratification and management of patients with coronary artery disease undergoing major vascular surgery

PURPOSE

The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature.Source documents: We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery.

PRINCIPAL FINDINGS

Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or beta-blocker therapy) have yielded conflicting results. The use of high doses of preoperative beta-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding.

CONCLUSION

Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or beta-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.

Diagnostic performance of coronary angiography by 64-row CT

BACKGROUND

The accuracy of multidetector computed tomographic (CT) angiography involving 64 detectors has not been well established.

METHODS

We conducted a multicenter study to examine the accuracy of 64-row, 0.5-mm multidetector CT angiography as compared with conventional coronary angiography in patients with suspected coronary artery disease. Nine centers enrolled patients who underwent calcium scoring and multidetector CT angiography before conventional coronary angiography. In 291 patients with calcium scores of 600 or less, segments 1.5 mm or more in diameter were analyzed by means of CT and conventional angiography at independent core laboratories. Stenoses of 50% or more were considered obstructive. The area under the receiver-operating-characteristic curve (AUC) was used to evaluate diagnostic accuracy relative to that of conventional angiography and subsequent revascularization status, whereas disease severity was assessed with the use of the modified Duke Coronary Artery Disease Index.

RESULTS

A total of 56% of patients had obstructive coronary artery disease. The patient-based diagnostic accuracy of quantitative CT angiography for detecting or ruling out stenoses of 50% or more according to conventional angiography revealed an AUC of 0.93 (95% confidence interval [CI], 0.90 to 0.96), with a sensitivity of 85% (95% CI, 79 to 90), a specificity of 90% (95% CI, 83 to 94), a positive predictive value of 91% (95% CI, 86 to 95), and a negative predictive value of 83% (95% CI, 75 to 89). CT angiography was similar to conventional angiography in its ability to identify patients who subsequently underwent revascularization: the AUC was 0.84 (95% CI, 0.79 to 0.88) for multidetector CT angiography and 0.82 (95% CI, 0.77 to 0.86) for conventional angiography. A per-vessel analysis of 866 vessels yielded an AUC of 0.91 (95% CI, 0.88 to 0.93). Disease severity ascertained by CT and conventional angiography was well correlated (r=0.81; 95% CI, 0.76 to 0.84). Two patients had important reactions to contrast medium after CT angiography.

CONCLUSIONS

Multidetector CT angiography accurately identifies the presence and severity of obstructive coronary artery disease and subsequent revascularization in symptomatic patients. The negative and positive predictive values indicate that multidetector CT angiography cannot replace conventional coronary angiography at present. (ClinicalTrials.gov number, NCT00738218.)

Coronary CT angiography using 64 detector rows: methods and design of the multi-centre trial CORE-64

Multislice computed tomography (MSCT) for the noninvasive detection of coronary artery stenoses is a promising candidate for widespread clinical application because of its non-invasive nature and high sensitivity and negative predictive value as found in several previous studies using 16 to 64 simultaneous detector rows. A multi-centre study of CT coronary angiography using 16 simultaneous detector rows has shown that 16-slice CT is limited by a high number of nondiagnostic cases and a high false-positive rate. A recent meta-analysis indicated a significant interaction between the size of the study sample and the diagnostic odds ratios suggestive of small study bias, highlighting the importance of evaluating MSCT using 64 simultaneous detector rows in a multi-centre approach with a larger sample size. In this manuscript we detail the objectives and methods of the prospective "CORE-64" trial ("Coronary Evaluation Using Multidetector Spiral Computed Tomography Angiography using 64 Detectors"). This multi-centre trial was unique in that it assessed the diagnostic performance of 64-slice CT coronary angiography in nine centres worldwide in comparison to conventional coronary angiography. In conclusion, the multi-centre, multi-institutional and multi-continental trial CORE-64 has great potential to ultimately assess the per-patient diagnostic performance of coronary CT angiography using 64 simultaneous detector rows.

Serum phosphorus levels associate with coronary atherosclerosis in young adults

Phosphorus levels correlate with atherosclerosis in both animal models and humans with advanced chronic kidney disease, but whether this relationship exists among individuals with normal kidney function is unknown. This study aimed to determine whether an association exists between phosphorus levels and coronary artery calcium levels in a community-based cohort of 3015 healthy young adults in the prospective Coronary Artery Risk Development in Young Adults (CARDIA) study. Phosphorus levels were measured at baseline, and presence of coronary artery calcium was assessed by computed tomography 15 yr later. Mean age at study inception was 25.2 yr, and the mean levels of phosphorus and calcium were 3.6 and 9.5 mg/dl, respectively. Only 0.2% of participants had estimated GFR <60 ml/min per 1.73 m(2). Phosphorus levels were associated with coronary artery calcium in unadjusted models. In multivariate models, however, phosphorus levels were significantly associated with the category of coronary artery calcium level. In conclusion, higher serum phosphorus levels, even within the normal range, may be a risk factor for coronary artery atherosclerosis in healthy young adults.

Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography

OBJECTIVES

This study investigated whether cardiac computed tomography angiography (CTA) can predict all-cause mortality in symptomatic patients.

BACKGROUND

Noninvasive coronary angiography is being increasingly performed by CTA to assess for obstructive coronary artery disease (CAD), and minimal outcome data exist for coronary CTA. We have utilized a cohort of symptomatic patients who underwent electron beam tomography to allow for longer follow-up (up to 12 years) than currently available with newer 64-slice multidetector-row computed tomography studies.

METHODS

In all, 2,538 consecutive patients who underwent CTA by electron beam tomography (age 59 +/- 14 years, 70% males) without known CAD were studied. Computed tomographic angiography results were categorized as significant CAD (> or =50% luminal narrowing), mild CAD (<50% stenosis), and normal coronary arteries. Multivariable Cox proportional hazards models were developed to predict all-cause mortality. Risk-adjusted models incorporated traditional risk factors for coronary disease and coronary artery calcification (CAC).

RESULTS

During a mean follow-up of 78 +/- 12 months, the death rate was 3.4% (86 deaths). The CTA-diagnosed CAD was an independent predictor of mortality in a multivariable model adjusted for age, gender, cardiac risk factors, and CAC (p < 0.0001). The addition of CAC to CTA-diagnosed CAD increased the concordance index significantly (0.69 for risk factors, 0.83 for the CTA-diagnosed CAD, and 0.89 for the addition of CAC to CAD, p < 0.0001). Risk-adjusted hazard ratios for CTA-diagnosed CAD were 1.7-, 1.8-, 2.3-, and 2.6-fold for 3-vessel nonobstructive, 1-vessel obstructive, 2-vessel obstructive, and 3-vessel obstructive CAD, respectively (p < 0.0001), when compared with the group who did not have CAD.

CONCLUSIONS

The primary results of our study reveal that the burden of angiographic disease detected by CTA provides both independent and incremental value in predicting all-cause mortality in symptomatic patients independent of age, gender, conventional risk factors, and CAC.

Signs of subclinical coronary atherosclerosis in relation to risk factor distribution in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (HNR)

AIMS

Modern imaging technology allows us the visualization of coronary artery calcification (CAC), a marker of subclinical coronary atherosclerosis. The prevalence, quantity, and risk factors for CAC were compared between two studies with similar imaging protocols but different source populations: the Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (HNR).

METHODS AND RESULTS

The measured CAC in 2220 MESA participants were compared with those in 3,126 HNR participants with the inclusion criteria such as age 45-75 years, Caucasian race, and free of baseline cardiovascular disease. Despite similar mean levels of CAC of 244.6 among participants in MESA and of 240.3 in HNR (P = 0.91), the prevalence of CAC > 0 was lower in MESA (52.6%) compared with HNR (67.0%) with a prevalence rate ratio of CAC > 0 of 0.78 [95% confidence interval (CI): 0.72-0.85] after adjustment for known risk factors. Consequently, among participants with CAC > 0, the participants in MESA tended to have higher levels of CAC than those in HNR (ratio of CAC levels: 1.39; 95% CI: 1.19-1.63), since many HNR participants have small (near zero) CAC values.

CONCLUSIONS

The CAC prevalence was lower in the United States (MESA) cohort than in the German (HNR) cohort, which may be explained by more favourable risk factor levels among the MESA participants. The predictors for increased levels of CAC were, however, similar in both cohorts with the exception that male gender, blood pressure, and body mass index were more strongly associated in the HNR cohort.

Noninvasive assessment of coronary anatomy and myocardial perfusion: going toward an integrated imaging approach

Many noninvasive imaging techniques are available for the evaluation of patients with known or suspected chronic coronary artery disease. Among these, computed tomography-based techniques allow the quantification of coronary atherosclerotic calcium and noninvasive imaging of coronary arteries, whereas nuclear cardiology is the most widely used noninvasive approach for the assessment of myocardial perfusion. The available single-photon emission computed tomography flow agents are characterized by a cardiac uptake proportional to myocardial blood flow. In addition, different positron emission tomography tracers may be used for the quantitative measurement of myocardial blood flow and coronary flow reserve. Extensive research is currently being performed in the development of noninvasive coronary angiography and myocardial perfusion imaging using cardiac magnetic resonance. Finally, new multimodality imaging systems have been recently developed, bringing together anatomical and functional information. This review sought to provide a description of the relative merits of noninvasive imaging techniques in the assessment of coronary anatomy and myocardial perfusion in patients with known or suspected coronary artery disease.

Relationship between coronary artery and descending thoracic aortic calcification as detected by computed tomography: the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Cardiac computed tomography (CT) is a well-established tool for the detection of cardiovascular calcium. Coronary artery calcification (CAC) is highly sensitive for the detection of coronary artery disease (CAD) as well as predictive of future cardiovascular (CV) events. Descending thoracic aortic calcification (DTAC) is common in the elderly and its presence is also associated with increased risk of CV events. Previous studies demonstrate that DTAC is associated with obstructive CAD and coronary risk factors. However, no prior studies have examined the association of CAC and DTAC as detected by cardiac CT in a large population-based cohort.

METHODS

In the Multi-Ethnic Study of Atherosclerosis, the study population included a population-based sample of four ethnic groups (Chinese, White, Hispanic and African-American) of 6814 women and men ages 45-84 years old. Participants underwent non-enhanced cardiac CT and both CAC and DTAC were quantified. DTAC was measured from the lower edge of the pulmonary artery bifurcation to the cardiac apex. Multivariable relative risk regression was used to evaluate relationships between CAC, DTAC and measured cardiovascular risk factors.

RESULTS

Overall 3030 (44%) did not demonstrate any detectable CAC or DTAC. A total of 1930 (28%) had only CAC, 386 (6%) had isolated DTAC, and 1464 (22%) participants were found to have both CAC and DTAC. CAC had a higher prevalence than DTAC in men (58% vs. 45%). Participants with DTAC were older than those with CAC (mean age was 71 and 66 years old, respectively). Participants with DTAC had increased risk for the presence of CAC independent of cardiovascular risk factors (prevalence ratio [PR]: 1.17, 95% CI: 1.07-1.28). Severity of DTAC was a stronger predictor of the presence of CAC in women as compared to men (PR: 1.04, 95% CI: 1.02-1.06, and PR: 0.99, 95% CI: 0.98-1.01, respectively).

CONCLUSIONS

DTAC was found to be a strong predictor of CAC independent of CV risk factors. Ongoing follow-up of this cohort will evaluate whether DTAC is an independent marker of risk for CV events.

Physiopathology of the aging heart

Coronary heart disease remains the leading cause of morbidity and mortality in older adults, despite improved survival and declining mortality. Prevalence in and impact of heart disease on elderly people, increasing risk factors, and the underlying physiologic changes of aging are briefly reviewed. High prevalence of clinical and subclinical heart disease provides a basis for considering opportunities for prevention and follow-up. This article focuses on recently developed noninvasive techniques, such as cardiac multislice CT and cardiac MR imaging.

Can we finally get a coronary angiography with the least amount of dye?

The incidence of adverse events complicating coronary angiography is still considerably high. Founded concerns about risks of coronary angiography, and mainly its inherent invasiveness, have favored the increasing request for noninvasive techniques to evaluate the coronary anatomy, such as multislice computed tomography (MSCT). Nonetheless, it has to be kept in mind that several risks and complications are the same both for MSCT and conventional coronary angiography. Rotational angiography has been shown to be a powerful imaging tool for the evaluation of coronary anatomy resulting in the use of less contrast media and less radiation, without losing the possibility to obtain a precise, efficient and fast characterization of obstructive coronary artery disease. It is likely that in the next future the overall performance, taking into account both the diagnostic accuracy and the risk of exposure to radiation and contrast media, of MSCT techniques will have to be compared to that of rotational angiography, especially when the latter is coupled with minimally invasive approaches.

Comparison of fluoroscopic coronary angiography and multi-slice coronary angiography in the characterization of anomalous coronary artery

Anomalous coronary arteries with an inter-arterial course are associated with sudden cardiac death. We reported a study comparing the accuracy of fluoroscopic coronary angiography (FCA) with that of multi-slice computed tomography (MSCT) coronary angiography in determining the proximal course of anomalous coronary arteries. Twelve patients with thirteen anomalous coronary arteries had both FCA and MSCT coronary angiography were included in this study. Twelve cardiologists individually reviewed FCAs of anomalous coronary arteries and determined the proximal course of anomalous coronary arteries as retro-aortic, inter-arterial or ante-pulmonary. Their diagnoses were compared with MSCT coronary angiography which was regarded as the reference standard in this study. On MSCT coronary angiography, there were six anomalous left circumflex arteries with a retro-aortic course, five anomalous right coronary arteries and one anomalous left anterior descending artery with inter-arterial courses, and a single anomalous left main artery with an ante-pulmonary course. The percentage of correct diagnosis made by 12 cardiologists based on FCA findings was 93/156 or 60%. None of the cardiologists was correct in determining the proximal course of all anomalous coronary arteries. The median number of anomalous coronary arteries with their proximal courses correctly identified by the cardiologists was 7.5 (range 3-12). In conclusion, FCA was limited in delineating the proximal course of anomalous coronary arteries in comparison with MSCT coronary angiography.