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Wang NC, Matthews KA, Barinas-Mitchell EJ, Chang CCH, El Khoudary SR. Inflammatory/hemostatic biomarkers and coronary artery calcification in midlife women of African-American and White race/ethnicity: the Study of Women's Health Across the Nation (SWAN) heart study. Menopause 2016; 23:653-61. [PMID: 27023861 PMCID: PMC5370572 DOI: 10.1097/gme.0000000000000605] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Inflammatory/hemostatic biomarkers are associated with coronary heart disease events, but relationships in asymptomatic midlife women are uncertain. We evaluated separately whether high-sensitivity C-reactive protein (hsCRP), fibrinogen, plasminogen-activator inhibitor 1, tissue plasminogen activator antigen, and circulating factor VII (factor VIIc) were associated with coronary artery calcification (CAC) in healthy midlife women. METHODS A cross-sectional study was performed of participants from the Study of Women's Health Across the Nation. Logistic and Tobit regression was used to assess associations between log-transformed biomarkers, and CAC presence (CAC > 0) and extent. Effect modification by race/ethnicity was evaluated. RESULTS The study included 372 women (mean age 51.3 y; 35.2% African-American). All biomarkers were positively associated with CAC presence and extent (P < 0.001 for all), adjusting for Framingham risk score, site, race/ethnicity, menopause status, income, and education. Additional adjustment for body mass index explained all associations except for factor VIIc, which remained associated with CAC extent only (P = 0.02). Final adjustment for insulin resistance, family history of cardiovascular disease, and cardiovascular medication use produced similar results. Associations between hsCRP, and CAC presence and extent were modified by race/ethnicity (P < 0.05). Log(hsCRP) was positively associated with CAC presence (odds ratio 3.25; 95% CI, 1.53-6.90; P = 0.002; per 1 log unit increase) and CAC extent (β = 19.66; SE = 7.67; P = 0.01; per 1 log unit increase) in African-Americans only. CONCLUSIONS Inflammatory/hemostatic biomarkers were associated with CAC through obesity, except for factor VIIc. Among African-American women only, hsCRP was independently associated with CAC, suggesting that hsCRP may have a role in coronary heart disease prevention in African-American midlife women.
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Affiliation(s)
- Norman C. Wang
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Karen A. Matthews
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Medicine, Department of Psychiatry
| | | | - Chung-Chou H. Chang
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Samar R. El Khoudary
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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152
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Braber TL, Mosterd A, Prakken NH, Rienks R, Nathoe HM, Mali WP, Doevendans PA, Backx FJ, Bots ML, Grobbee DE, Velthuis BK. Occult coronary artery disease in middle-aged sportsmen with a low cardiovascular risk score: The Measuring Athlete's Risk of Cardiovascular Events (MARC) study. Eur J Prev Cardiol 2016; 23:1677-84. [PMID: 27222386 DOI: 10.1177/2047487316651825] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 05/06/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Most exercise-related cardiac arrests in men aged ≥45 years are due to coronary artery disease (CAD). The current sports medical evaluation (SME) of middle-aged sportsmen includes medical history, physical examination and resting and exercise electrocardiography (ECG). We investigated the added value of low-dose cardiac computed tomography (CCT) - both non-contrast CT for coronary artery calcium scoring (CACS) and contrast-enhanced coronary CT angiography (CCTA) - in order to detect occult CAD in asymptomatic recreational sportsmen aged ≥45 years without known cardiovascular disease. METHODS Following a normal SME (with resting and bicycle exercise ECG), 318 asymptomatic sportsmen underwent CCT and 300 (94%) had a low European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE) risk. Occult CAD was defined as a CACS ≥100 Agatston units (AU) or obstructive (≥50%) luminal stenosis on CCTA. The number needed to screen (NNS) in order to prevent one cardiovascular event within 5 years with statin treatment was estimated. RESULTS Fifty-two (16.4%, 95% confidence interval (CI): 12.7-20.8%) of 318 participants had a CACS ≥100 AU. The CCTA identified an additional eight participants with luminal narrowing ≥50% (and a CACS <100 AU). Taken together, CCT identified CAD in 60 (18.9%, 95% CI: 14.9-23.5%) of 318 participants. The 5-year estimated NNS was 183 (95% CI: 144-236) for CACS and 159 (95% CI: 128-201) for CACS combined with CCTA. CONCLUSIONS Coronary CT detects occult CAD in almost one in five asymptomatic sportsmen aged ≥45 years after a normal SME that included resting and bicycle exercise ECG. CACS reveals most of the relevant CAD with limited additional value of contrast-enhanced CCTA. The NNS in order to prevent one cardiovascular event compares favourably to that of other screening tests.
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Affiliation(s)
- Thijs L Braber
- Department of Radiology, University Medical Center Utrecht, The Netherlands Department of Cardiology, University Medical Center Utrecht, The Netherlands Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Niek H Prakken
- Department of Radiology, University Medical Center Groningen, The Netherlands
| | - Rienk Rienks
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Willem P Mali
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Frank J Backx
- Department of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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153
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Xie JX, Shaw LJ. Arterial Calcification in Cardiovascular Risk Prediction: Should We Shift the Target for Screening Beyond the Coronaries? Circ Cardiovasc Imaging 2016; 8:CIRCIMAGING.115.004171. [PMID: 26659367 DOI: 10.1161/circimaging.115.004171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Joe X Xie
- From the Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Leslee J Shaw
- From the Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA.
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154
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Thanassoulis G, Williams K, Altobelli KK, Pencina MJ, Cannon CP, Sniderman AD. Individualized Statin Benefit for Determining Statin Eligibility in the Primary Prevention of Cardiovascular Disease. Circulation 2016; 133:1574-81. [PMID: 26945047 DOI: 10.1161/circulationaha.115.018383] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines recommend statins in the primary prevention of cardiovascular disease on the basis of predicted cardiovascular risk without directly considering the expected benefits of statin therapy based on the available randomized, controlled trial evidence. METHODS AND RESULTS We included 2134 participants representing 71.8 million American residents potentially eligible for statins in primary prevention from the National Health and Nutrition Examination Survey for the years 2005 to 2010. We compared statin eligibilities using 2 separate approaches: a 10-year risk-based approach (≥7.5% 10-year risk) and an individualized benefit approach (ie, based on predicted absolute risk reduction over 10 years [ARR10] ≥2.3% from randomized, controlled trial data). A risk-based approach led to the eligibility of 15.0 million (95% confidence interval, 12.7-17.3 million) Americans, whereas a benefit-based approach identified 24.6 million (95% confidence interval, 21.0-28.1 million). The corresponding numbers needed to treat over 10 years were 21 (range, 9-44) and 25 (range, 9-44). The benefit-based approach identified 9.5 million lower-risk (<7.5% 10-year risk) Americans not currently eligible for statin treatment who had the same or greater expected benefit from statins (≥2.3% ARR10) compared with higher-risk individuals. This lower-risk/acceptable-benefit group includes younger individuals (mean age, 55.2 versus 62.5 years; P<0.001 for benefit based versus risk based) with higher low-density lipoprotein cholesterol (140 versus133 mg/dL; P=0.01). Statin treatment in this group would be expected to prevent an additional 266 508 cardiovascular events over 10 years. CONCLUSIONS An individualized statin benefit approach can identify lower-risk individuals who have equal or greater expected benefit from statins in primary prevention compared with higher-risk individuals. This approach may help develop guideline recommendations that better identify individuals who meaningfully benefit from statin therapy.
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Affiliation(s)
- George Thanassoulis
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.).
| | - Ken Williams
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Kathleen Kimler Altobelli
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Michael J Pencina
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Christopher P Cannon
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Allan D Sniderman
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
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155
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Shah NP, Cainzos-Achirica M, Feldman DI, Blumenthal RS, Nasir K, Miner MM, Billups KL, Blaha MJ. Cardiovascular Disease Prevention in Men with Vascular Erectile Dysfunction: The View of the Preventive Cardiologist. Am J Med 2016; 129:251-9. [PMID: 26477950 DOI: 10.1016/j.amjmed.2015.08.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 12/25/2022]
Abstract
Vascular erectile dysfunction is a powerful marker of increased cardiovascular risk. However, current guidelines lack specific recommendations on the role that the evaluation of vascular erectile dysfunction should play in cardiovascular risk assessment, as well on the risk stratification strategy that men with vascular erectile dysfunction should undergo. In the last 3 years, erectile dysfunction experts have made a call for more specific guidance and have proposed the selective use of several prognostic tests for further cardiovascular risk assessment in these patients. Among them, stress testing has been prioritized, whereas other tests are considered second-line tools. In this review, we provide additional perspective from the viewpoint of the preventive cardiologist. We discuss the limitations of current risk scores and the potential interplay between erectile dysfunction assessment and the use of personalized prognostic tools, such as the coronary artery calcium score, in the cardiovascular risk stratification and management of men with vascular erectile dysfunction. Finally, we present an algorithm for primary care physicians, urologists, and cardiologists to aid clinical decision-making.
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Affiliation(s)
- Nishant P Shah
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Miguel Cainzos-Achirica
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md; Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Md
| | - David I Feldman
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Khurram Nasir
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md; Baptist Health South Florida, Miami, Fla
| | - Martin M Miner
- Department of Family Medicine and Urology, Miriam Hospital and Brown University, Providence, RI
| | - Kevin L Billups
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Md
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md.
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156
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Hoffmann U, Massaro JM, D'Agostino RB, Kathiresan S, Fox CS, O'Donnell CJ. Cardiovascular Event Prediction and Risk Reclassification by Coronary, Aortic, and Valvular Calcification in the Framingham Heart Study. J Am Heart Assoc 2016; 5:e003144. [PMID: 26903006 PMCID: PMC4802453 DOI: 10.1161/jaha.115.003144] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND We determined whether vascular and valvular calcification predicted incident major coronary heart disease, cardiovascular disease (CVD), and all-cause mortality independent of Framingham risk factors in the community-based Framingham Heart Study. METHODS AND RESULTS Coronary artery calcium (CAC), thoracic and abdominal aortic calcium, and mitral or aortic valve calcium were measured by cardiac computed tomography in participants free of CVD. Participants were followed for a median of 8 years. Multivariate Cox proportional hazards models were used to determine association of CAC, thoracic and abdominal aortic calcium, and mitral and aortic valve calcium with end points. Improvement in discrimination beyond risk factors was tested via the C-statistic and net reclassification index. In this cohort of 3486 participants (mean age 50±10 years; 51% female), CAC was most strongly associated with major coronary heart disease, followed by major CVD, and all-cause mortality independent of Framingham risk factors. Among noncoronary calcifications, mitral valve calcium was associated with major CVD and all-cause mortality independent of Framingham risk factors and CAC. CAC significantly improved discriminatory value beyond risk factors for coronary heart disease (area under the curve 0.78-0.82; net reclassification index 32%, 95% CI 11-53) but not for CVD. CAC accurately reclassified 85% of the 261 patients who were at intermediate (5-10%) 10-year risk for coronary heart disease based on Framingham risk factors to either low risk (n=172; no events observed) or high risk (n=53; observed event rate 8%). CONCLUSIONS CAC improves discrimination and risk reclassification for major coronary heart disease and CVD beyond risk factors in asymptomatic community-dwelling persons and accurately reclassifies two-thirds of the intermediate-risk population.
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Affiliation(s)
- Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Joseph M Massaro
- Department of Mathematics, Boston University, Boston, MA The Framingham Heart Study of the National Heart, Lung and Blood Institute (NHLBI) and Boston University, Framingham, MA
| | - Ralph B D'Agostino
- Department of Mathematics, Boston University, Boston, MA The Framingham Heart Study of the National Heart, Lung and Blood Institute (NHLBI) and Boston University, Framingham, MA
| | - Sekar Kathiresan
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Caroline S Fox
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA The Framingham Heart Study of the National Heart, Lung and Blood Institute (NHLBI) and Boston University, Framingham, MA Division of Intramural Research, NHLBI, Bethesda, MD
| | - Christopher J O'Donnell
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA The Framingham Heart Study of the National Heart, Lung and Blood Institute (NHLBI) and Boston University, Framingham, MA Division of Intramural Research, NHLBI, Bethesda, MD
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157
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Ridker PM. A Test in Context. J Am Coll Cardiol 2016; 67:712-723. [DOI: 10.1016/j.jacc.2015.11.037] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/03/2015] [Accepted: 11/11/2015] [Indexed: 12/16/2022]
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158
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Hecht HS. Coronary artery calcium scanning: past, present, and future. JACC Cardiovasc Imaging 2016; 8:579-596. [PMID: 25937196 DOI: 10.1016/j.jcmg.2015.02.006] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/01/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023]
Abstract
Coronary artery calcium scanning (CAC) has emerged as the most robust predictor of coronary events in the asymptomatic primary prevention population, particularly in the intermediate-risk cohort. Every study has demonstrated its superiority to risk factor-based paradigms, e.g., the Framingham Risk Score, with outcome-based net reclassification indexes ranging from 52.0% to 65.6% in the intermediate-risk, 34.0% to 35.8% in the high-risk, and 11.6% to 15.0% in the low-risk cohorts. CAC improves medication and lifestyle adherence and is cost-effective in specified populations, with the ability to effectively stratify the number needed to treat and scan for different therapeutic strategies and patient cohorts. Data have emerged clearly demonstrating the worse prognosis associated with increasing CAC on serial scans, suggesting a potential role for evaluating residual risk and treatment success or failure. CAC is also strongly associated with the development of stroke and congestive heart failure.
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Affiliation(s)
- Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, New York, New York.
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159
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Nasir K, Bittencourt MS, Blaha MJ, Blankstein R, Agatson AS, Rivera JJ, Miedema MD, Sibley CT, Shaw LJ, Blumenthal RS, Budoff MJ, Krumholz HM. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2016; 66:1657-68. [PMID: 26449135 DOI: 10.1016/j.jacc.2015.07.066] [Citation(s) in RCA: 342] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy. OBJECTIVES This study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not. METHODS MESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis. RESULTS The study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years. CONCLUSIONS Significant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy.
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Affiliation(s)
- Khurram Nasir
- Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Department of Epidemiology, Robert Stempel College of Public Health and Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida.
| | - Marcio S Bittencourt
- Center for Clinical and Epidemiological Research and Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil; Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Preventive Medicine Centre, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Arthur S Agatson
- Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida
| | | | | | - Christopher T Sibley
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland Oregon
| | - Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, Georgia
| | - Roger S Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Matthew J Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
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160
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Zhang J, Lv Z, Zhao D, Liu L, Wan Y, Fan T, Li H, Guan Y, Liu B, Yang Q. Coronary Plaque Characteristics Assessed by 256-Slice Coronary CT Angiography and Association with High-Sensitivity C-Reactive Protein in Symptomatic Patients with Type 2 Diabetes. J Diabetes Res 2016; 2016:4365156. [PMID: 27579325 PMCID: PMC4992762 DOI: 10.1155/2016/4365156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/24/2016] [Indexed: 01/04/2023] Open
Abstract
Little is known regarding plaque distribution, composition, and the association with inflammation in type 2 diabetes mellitus (DM2). This study aimed to assess the relationship between coronary plaque subtypes and high-sensitivity C-reactive protein levels. Coronary CTA were performed in 98 symptomatic DM2 patients and 107 non-DM2 patients using a 256-slice CT. The extent and types of plaque as well as luminal narrowing were evaluated. Patients with DM2 were more likely to have significant stenosis (>50%) with calcified plaques in at least one coronary segment (p < 0.01); the prevalence rates of diffuse calcified plaques in the DM2 and non-DM2 groups were 31.6% and 4.7%, respectively (p < 0.01). Plasma hs-CRP levels in DM2 with calcified plaques were higher compared with values obtained for the non-DM2 group (p < 0.01). In conclusion, combination of coronary CTA and hs-CRP might improve risk stratification in symptomatic DM2 patients.
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Affiliation(s)
- Jinling Zhang
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Zhehao Lv
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Deli Zhao
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Lili Liu
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Yong Wan
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Tingting Fan
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Huimin Li
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Ying Guan
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Bailu Liu
- Department of CT, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Qi Yang
- Department of Radiology, Xuanwu Hospital, Beijing 100053, China
- Biomedical Imaging Research Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
- *Qi Yang:
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161
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Lin GM, Liu K, Colangelo LA, Lakoski SG, Tracy RP, Greenland P. Low-Density Lipoprotein Cholesterol Concentrations and Association of High-Sensitivity C-Reactive Protein Concentrations With Incident Coronary Heart Disease in the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 2016; 183:46-52. [PMID: 26597828 DOI: 10.1093/aje/kwv144] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/01/2015] [Indexed: 12/26/2022] Open
Abstract
High-sensitivity C-reactive protein (hs-CRP) has been associated with coronary heart disease (CHD) in numerous but not all observational studies, and whether low levels of low-density lipoprotein cholesterol (LDL-C) alter this association is unknown. In the Multi-Ethnic Study of Atherosclerosis (2000-2012), we prospectively assessed the association of hs-CRP concentrations with incident CHD in participants who did not receive lipid-lowering therapy, as well as in those with LDL-C concentrations less than 130 mg/dL (n = 3,106) and those with LDL-C concentrations of 130 mg/dL or greater (n = 1,716) at baseline (2000-2002). Cox proportional hazard analyses were used to assess the associations after adjustment for socioeconomic status, traditional risk factors, body mass index, diabetes, aspirin use, kidney function, and coronary artery calcium score. Loge hs-CRP was associated with incident CHD in participants with LDL-C concentrations of 130 mg/dL or higher (hazard ratio (HR) = 1.29, 95% confidence interval (CI): 1.05, 1.60) but not in those with LDL-C concentrations less than 130 mg/dL (HR = 0.88, 95% CI: 0.74, 1.05; P for interaction = 0.003). As a whole, loge hs-CRP was not associated with incident CHD in participants who had not received lipid-lowering therapy at baseline (HR = 1.05, 95% CI: 0.92, 1.20) and who had mean LDL-C concentrations less than 130 mg/dL. These findings suggest that LDL-C concentrations might be a moderator of the contribution of hs-CRP to CHD.
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3744] [Impact Index Per Article: 416.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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163
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Coronary artery calcium in hypertension: a review. ACTA ACUST UNITED AC 2015; 9:993-1000. [DOI: 10.1016/j.jash.2015.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/31/2015] [Accepted: 09/04/2015] [Indexed: 11/22/2022]
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Naue VM, Camargo G, Sabioni LR, Lima RDSL, Derenne ME, Lorenzo ARD, Freire MDC, Azevedo Filho CF, Resende ES, Gottlieb I. Changes in Medical Management after Coronary CT Angiography. Arq Bras Cardiol 2015; 105:410-7. [PMID: 26559988 PMCID: PMC4633005 DOI: 10.5935/abc.20150088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 05/06/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction Coronary computed tomography angiography (CCTA) allows for non-invasive coronary
artery disease (CAD) phenotyping. There are still some uncertainties regarding the
impact this knowledge has on the clinical care of patients. Objective To determine whether CAD phenotyping by CCTA influences clinical decision making
by the prescription of cardiovascular drugs and their impact on non-LDL
cholesterol (NLDLC) levels. Methods We analysed consecutive patients from 2008 to 2011 submitted to CCTA without
previous diagnosis of CAD that had two serial measures of NLDLC, one up to 3
months before CCTA and the second from 3 to 6 months after. Results A total of 97 patients were included, of which 69% were men, mean age 64 ±
12 years. CCTA revealed that 18 (18%) patients had no CAD, 38 (39%) had
non-obstructive (< 50%) lesions and 41 (42%) had at least one obstructive
≥ 50% lesion. NLDLC was similar at baseline between the grups (138 ±
52 mg/dL vs. 135 ± 42 mg/dL vs. 131 ± 44 mg/dL, respectively, p =
0.32). We found significative reduction in NLDLC among patients with obstrctive
lesions (-18%, p = 0.001). We also found a positive relationship between clinical
treatment intensification with aspirin and cholesterol reducing drugs and the
severity of CAD. Conclusion Our data suggest that CCTA results were used for cardiovascular clinical treatment
titration, with especial intensification seen in patients with obstructive
≥50% CAD.
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Isma’eel HA, Almedawar MM, Harbieh B, Alajaji W, Al-Shaar L, Hourani M, El-Merhi F, Alam S, Abchee A. Quantifying the impact of using Coronary Artery Calcium Score for risk categorization instead of Framingham Score or European Heart SCORE in lipid lowering algorithms in a Middle Eastern population. J Saudi Heart Assoc 2015; 27:234-43. [PMID: 26557741 PMCID: PMC4614893 DOI: 10.1016/j.jsha.2015.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 04/15/2015] [Accepted: 05/12/2015] [Indexed: 11/29/2022] Open
Abstract
Background The use of the Coronary Artery Calcium Score (CACS) for risk categorization instead of the Framingham Risk Score (FRS) or European Heart SCORE (EHS) to improve classification of individuals is well documented. However, the impact of reclassifying individuals using CACS on initiating lipid lowering therapy is not well understood. We aimed to determine the percentage of individuals not requiring lipid lowering therapy as per the FRS and EHS models but are found to require it using CACS and vice versa; and to determine the level of agreement between CACS, FRS and EHS based models. Methods Data was collected for 500 consecutive patients who had already undergone CACS. However, only 242 patients met the inclusion criteria and were included in the analysis. Risk stratification comparisons were conducted according to CACS, FRS, and EHS, and the agreement (Kappa) between them was calculated. Results In accordance with the models, 79.7% to 81.5% of high-risk individuals were down-classified by CACS, while 6.8% to 7.6% of individuals at intermediate risk were up-classified to high risk by CACS, with slight to moderate agreement. Moreover, CACS recommended treatment to 5.7% and 5.8% of subjects untreated according to European and Canadian guidelines, respectively; whereas 75.2% to 81.2% of those treated in line with the guidelines would not be treated based on CACS. Conclusion In this simulation, using CACS for risk categorization warrants lipid lowering treatment for 5–6% and spares 70–80% from treatment in accordance with the guidelines. Current strong evidence from double randomized clinical trials is in support of guideline recommendations. Our results call for a prospective trial to explore the benefits/risks of a CACS-based approach before any recommendations can be made.
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Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study. PLoS One 2015; 10:e0138092. [PMID: 26422204 PMCID: PMC4589241 DOI: 10.1371/journal.pone.0138092] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 08/26/2015] [Indexed: 02/07/2023] Open
Abstract
Background Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown. Methods We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45–75 and women 55–75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe. Results Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event. Conclusions Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.
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Shah RV, Allison MA, Lima JAC, Bluemke DA, Abbasi SA, Ouyang P, Jerosch-Herold M, Ding J, Budoff MJ, Murthy VL. Liver fat, statin use, and incident diabetes: The Multi-Ethnic Study of Atherosclerosis. Atherosclerosis 2015; 242:211-7. [PMID: 26209814 PMCID: PMC4546884 DOI: 10.1016/j.atherosclerosis.2015.07.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 06/25/2015] [Accepted: 07/07/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS To balance competing cardiovascular benefits and metabolic risks of statins, markers of type 2 diabetes (T2D) susceptibility are needed. We sought to define a competing risk/benefit of statin therapy on T2D and cardiovascular disease (CVD) events using liver attenuation and coronary artery calcification (CAC). METHODS AND RESULTS 3153 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA) without CVD, T2D/impaired fasting glucose, or baseline statin therapy had CT imaging for CAC and hepatic attenuation (hepatic steatosis). Cox models and rates of CVD and T2D were calculated to assess the role of liver attenuation in T2D and the relative risks/benefits of statins on CVD and T2D. 216 T2D cases were diagnosed at median 9.1 years follow-up. High liver fat and statin therapy were associated with diabetes (HR 2.06 [95%CI 1.52-2.79, P < 0.0001] and 2.01 [95%CI 1.46-2.77, P < 0.0001], respectively), after multivariable adjustment. With low liver fat and CAC = 0, the number needed to treat (NNT) for statin to prevent one CVD event (NNT 218) was higher than the number needed to harm (NNH) with an incident case of T2D (NNH 68). Conversely, those with CAC >100 and low liver fat were more likely to benefit from statins for CVD reduction (NNT 29) relative to T2D risk (NNH 67). Among those with CAC >100 and fatty liver, incremental reduction in CVD with statins (NNT 40) was less than incremental risk increase for T2D (NNH 24). CONCLUSIONS Liver fat is associated with incident T2D and stratifies competing metabolic/CVD risks with statin therapy. Hepatic fat may inform T2D surveillance and lipid therapeutic strategies.
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Affiliation(s)
- Ravi V Shah
- Department of Cardiology and Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Matthew A Allison
- Department of Family and Preventative Medicine, University of California-San Diego, San Diego, CA, United States
| | - João A C Lima
- Cardiology Division, Johns Hopkins Medical Institute, Baltimore, MD, United States
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, National Institute of Biomedical Imaging and Bioengineering, United States
| | - Siddique A Abbasi
- Department of Cardiology and Medicine, Brown University, Providence, RI, United States
| | - Pamela Ouyang
- Cardiology Division, Johns Hopkins Medical Institute, Baltimore, MD, United States
| | - Michael Jerosch-Herold
- Non-Invasive Cardiovascular Imaging, Brigham and Women's Hospital, Boston, MA, United States
| | - Jingzhong Ding
- Department of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Matthew J Budoff
- Department of Cardiology and Medicine, University of California-Los Angeles, Los Angeles, CA, United States
| | - Venkatesh L Murthy
- Department of Medicine (Cardiovascular Medicine Division) and Department of Radiology (Nuclear Medicine Division), University of Michigan, Ann Arbor, MI, United States.
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Weber LA, Cheezum MK, Reese JM, Lane AB, Haley RD, Lutz MW, Villines TC. Cardiovascular Imaging for the Primary Prevention of Atherosclerotic Cardiovascular Disease Events. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8:36. [PMID: 26301038 PMCID: PMC4534502 DOI: 10.1007/s12410-015-9351-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Traditional cardiovascular risk factors have well-known limitations for the accurate assessment of individual cardiovascular risk. Unlike risk factor-based scores which rely on probabilistic calculations derived from population-based studies, coronary artery calcium (CAC) scoring, and carotid ultrasound allow for the direct visualization and quantification of subclinical atherosclerosis with the potential for a more accurate, personalized risk assessment and treatment approach. Among strategies used to guide preventive management, CAC scoring has consistently and convincingly outperformed traditional risk factors for the prediction of adverse cardiovascular events. Moreover, several studies have demonstrated the potential of CAC testing to improve precision for the use of more intensive pharmacologic therapies, such as aspirin and statins, in patients most likely to derive benefit, as compared to atherosclerotic cardiovascular disease risk calculators. By comparison to CAC, the role of carotid ultrasound for the measurement of carotid intima-media thickness (CIMT) remains less well-elucidated but may be significantly improved with the inclusion of plaque screening and novel three-dimensional measurements of plaque volume and morphology. Despite significant evidence supporting the ability of non-invasive atherosclerosis imaging (particularly CAC) to guide preventive management, imaging remains an under-utilized strategy among current guidelines and clinical practice. Herein, we review evidence regarding CAC and carotid ultrasound for patient risk classification, with a comparison of these techniques to currently advocated traditional risk factor-based scores.
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Affiliation(s)
- Lauren A. Weber
- />Cardiology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Michael K. Cheezum
- />Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women’s Hospital, Non-Invasive Cardiovascular Imaging Program, Boston, MA 02115 USA
| | - Jason M. Reese
- />Cardiology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Alison B. Lane
- />Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Ryan D. Haley
- />Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Meredith W. Lutz
- />Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Todd C. Villines
- />Cardiology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
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Han D, Lee JH, Hartaigh BÓ, Min JK. Role of computed tomography screening for detection of coronary artery disease. Clin Imaging 2015; 40:307-10. [PMID: 26342860 DOI: 10.1016/j.clinimag.2015.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/10/2015] [Indexed: 01/21/2023]
Abstract
Coronary artery disease (CAD) is a leading cause of morbidity and mortality in Western populations, and the prediction and prevention of CAD is an inherent challenge facing current health care societies. Computed tomography (CT) has emerged as a noninvasive imaging tool in the field of cardiovascular disease. Notably, CT scanning for detection of coronary artery calcium (CAC) has proven useful in predicting adverse cardiovascular outcomes as well as early identification of CAD. In asymptomatic persons undergoing screening for CAD, CAC is well established as a surrogate of CAD risk and has demonstrated incremental benefit over and above traditional risk prediction tools. In addition, a zero CAC score has shown to reflect a substantially lower risk of CAD and may therefore be considered an important marker of CAD protection. Irrespective of screening in the asymptomatic population, CAC scanning has also displayed a beneficial role in the symptomatic population, specifically as gatekeeper in guiding further treatment decision making. Further still, the combination of alternative CT screening strategies such as CT screening for lung cancer with CAC scanning may hold particular promise as an effective screening approach by lowering overall health costs as well as limiting radiation exposure.
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Affiliation(s)
- Donghee Han
- Department of Radiology, Weill Cornell Medical College, New York, New York; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, New York, NY
| | - Ji Hyun Lee
- Department of Radiology, Weill Cornell Medical College, New York, New York; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, New York, NY
| | - Bríain Ó Hartaigh
- Department of Radiology, Weill Cornell Medical College, New York, New York; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, New York, NY
| | - James K Min
- Department of Radiology, Weill Cornell Medical College, New York, New York; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, New York.
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Association between Aspirin Therapy and Clinical Outcomes in Patients with Non-Obstructive Coronary Artery Disease: A Cohort Study. PLoS One 2015; 10:e0129584. [PMID: 26035823 PMCID: PMC4452779 DOI: 10.1371/journal.pone.0129584] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/11/2015] [Indexed: 01/06/2023] Open
Abstract
Background Presence of non-obstructive coronary artery disease (CAD) is associated with increased prescription of cardiovascular preventive medications including aspirin. However, the association between aspirin therapy with all-cause mortality and coronary revascularization in this population has not been investigated. Methods and Findings Among the cohort of individuals who underwent coronary computed tomography angiography (CCTA) from 2007 to 2011, 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) were identified. Patients with statin or aspirin prescription before CCTA, and those with history of revascularization before CCTA were excluded. We analyzed the differences of all-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) between aspirin users (n=3751; 44.8%) and non-users. During a median of 828 (interquartile range 385–1,342) days of follow-up, 221 (2.6%) mortality cases and 295 (3.5%) cases of composite endpoint were observed. Annualized mortality rates were 0.97% in aspirin users versus 1.28% in non-users, and annualized rates of composite endpoint were 1.56% versus 1.48%, respectively. Aspirin therapy was associated with significantly lower risk of all-cause mortality (adjusted HR 0.649; 95% CI 0.492–0.857; p=0.0023), but not with the composite endpoint (adjusted HR 0.841; 95% CI 0.662–1.069; p=0.1577). Association between aspirin and lower all-cause mortality was limited to patients with age ≥65 years, diabetes, hypertension, decreased renal function, and higher levels of coronary artery calcium score, low-density lipoprotein cholesterol and high-sensitivity C-reactive protein. Conclusions Among the patients with non-obstructive CAD documented by CCTA, aspirin is associated with lower all-cause mortality only in those with higher risk.
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Thomas DM, Divakaran S, Villines TC, Nasir K, Shah NR, Slim AM, Blankstein R, Cheezum MK. Management of Coronary Artery Calcium and Coronary CTA Findings. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8:18. [PMID: 25960825 PMCID: PMC4412516 DOI: 10.1007/s12410-015-9334-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient's risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.
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Affiliation(s)
- Dustin M. Thomas
- />Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Sanjay Divakaran
- />Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Todd C. Villines
- />Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Khurram Nasir
- />Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL USA
| | - Nishant R. Shah
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
| | - Ahmad M. Slim
- />Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Ron Blankstein
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
| | - Michael K. Cheezum
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
- />Non-invasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 USA
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Al-Mallah MH, Aljizeeri A. An Increasing Population with Metabolic Syndrome and/or Diabetes Mellitus in the Middle East—Is There an Added Value of Coronary Calcium Scoring to Myocardial Perfusion Imaging? CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9331-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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173
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Kawai VK, Chung CP, Solus JF, Oeser A, Raggi P, Stein CM. The ability of the 2013 American College of Cardiology/American Heart Association cardiovascular risk score to identify rheumatoid arthritis patients with high coronary artery calcification scores. Arthritis Rheumatol 2015; 67:381-5. [PMID: 25371313 DOI: 10.1002/art.38944] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/09/2014] [Accepted: 10/30/2014] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) have increased risk of atherosclerotic cardiovascular disease that is underestimated by the Framingham Risk Score (FRS). We undertook this study to test the hypothesis that the 2013 American College of Cardiology/American Heart Association (ACC/AHA) 10-year risk score would perform better than the FRS and the Reynolds Risk Score (RRS) in identifying RA patients known to have elevated cardiovascular risk based on high coronary artery calcification (CAC) scores. METHODS Among 98 RA patients eligible for risk stratification using the ACC/AHA risk score, we identified 34 patients with high CAC (defined as ≥300 Agatston units or ≥75th percentile of expected coronary artery calcium for age, sex, and ethnicity) and compared the ability of the 10-year FRS, RRS, and ACC/AHA risk scores to correctly assign these patients to an elevated risk category. RESULTS All 3 risk scores were higher in patients with high CAC (P < 0.05). The percentage of patients with high CAC correctly assigned to the elevated risk category was similar among the 3 scores (FRS 32%, RRS 32%, ACC/AHA risk score 41%) (P = 0.223). The C statistics for the FRS, RRS, and ACC/AHA risk score predicting the presence of high CAC were 0.65, 0.66, and 0.65, respectively. CONCLUSION The ACC/AHA 10-year risk score does not offer any advantage compared to the traditional FRS and RRS in the identification of RA patients with elevated risk as determined by high CAC. The ACC/AHA risk score assigned almost 60% of patients with high CAC to a low risk category. Risk scores and standard risk prediction models used in the general population do not adequately identify many RA patients with elevated cardiovascular risk.
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Cainzos-Achirica M, Eissler K, Blaha MJ, Blumenthal RS, Martin SS. Tools for Cardiovascular Risk Assessment in Clinical Practice. CURRENT CARDIOVASCULAR RISK REPORTS 2015. [DOI: 10.1007/s12170-015-0455-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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175
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AlJaroudi WA, Einstein AJ, Chaudhry FA, Lloyd SG, Hage FG. Multi-modality imaging: Bird's-eye view from the 2014 American Heart Association Scientific Sessions. J Nucl Cardiol 2015; 22:364-71. [PMID: 25698480 DOI: 10.1007/s12350-015-0076-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/04/2015] [Indexed: 10/24/2022]
Abstract
A large number of studies were presented at the 2014 American Heart Association Scientific Sessions. In this review, we will summarize key studies in nuclear cardiology, computed tomography, echocardiography, and cardiac magnetic resonance imaging. This brief review will be helpful for readers of the Journal who are interested in being updated on the latest research covering these imaging modalities.
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Zeb I, Budoff M. Coronary artery calcium screening: does it perform better than other cardiovascular risk stratification tools? Int J Mol Sci 2015; 16:6606-20. [PMID: 25807266 PMCID: PMC4394551 DOI: 10.3390/ijms16036606] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 02/17/2015] [Accepted: 03/05/2015] [Indexed: 01/07/2023] Open
Abstract
Coronary artery calcium (CAC) has been advocated as one of the strongest cardiovascular risk prediction markers. It performs better across a wide range of Framingham risk categories (6%-10% and 10%-20% 10-year risk categories) and also helps in reclassifying the risk of these subjects into either higher or lower risk categories based on CAC scores. It also performs better among population subgroups where Framingham risk score does not perform well, especially young subjects, women, family history of premature coronary artery disease and ethnic differences in coronary risk. The absence of CAC is also associated with excellent prognosis, with 10-year event rate of 1%. Studies have also compared with other commonly used markers of cardiovascular disease risk such as Carotid intima-media thickness and highly sensitive C-reactive protein. CAC also performs better compared with carotid intima-media thickness and highly sensitive C-reactive protein in prediction of coronary heart disease and cardiovascular disease events. CAC scans are associated with relatively low radiation exposure (0.9-1.1 mSv) and provide information that can be used not only for risk stratification but also can be used to track the progression of atherosclerosis and the effects of statins.
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Affiliation(s)
- Irfan Zeb
- Department of Medicine, Bronx-Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, USA.
| | - Matthew Budoff
- Department of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA.
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177
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Roberts ET, Horne A, Martin SS, Blaha MJ, Blankstein R, Budoff MJ, Sibley C, Polak JF, Frick KD, Blumenthal RS, Nasir K. Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the Multi-Ethnic Study of Atherosclerosis (MESA). PLoS One 2015; 10:e0116377. [PMID: 25786208 PMCID: PMC4364761 DOI: 10.1371/journal.pone.0116377] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 11/05/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated. OBJECTIVE To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines. METHODS We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a "treat all" strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas. RESULTS We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use. CONCLUSION Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.
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Affiliation(s)
- Eric T. Roberts
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, United States of America
| | - Aaron Horne
- Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America
| | - Seth S. Martin
- Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America
| | - Michael J. Blaha
- Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America
| | - Ron Blankstein
- Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts, United States of America
| | - Matthew J. Budoff
- UCLA School of Medicine, Department of Cardiology, Los Angeles, California, United States of America
| | - Christopher Sibley
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States of America
| | - Joseph F. Polak
- Tufts University School of Medicine, Lemuel Shattuck Hospital, Boston, Massachusetts, United States of America
| | - Kevin D. Frick
- Johns Hopkins Carey Business School and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Roger S. Blumenthal
- Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America
| | - Khurram Nasir
- Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, United States of America
- Miami Cardiovascular Institute (MCVI), Baptist Health South Florida, Miami, FL, United States of America
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, United States of America
- * E-mail:
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Abstract
The effective prevention of cardiovascular disease (CVD) remains a global health challenge. Adopting a combined primary (prevention of the first episode of coronary heart disease or stroke) and primordial (prevention of the causal risk factors of CVD) prevention strategy is the best approach to prevent CVD. Most importantly, the primordial prevention strategy should in the first place be to promote cardiovascular health across individual and population levels by improving the underlying causal risk factors for CVD (i.e., unhealthy diets, physical inactivity, obesity, and cigarette smoking). Epidemiological evidence indicates that maintaining favorable underlying risk factors (lifestyle factors) is associated with a lower risk of incident CVD. Prevention of early atherosclerotic vascular disease is also an important strategy to prevent CVD. However, there has been limited research on the association between lifestyle factors and early atherosclerotic vascular disease (i.e., coronary or carotid atherosclerosis) across race and gender groups in population-based studies. This article briefly reviews whether lifestyle factors relate to subclinical atherosclerosis as assessed by coronary artery calcification in asymptomatic individuals.
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Affiliation(s)
- Chong-Do Lee
- Healthy Lifestyles Research Center, Arizona State University, Phoenix, Ariz., USA
| | - Sae Young Jae
- Health and Integrative Physiology Laboratory, University of Seoul, Seoul, South Korea
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179
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Bashir A, Moody WE, Edwards NC, Ferro CJ, Townend JN, Steeds RP. Coronary Artery Calcium Assessment in CKD: Utility in Cardiovascular Disease Risk Assessment and Treatment? Am J Kidney Dis 2015; 65:937-48. [PMID: 25754074 DOI: 10.1053/j.ajkd.2015.01.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/07/2015] [Indexed: 02/08/2023]
Abstract
Coronary artery calcification (CAC) is a strong predictor of cardiovascular event rates in the general population, and scoring with multislice computed tomography commonly is used to improve risk stratification beyond clinical variables. CAC is accelerated in chronic kidney disease, but this occurs as a result of 2 distinct pathologic processes that result in medial (arteriosclerosis) and intimal (atherosclerosis) deposition. Although there are data that indicate that very high CAC scores may be associated with increased risk of death in hemodialysis, average CAC scores in most patients are elevated at a level at which discriminatory power may be reduced. There is a lack of data to guide management strategies in these patients based on CAC scores. There are even fewer data available for nondialysis patients, and it is uncertain whether CAC score confers an elevated risk of premature cardiovascular morbidity and mortality in such patients. In this article, we review the evidence regarding the utility of CAC score for noninvasive cardiovascular risk assessment in individuals with chronic kidney disease, using a clinical vignette that highlights some of the limitations in using CAC score and considerations in risk stratification.
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Affiliation(s)
- Ahmed Bashir
- Department of Cardiology, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
| | - William E Moody
- Department of Cardiology, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom; Clinical Cardiovascular Science, School of Clinical & Experimental Medicine, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Nicola C Edwards
- Department of Cardiology, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom; Clinical Cardiovascular Science, School of Clinical & Experimental Medicine, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Charles J Ferro
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Jonathan N Townend
- Department of Cardiology, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Department of Cardiology, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom.
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180
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Braber TL, Mosterd A, Prakken NHJ, Doevendans PAFM, Mali WPTM, Backx FJG, Grobbee DE, Rienks R, Nathoe HM, Bots ML, Velthuis BK. Rationale and design of the Measuring Athlete's Risk of Cardiovascular events (MARC) study : The role of coronary CT in the cardiovascular evaluation of middle-aged sportsmen. Neth Heart J 2015; 23:133-8. [PMID: 25410576 PMCID: PMC4315792 DOI: 10.1007/s12471-014-0630-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background More than 90 % of exercise-related cardiac arrests occur in men, predominantly those aged 45 years and older with coronary artery disease (CAD) as the main cause. The current sports medical evaluation (SME) of middle-aged recreational athletes consists of a medical history, physical examination, and resting and exercise electrocardiography. Coronary CT (CCT) provides a minimally invasive low radiation dose opportunity to image the coronary arteries. We present the study protocol of the Measuring Athlete’s Risk of Cardiovascular events (MARC) study. MARC aims to assess the additional value of CCT to a routine SME in asymptomatic sportsmen ≥45 years without known CAD. Design MARC is a prospective study of 300 asymptomatic sportsmen ≥45 years who will undergo CCT if the SME does not reveal any cardiac abnormalities. The prevalence and determinants of CAD (coronary artery calcium score ≥100 Agatston Units (AU) or ≥50 % luminal stenosis) will be reported. The number needed to screen to prevent the occurrence of one cardiovascular event in the next 5 years, conditional to adequate treatment, will be estimated. Discussion We aim to determine the prevalence and severity of CAD and the additional value of CCT in asymptomatic middle-aged (≥45 years) sportsmen whose routine SME revealed no cardiac abnormalities. Electronic supplementary material The online version of this article (doi:10.1007/s12471-014-0630-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T L Braber
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands,
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181
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Chang SM, Nabi F, Xu J, Pratt CM, Mahmarian AC, Frias ME, Mahmarian JJ. Value of CACS Compared With ETT and Myocardial Perfusion Imaging for Predicting Long-Term Cardiac Outcome in Asymptomatic and Symptomatic Patients at Low Risk for Coronary Disease. JACC Cardiovasc Imaging 2015; 8:134-44. [DOI: 10.1016/j.jcmg.2014.11.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/22/2014] [Accepted: 11/05/2014] [Indexed: 02/08/2023]
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182
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van Rosendael AR, de Graaf MA, Scholte AJ. Cardiac arrest during vigorous exercise: coronary plaque rupture or myocardial ischaemia? Neth Heart J 2015; 23:130-2. [PMID: 25573850 PMCID: PMC4315801 DOI: 10.1007/s12471-014-0647-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alexander R van Rosendael
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Postal zone 2300 RC, 2333 ZA, Leiden, The Netherlands,
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183
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Hermann DM, Lehmann N, Gronewold J, Bauer M, Mahabadi AA, Weimar C, Berger K, Moebus S, Jöckel KH, Erbel R, Kälsch H. Thoracic aortic calcification is associated with incident stroke in the general population in addition to established risk factors. Eur Heart J Cardiovasc Imaging 2014; 16:684-90. [PMID: 25550362 DOI: 10.1093/ehjci/jeu293] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/26/2014] [Indexed: 11/13/2022] Open
Abstract
AIMS The aorta is a major source of cerebral thromboembolism, but its role in stroke pathogenesis is not well understood due to its poor accessibility for non-invasive imaging. We examined whether thoracic aortic calcification (TAC), a marker of aortic plaque load, is associated with stroke in addition to established risk factors. METHODS AND RESULTS A total of 3930 subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.1% men) without previous stroke, coronary heart disease, or myocardial infarction were evaluated for incident stroke events over 109.0 ± 23.3 months. Cox proportional hazards regressions were used to examine associations with stroke of TAC in addition to established risk factors (age, sex, systolic blood pressure, LDL, HDL, diabetes, and smoking) and coronary artery calcification (CAC). 101 incident strokes occurred during the follow-up period. Subjects suffering a stroke had significantly higher TAC values at baseline than the remaining subjects (median = 83.1 [Q1;Q3 = 4.7;472.9] vs. 15.7 [0.0;117.1]; P < 0.001). In a multivariable Cox proportional hazards regression, log(TAC + 1) (hazards ratio [HR] = 1.09 [95% confidence interval = 1.00-1.19]; P = 0.044) was associated with stroke in addition to established risk factors. Further analyses revealed that log(DTAC + 1), i.e. calcification of the descending aorta (1.11 [1.02-1.20]; P = 0.016), but not log(ATAC + 1), i.e. calcification of the ascending aorta (1.02 [0.93-1.11]; P = 0.713), was associated with stroke. The HR for log(TAC + 1) decreased to 1.06 (0.97-1.16; P = 0.202), when log(CAC + 1) was also inserted into multivariable analyses. CONCLUSION Calcification of the thoracic aorta, more specifically its descending segment, is associated with incident stroke in addition to established risk factors. CAC outperforms aortic calcification as a stroke predictor.
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Affiliation(s)
- Dirk M Hermann
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, D-45122 Essen, Germany
| | - Nils Lehmann
- Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen Essen, Germany
| | - Janine Gronewold
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, D-45122 Essen, Germany
| | - Marcus Bauer
- Department of Cardiology, University Hospital Essen, Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology, University Hospital Essen, Essen, Germany
| | - Christian Weimar
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, D-45122 Essen, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Susanne Moebus
- Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen Essen, Germany
| | - Karl-Heinz Jöckel
- Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen Essen, Germany
| | - Raimund Erbel
- Department of Cardiology, University Hospital Essen, Essen, Germany
| | - Hagen Kälsch
- Department of Cardiology, University Hospital Essen, Essen, Germany
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184
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Divakaran S, Cheezum MK, Hulten EA, Bittencourt MS, Silverman MG, Nasir K, Blankstein R. Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management. Br J Radiol 2014; 88:20140594. [PMID: 25494818 DOI: 10.1259/bjr.20140594] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinicians often use risk factor-based calculators to estimate an individual's risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management.
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Affiliation(s)
- S Divakaran
- 1 Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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185
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Zhao Y, Malik S, Wong ND. Evidence for Coronary Artery Calcification Screening in the Early
Detection of Coronary Artery Disease and Implications of Screening in
Developing Countries. Glob Heart 2014; 9:399-407. [DOI: 10.1016/j.gheart.2014.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 01/09/2023] Open
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Cardiovascular Disease Risk Assessment: a Review of Risk Factor-based Algorithms and Assessments of Vascular Health. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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187
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Kohli P, Whelton SP, Hsu S, Yancy CW, Stone NJ, Chrispin J, Gilotra NA, Houston B, Ashen MD, Martin SS, Joshi PH, McEvoy JW, Gluckman TJ, Michos ED, Blaha MJ, Blumenthal RS. Clinician's guide to the updated ABCs of cardiovascular disease prevention. J Am Heart Assoc 2014; 3:e001098. [PMID: 25246448 PMCID: PMC4323829 DOI: 10.1161/jaha.114.001098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To facilitate the guideline-based implementation of treatment recommendations in the ambulatory setting and to encourage participation in the multiple preventive health efforts that exist, we have organized several recent guideline updates into a simple ABCDEF approach. We would remind clinicians that evidence-based medicine is meant to inform recommendations but that synthesis of patient-specific data and use of appropriate clinical judgment in each individual situation is ultimately preferred.
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Affiliation(s)
- Payal Kohli
- Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA (P.K.)
| | - Seamus P. Whelton
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Steven Hsu
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y., N.J.S.)
| | - Neil J. Stone
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y., N.J.S.)
| | - Jonathan Chrispin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Nisha A. Gilotra
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Brian Houston
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - M. Dominique Ashen
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Seth S. Martin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Parag H. Joshi
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - John W. McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Ty J. Gluckman
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Erin D. Michos
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Michael J. Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Roger S. Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
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Distribution of calcification in carotid endarterectomy tissues: Comparison of micro-computed tomography imaging with histology. Vasc Med 2014; 19:343-50. [DOI: 10.1177/1358863x14549270] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Calcification in atherosclerotic plaques has been viewed as a marker of plaque stability, but whether calcification accumulates in specific anatomic sites in the carotid artery is unknown. We determined the burden and distribution of calcified plaque in carotid endarterectomy (CEA) tissues. Methods: A total of 22 CEA tissues were imaged with high-resolution micro-computed tomography (micro-CT). Total plaque burden and total calcium score using the Agatston method were quantified. The Agatston score (AS) was also normalized for tissue size. Plaque and calcium distribution were analyzed separately for three CEA regions: common segment (CS), bulb segment (BS), and internal/external segments (IES). Results: The average CEA tissue length was 40.83 (interquartile range [IQR] 33.31–42.41) mm with total plaque burden of 103.45 (IQR: 78.84–156.81) mm3 and total AS of 38.58 (IQR 11.59–89.97). Total plaque volume was 21.02 (IQR: 14.47–25.42) mm3 in the CS, 37.89 (22.59–48.32) mm3 in the BS, and 54.05 (36.87–74.52) mm3 in the IES. Of the 22 tissues, 15 had no calcium in the CS compared with three in the bulb and two in the IES. Normalized calcified plaque was most prevalent in the BS, the IES and was least prevalent in the CS. The overall correlation of calcification between histology sections and matched micro-CT images was 0.86 ( p<0.001). Conclusions: Calcified plaque is heterogeneously distributed in CEA tissues with most in the bulb and IES regions. The amount of calcification in micro-CT slices shows a high correlation with matched histology sections.
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189
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Andersson C, Vasan RS. Is there a role for coronary artery calcium scoring for management of asymptomatic patients at risk for coronary artery disease?: Clinical risk scores are sufficient to define primary prevention treatment strategies among asymptomatic patients. Circ Cardiovasc Imaging 2014; 7:390-7; discussion 397. [PMID: 24642921 DOI: 10.1161/circimaging.113.000470] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Charlotte Andersson
- The National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
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190
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Blaha MJ, Silverman MG, Budoff MJ. Is there a role for coronary artery calcium scoring for management of asymptomatic patients at risk for coronary artery disease?: Clinical risk scores are not sufficient to define primary prevention treatment strategies among asymptomatic patients. Circ Cardiovasc Imaging 2014; 7:398-408; discussion 408. [PMID: 24642922 DOI: 10.1161/circimaging.113.000341] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Although risk factors have proven to be useful therapeutic targets, they are poor predictors of risk. Traditional risk scores are moderately successful in predicting future CHD events and can be a starting place for general risk categorization. However, there is substantial heterogeneity between traditional risk and actual atherosclerosis burden, with event rates predominantly driven by burden of atherosclerosis. Serum biomarkers have yet to show any clinically significant incremental value to the FRS and even when combined cannot match the predictive value of atherosclerosis imaging. As clinicians, are we willing to base therapy decisions on risk models that lack optimum-achievable accuracy and limit personalization? The decision to treat a patient in primary prevention must be a careful one because the benefit of therapy in an asymptomatic patient must clearly outweigh the potential risk. CAC, in particular, provides a personalized assessment of risk and may identify patients who will be expected to derive the most, and the least, net absolute benefit from treatment. Emerging evidence hints that CAC may also promote long-term adherence to aspirin, exercise, diet, and statin therapy. When potentially lifelong treatment decisions are on the line, clinicians must arm their patients with the most accurate risk prediction tools, and subclinical atherosclerosis testing with CAC is, at the present time, superior to any combination of risk factors and serum biomarkers.
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Affiliation(s)
- Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
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Blankstein R, Foody JM. Screening for coronary artery disease in patients with family history… how, when, and in whom? Circ Cardiovasc Imaging 2014; 7:417-9. [PMID: 24847006 DOI: 10.1161/circimaging.114.001985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ron Blankstein
- From the Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA (R.B.); Harvard Medical School, Boston, MA (R.B., J.M.F.); and Preventive Cardiology, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B., J.M.F.).
| | - JoAnne M Foody
- From the Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA (R.B.); Harvard Medical School, Boston, MA (R.B., J.M.F.); and Preventive Cardiology, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B., J.M.F.)
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Affiliation(s)
- John W. McEvoy
- From the Department of Medicine, Division of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Michael J. Blaha
- From the Department of Medicine, Division of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
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Headed in the right direction but at risk for miscalculation: a critical appraisal of the 2013 ACC/AHA risk assessment guidelines. J Am Coll Cardiol 2014; 63:2789-94. [PMID: 24814487 DOI: 10.1016/j.jacc.2014.04.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 04/09/2014] [Indexed: 11/21/2022]
Abstract
The newly released 2013 ACC/AHA Guidelines for Assessing Cardiovascular Risk makes progress compared with previous cardiovascular risk assessment algorithms. For example, the new focus on total atherosclerotic cardiovascular diseases (ASCVD) is now inclusive of stroke in addition to hard coronary events, and there are now separate equations to facilitate estimation of risk in non-Hispanic white and black individuals and separate equations for women. Physicians may now estimate lifetime risk in addition to 10-year risk. Despite this progress, the new risk equations do not appear to lead to significantly better discrimination than older models. Because the exact same risk factors are incorporated, using the new risk estimators may lead to inaccurate assessment of atherosclerotic cardiovascular risk in special groups such as younger individuals with unique ASCVD risk factors. In general, there appears to be an overestimation of risk when applied to modern populations with greater use of preventive therapy, although the magnitude of overestimation remains unclear. Because absolute risk estimates are directly used for treatment decisions in the new cholesterol guidelines, these issues could result in overuse of pharmacologic management. The guidelines could provide clearer direction on which individuals would benefit from additional testing, such as coronary calcium scores, for more personalized preventive therapies. We applaud the advances of these new guidelines, and we aim to critically appraise the applicability of the risk assessment tools so that future iterations of the estimators can be improved to more accurately assess risk in individual patients.
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Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, Silverman MG, Blankstein R, Budoff MJ, Greenland P, Folsom AR. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes 2014; 7:453-60. [PMID: 24803472 DOI: 10.1161/circoutcomes.113.000690] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aspirin for the primary prevention of coronary heart disease (CHD) is only recommended for individuals at high risk for CHD although the majority of CHD events occur in individuals who are at low to intermediate risk. METHODS AND RESULTS To estimate the potential of coronary artery calcium (CAC) scoring to guide aspirin use for primary prevention of CHD, we studied 4229 participants from the Multi-Ethnic Study of Atherosclerosis who were not on aspirin at baseline and were free of diabetes mellitus. Using data from median 7.6-year follow-up, 5-year number-needed-to-treat estimations were calculated by applying an 18% relative CHD reduction to the observed event rates. This was contrasted to 5-year number-needed-to-harm estimations based on the risk of major bleeding reported in an aspirin meta-analysis. Results were stratified by a 10% 10-year CHD Framingham Risk Score (FRS). Individuals with CAC≥100 had an estimated net benefit with aspirin regardless of their traditional risk status (estimated 5-year number needed to treat of 173 for individuals <10% FRS and 92 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Conversely, individuals with zero CAC had unfavorable estimations (estimated 5-year number needed to treat of 2036 for individuals <10% FRS and 808 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Sex-specific and age-stratified analyses showed similar results. CONCLUSIONS For the primary prevention of CHD, Multi-Ethnic Study of Atherosclerosis participants with CAC≥100 had favorable risk/benefit estimations for aspirin use while participants with zero CAC were estimated to receive net harm from aspirin.
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Affiliation(s)
- Michael D Miedema
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Daniel A Duprez
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jeffrey R Misialek
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael J Blaha
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Khurram Nasir
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael G Silverman
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ron Blankstein
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew J Budoff
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip Greenland
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aaron R Folsom
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
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Shreibati JB, Baker LC, McConnell MV, Hlatky MA. Outcomes after coronary artery calcium and other cardiovascular biomarker testing among asymptomatic medicare beneficiaries. Circ Cardiovasc Imaging 2014; 7:655-62. [PMID: 24777939 DOI: 10.1161/circimaging.113.001869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Biomarkers improve cardiovascular disease (CVD) risk prediction, but their comparative effectiveness in clinical practice is not known. We sought to compare the use, spending, and clinical outcomes in asymptomatic Medicare beneficiaries evaluated for CVD with coronary artery calcium (CAC) or other cardiovascular risk markers. METHODS AND RESULTS We used a 20% sample of 2005 to 2011 Medicare claims to identify fee-for-service beneficiaries aged ≥65.5 years with no CVD claims in the previous 6 months. We matched patients with CAC with patients who received high-sensitivity C-reactive protein (hs-CRP; n=8358) or lipid screening (n=6250) using propensity-score methods. CAC was associated with increased noninvasive cardiac testing within 180 days (hazard ratio, 2.22, 95% confidence interval, 1.68-2.93, P<0.001, versus hs-CRP; hazard ratio, 4.30, 95% confidence interval, 3.04-6.06, P<0.001, versus lipid screening) and increased coronary angiography and revascularization. During 3-year follow-up, CAC was associated with higher CVD-related spending ($6525 versus $4432 for hs-CRP, P<0.001; and $6500 versus $3073 for lipid screening, P<0.001) and fewer CVD-related events when compared with hs-CRP (hazard ratio, 0.74, 95% confidence interval, 0.58-0.94, P=0.017) but not compared with lipid screening (hazard ratio, 0.84, 95% confidence interval, 0.64-1.11, P=0.23). CONCLUSIONS CAC testing among asymptomatic Medicare beneficiaries was associated with increased use of cardiac tests and procedures, higher spending, and slightly improved clinical outcomes when compared with hs-CRP testing.
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Affiliation(s)
- Jacqueline Baras Shreibati
- From the Stanford University School of Medicine, Stanford, CA (J.B.S., L.C.B., M.V.M., M.A.H.); and National Bureau of Economic Research, Cambridge, MA (L.C.B.).
| | - Laurence C Baker
- From the Stanford University School of Medicine, Stanford, CA (J.B.S., L.C.B., M.V.M., M.A.H.); and National Bureau of Economic Research, Cambridge, MA (L.C.B.)
| | - Michael V McConnell
- From the Stanford University School of Medicine, Stanford, CA (J.B.S., L.C.B., M.V.M., M.A.H.); and National Bureau of Economic Research, Cambridge, MA (L.C.B.)
| | - Mark A Hlatky
- From the Stanford University School of Medicine, Stanford, CA (J.B.S., L.C.B., M.V.M., M.A.H.); and National Bureau of Economic Research, Cambridge, MA (L.C.B.)
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McEvoy JW, Diamond GA, Detrano RC, Kaul S, Blaha MJ, Blumenthal RS, Jones SR. Risk and the physics of clinical prediction. Am J Cardiol 2014; 113:1429-35. [PMID: 24581923 DOI: 10.1016/j.amjcard.2014.01.418] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/03/2014] [Accepted: 01/03/2014] [Indexed: 12/14/2022]
Abstract
The current paradigm of primary prevention in cardiology uses traditional risk factors to estimate future cardiovascular risk. These risk estimates are based on prediction models derived from prospective cohort studies and are incorporated into guideline-based initiation algorithms for commonly used preventive pharmacologic treatments, such as aspirin and statins. However, risk estimates are more accurate for populations of similar patients than they are for any individual patient. It may be hazardous to presume that the point estimate of risk derived from a population model represents the most accurate estimate for a given patient. In this review, we exploit principles derived from physics as a metaphor for the distinction between predictions regarding populations versus patients. We identify the following: (1) predictions of risk are accurate at the level of populations but do not translate directly to patients, (2) perfect accuracy of individual risk estimation is unobtainable even with the addition of multiple novel risk factors, and (3) direct measurement of subclinical disease (screening) affords far greater certainty regarding the personalized treatment of patients, whereas risk estimates often remain uncertain for patients. In conclusion, shifting our focus from prediction of events to detection of disease could improve personalized decision-making and outcomes. We also discuss innovative future strategies for risk estimation and treatment allocation in preventive cardiology.
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Affiliation(s)
- John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - George A Diamond
- Division of Cardiology, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Robert C Detrano
- Department of Radiology, School of Medicine, University of California, Irvine, California
| | - Sanjay Kaul
- Division of Cardiology, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven R Jones
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Luna JM, Moon YP, Liu KM, Spitalnik S, Paik MC, Cheung K, Sacco RL, Elkind MSV. High-sensitivity C-reactive protein and interleukin-6-dominant inflammation and ischemic stroke risk: the northern Manhattan study. Stroke 2014; 45:979-87. [PMID: 24627113 DOI: 10.1161/strokeaha.113.002289] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Interleukin-6 (IL-6) is a proinflammatory cytokine with known autoregulatory feedback mechanisms. We hypothesized that elevated high-sensitivity C-reactive protein (hsCRP) relative to IL-6 confers an increased risk of ischemic stroke (IS), and low hsCRP relative to IL-6 a decreased risk, for individuals in the prospective, multiethnic, population-based Northern Manhattan Study (NOMAS). METHODS Serum hsCRP and IL-6 were measured in NOMAS participants at baseline. We created a trichotomized predictor based on the dominant biomarker in terms of quartiles: hsCRP-dominant, IL-6-dominant, and codominant groups. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals for the association between inflammatory biomarker group status and risk of incident IS. RESULTS Of 3298 participants, both hsCRP and IL-6 were available in 1656 participants (mean follow-up, 7.8 years; 113 incident IS). The hsCRP-dominant group had increased risk of IS (adjusted hazard ratio, 2.62; 95% confidence interval, 1.56-4.41) and the IL-6-dominant group had decreased risk (adjusted hazard ratio, 0.38; 95% confidence interval, 0.18-0.82) when compared with the referent group, after adjusting for potential confounders. Model fit was improved using the inflammation-dominant construct, over either biomarker alone. CONCLUSIONS In this multiethnic cohort, when hsCRP-quartile was higher than IL-6 quartile, IS risk was increased, and conversely when IL-6 quartiles were elevated relative to hsCRP, IS risk was decreased. Construct validity requires confirmation in other cohorts.
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Affiliation(s)
- Jorge M Luna
- From the Department of Epidemiology, Mailman School of Public Health, New York, NY (J.M.L., M.S.V.E.); Departments of Neurology (Y.P.M., M.S.V.E.) and Pathology (K.M.L., S.S.), Columbia University College of Physicians and Surgeons, New York, NY; Division of Biostatistics, Mailman School of Public Health, New York, NY (M.C.P., K.C.); Departments of Neurology, Epidemiology, and Human Genetics, Miller School of Medicine, University of Miami, FL (R.L.S.); and Gertrude H. Sergievsky Center, Columbia University, New York, NY (M.S.V.E.)
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Kim J, McEvoy JW, Nasir K, Budoff MJ, Arad Y, Blumenthal RS, Blaha MJ. Critical review of high-sensitivity C-reactive protein and coronary artery calcium for the guidance of statin allocation: head-to-head comparison of the JUPITER and St. Francis Heart Trials. Circ Cardiovasc Qual Outcomes 2014; 7:315-22. [PMID: 24619319 DOI: 10.1161/circoutcomes.113.000519] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Joonseok Kim
- Department of Medicine, Michigan State University, East Lansing, MI
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Kiu Weber CI, Duchateau-Nguyen G, Solier C, Schell-Steven A, Hermosilla R, Nogoceke E, Block G. Cardiovascular risk markers associated with arterial calcification in patients with chronic kidney disease Stages 3 and 4. Clin Kidney J 2014; 7:167-173. [PMID: 24683472 PMCID: PMC3968563 DOI: 10.1093/ckj/sfu017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/13/2014] [Indexed: 01/04/2023] Open
Abstract
Background The contribution of pro-inflammatory markers to cardiovascular (CV) risk and vascular calcification in chronic kidney disease (CKD) remains largely to be elucidated. We investigated the association between plasma levels of several biomarkers and calcification volume in three different vascular beds in CKD Stages 3 and 4 patients. Methods This is a cross-sectional, exploratory study in patients with an estimated glomerular filtration rate (eGFR) ≥20 and ≤45 mL/min/1.73 m2 and serum phosphorus ≥3.5 and <6.0 mg/dL enrolled in a previously published randomized, double blind, placebo-controlled single-centre trial. Ethylenediaminetetraacetic acid (EDTA) plasma samples were collected at baseline before patients received study medication and analysed for the presence of a number of biomarkers. Coronary artery calcium (CAC), thoracic aortic calcification (TAC) and abdominal aortic calcification (AAC) volumes were measured using standard electron-beam computed tomography protocols. Associations were adjusted for age, sex, smoking, body mass index, diabetes mellitus status, low-density lipoprotein cholesterol (LDL-C), systolic blood pressure and eGFR. Results Associations with CAC were found for β2-microglobulin (B2M), fibroblast growth factor 23 (FGF23), interleukin-8 (IL-8) and IL-18. AAC was associated with: B2M, FGF23 and IL-2 receptor alpha (IL-2 RA). TAC was associated with: B2M, FGF23, IL-2 RA, IL-18 and tumour necrosis factor receptor type I. For most of the analysed biomarkers, there were non-significant trends of associations with calcification. Conclusions This exploratory study found that elevated plasma levels of several inflammatory biomarkers are significantly associated with arterial calcification in CKD Stages 3 and 4 patients. A greater understanding of inflammation and calcification in CKD patients may help the development of CV risk-assessment algorithms for better management of these patients.
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Affiliation(s)
- Chek Ing Kiu Weber
- Cardiovascular and Metabolism Disease Therapeutic Area , F. Hoffmann-La Roche Ltd , Basel , Switzerland
| | | | - Corinne Solier
- Non-Clinical Safety , F. Hoffmann-La Roche Ltd , Basel , Switzerland
| | | | - Ricardo Hermosilla
- Cardiovascular and Metabolism Disease Therapeutic Area , F. Hoffmann-La Roche Ltd , Basel , Switzerland
| | - Everson Nogoceke
- Cardiovascular and Metabolism Disease Therapeutic Area , F. Hoffmann-La Roche Ltd , Basel , Switzerland
| | - Geoffrey Block
- Denver Nephrology , Clinical Research , Denver, CO , USA
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