Coronary Artery Calcium as an Independent Surrogate Marker in the Risk Assessment of Patients With Atrial Fibrillation and an Intermediate Pretest Likelihood for Coronary Artery Disease Admitted to a German Chest Pain Unit

Investigating the link between coronary artery calcification and atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Both coronary artery calcification (CAC) and atrial fibrillation (AF) are associated with common risk factors, such as age, hypertension, diabetes, and dyslipidemia. Investigating their association may provide insights into shared pathophysiological mechanisms and overlapping risk profiles.

METHODS

A systematically search was performed covering various data bases including PubMed, Scopus, ISI, and Google Scholar from January 2000 until December 2023 for English-published articles. We focused on observational studies-cohort, case-control, and cross-sectional-that involved adult participants (aged 18 and older) and provided data on the any association between CAC and AF. We excluded studies if the full text was unavailable, the publication was not in English, there was insufficient numerical data or relative risk information.

RESULTS

All the included articles (n = 14), were observational studies (n = 5 case-control and n = 9 cohort). All of the included papers (100%), reported a link between CAC and higher rate of major adverse cardiovascular events such as stroke and mortality in AF patients. The overall prevalence of AF across 5 studies was estimated to be 9.00% (95% confidence intervals [CI]: 2.00, 16.00), and 60% of the AF population were male. The overall proportion of AF in individuals with a coronary artery calcification score (CACS) of 0 is relatively high at 0.48 (95% CI: 0.32, 0.64), followed by CACS (1-99) which was 0.22 (95% CI: 0.16, 0.28), CACS (100-399) which was 0.17 (95% CI: 0.07, 0.28), and CACS (≥ 400) as 0.14 (95% CI: 0.07, 0.22).

CONCLUSION

It can be concluded that there is a robust and consistent association between CAC and AF. Our systematic review underscores the importance of considering CAC as a potential factor in assessing the risk of AF, while also recognizing the multifactorial nature of this relationship.

Diagnostic role of coronary CT angiography in paroxysmal or first diagnosed atrial fibrillation

OBJECTIVES

The presence of coronary artery disease (CAD) in patients hospitalised with paroxysmal or first diagnosed atrial fibrillation (AF) has major implications for antithrombotic therapy and cardiovascular event rate. Coronary CT angiography (CCTA) is a feasible tool to identify patients with concealed CAD. We aimed to evaluate the diagnostic role of early CCTA in patients hospitalised with paroxysmal or first diagnosed AF.

METHODS

In a 5-year single-centre retrospective analysis, 566 patients with paroxysmal or first diagnosed AF who underwent CCTA were enrolled to investigate the presence of CAD.

RESULTS

In patients with paroxysmal or first diagnosed AF, CCTA revealed CAD (coronary artery stenosis ≥50%) in 39.2%. Cardiac catheterisation was performed in 31.6%, confirming CAD in 13.1% of all patients. In 8.0% percutaneous coronary intervention and in 0.5% coronary artery bypass grafting was performed. In patients with paroxysmal or first diagnosed AF: (1) angina pectoris per se does not predict CAD; (2) multivariable regression analysis revealed age, male sex and diabetes as risk factors for CAD in AF; (3) Framingham Risk Score for coronary heart disease and CHA2DS2-VASc-Score were relevant risk scores of CAD and (4) the classification of Coronary Artery Calcium score reference values according to the Multi-Ethnic Study of Atherosclerosis was a predictor of CAD.

CONCLUSION

Patients with paroxysmal or first diagnosed AF are at risk for CAD, while CCTA is a feasible diagnostic tool for CAD. We recommend to integrate CT calcium scoring and CCTA into the diagnostic workup of patients with new-onset or paroxysmal AF.

German chest pain unit registry: data review after the first decade of certification

In 2008, the German Cardiac Society (GCS) introduced a certification program for specialized chest pain units (CPUs). In order to benchmark the performance of the certified CPUs, a nationwide German CPU registry was established. Since then, data for more than 34,000 patients have been included. The concept of certified CPUs in Germany has been widely accepted and its success is underlined by its recent inclusion in national and international guidelines. As of December 2019, 286 CPUs have been successfully certified or recertified by the GCS. This review focuses on the data retrieved from the CPU registry during the first decade of certification. As demonstrated by 16 manuscripts stemming from the registry, certified German CPUs demonstrate high quality of care in acute coronary syndrome and beyond. It is also noted that the German CPU registry allowed for further analysis of the gap in guideline adherence. With the current update of the CPU certification criteria, central data collection as a best-practice criterion will be abandoned, and after some productive years the registry has temporarily been stopped.

Guideline-based statin/lipid-lowering therapy eligibility for primary prevention and accuracy of coronary artery calcium and clinical cardiovascular events: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

With multiple cholesterol guidelines, we evaluated the accuracy of recommended statin therapy on identifying coronary artery calcium (CAC) and cardiovascular disease (CVD) events by 2004 NCEP/ ATP III, 2016 ESC/EAS, and 2013 ACC/AHA guidelines.

HYPOTHESIS

ACC/AHA guidelines are more accurate in identifying persons at risk for CVD.

METHODS

5002/6814 participants age <75 years and free of CVD were included. CAC categories (>0, ≥100, and ≥300) and 10 years of CVD outcomes were considered. Sensitivity (SN), specificity (SP), positive and negative predictive value (PPV and NPV), and likelihood ratios (LR) were calculated. Mean age was 59 years; 47% of subjects were males.

RESULTS

1297 (26%), 1381 (28%), and 2538 (51%) had class I indications for statin/LLT by the NCEP ATP III, ESC/EAS, and AHA/ACC guidelines, respectively. SN, SP, NPV, and PPV for CAC ≥300 were: NCEP ATP III (41.1%, 75.5%, 93.3% and 13.4%), ESC/EAS (54.1%, 74.8%, 94.6% and16.6%), and ACC/AHA (87.2%, 52.6%, 97.8% and 14.5%). SN, SP, PPV, and NPV for corresponding CVD outcomes were: NCEP ATP III (45.8%, 75.1%, 96.3%, and 8.9%), ESC/EAS (50.5%, 72.9%, 98.7%, and 3.6%), and AHA/ACC (79.6%, 50.7%, 98%, and 7.7%). ESC/EAS had significantly higher positive LR 2.15 (95% CI, 1.95 - 2.38) and ACC/AHA had significantly lower negative LR [0.24, (95% CI 0.19 - 0.31)] for corresponding CVD.

CONCLUSIONS

Despite the increased in SN of statin eligibility by the ACC/AHA, it has similar NPV and PPV for CAC/future CVD events. The ACC/AHA class I indications for statin may be a superior screening tool for subclinical and clinical CVD.

Relationship Among Risk Score Systems and Coronary Atherosclerosis Determined by Multislice Computed Tomography

BACKGROUND

Risk score systems (RSS) were designed to estimate the risk of cardiac events. Their ability to predict coronary atherosclerosis (CA) has not been established.

HYPOTHESIS

Risk score systems can predict presence of CA in patients without typical symptoms or ischemia. Because design of each RSS is different, their predictive value could also differ.

METHODS

A retrospective analysis was done on patients from a low-risk region referred for cardiac multislice computed tomography (MSCT). The sample included low- to intermediate-risk patients with nontypical chest pain and asymptomatic high-risk patients. Patients with documented ischemia were excluded. Three RSS were determined: Framingham Risk Score (FRS), Regicor (FRS calibrated for Spanish population), and Systematic Coronary Risk Evaluation (SCORE). Coronary arteries were investigated to determine calcium score and presence of protruding atheromas.

RESULTS

We analyzed 582 patients (53.8% male; mean age 51 ± 11.5 years). Their mean estimated risk was intermediate: 15.6 ± 10.4 by FRS, 6.3 ± 4.3 by Regicor, and 3.9 ± 4.1 by SCORE. The MSCT showed no CA in 38.8%, nonobstructive plaques in 28.7%, and obstructive ones in 32.5%. The ability of the RSS to predict CA was not significantly different, with moderate diagnostic value (areas under ROC curves, 0.72-0.65). The prevalence of CA was high in low-risk patients: 40%, 47%, and 53% in FRS, Regicor, and SCORE low-risk patients, respectively.

CONCLUSIONS

Risk score systems have only moderate diagnostic value to predict presence of CA, without significant differences among them. Coronary artery disease is highly prevalent in patients considered low risk.