Incidental coronary artery calcification on non-gated CT thorax correlates with risk of cardiovascular events and death

Relationship between triglyceride glucose-body mass index and coronary artery calcium score in maintenance hemodialysis patients

Background

This study investigated the association between coronary artery calcification (CAC) and triglyceride glucose-body mass index (TyG-BMI) in patients receiving maintenance hemodialysis (MHD).

Methods

We used computed tomography (CT) to assess coronary artery calcification score (CACS) using the Agatston method. The TyG index was multiplied by BMI to derive the TyG-BMI index. Ordinal logistic regression models were used to analyze the relationship between TyG-BMI and CAC. The dose-response relationship was evaluated using restricted cubic spline regression. Weighted Quantile Sum regression was used to explore the weight of the TyG-BMI index components.

Results

Based on the TyG-BMI, 219 patients with MHD were stratified into three groups. The TyG-BMI index was shown to be an independent risk factor for CACS by multivariate ordinal logistic regression analysis (odds ratio, 1.011; [95% confidence interval, 1.002-1.021]; P = 0.021). The relationship between TyG-BMI and lg (CACS + 10) was linear (P-overall = 0.023, P-non-linear = 0.412). Body mass index (BMI) had the highest weight (0.566) when weights were assigned to the three components of TyG-BMI. In the non-diabetes and diabetes subgroups, TyG-BMI and lg (CACS + 10) did not exhibit a significant non-linear relationship.

Conclusion

TyG-BMI and CAC were independently positively correlated in patients undergoing MHD. These findings suggest that assessing TyG-BMI as a valuable tool for identifying the risk of CAC in patients with MHD.

Association of serum HIF-1α levels with coronary artery calcification in patients of non-dialysis chronic kidney disease

Vascular calcification is the main cause of death in patients with chronic kidney disease (CKD). The study aims to investigate the risk factor affecting coronary artery calcification (CAC), and the relationship between serum hypoxia-inducible factor-1α (HIF-1α) levels and CAC in non-dialysis CKD patients. One hundred and twenty-three patients were selected in the final analysis. Spearman rank correlation analysis assessed the correlation between HIF-1α levels and CAC scores. Logistic regression analysis was utilized to assess potential risk variables associated with CAC. A ROC curve was drawn to analyze the diagnostic value of HIF-1α in non-dialysis CKD patients with CAC. Compared to the non-CAC group, the CAC group was older age, with a higher proportion of males, smokers, hypertension and diabetes, lower eGFR and HDL-C, and higher SBP and HIF-1α levels. As the HIF-1α levels went up, the proportion of patients with VC increased, as well as Agatston scores. Spearman rank correlation analysis showed that HIF-1α levels were positively correlated with VC and Agatston scores. Logistic regression analysis indicated that being male (OR = 0.242, P = 0.036), older age (OR = 1.093, P < 0.001), and increased HIF-1α levels (OR = 1.002, P = 0.025) were risk factors for the occurrence of CAC. Furthermore, ROC curve analysis determined that a HIF-1α cutoff value of 451.177 pg·mL-1 provided the best diagnostic value for non-dialysis CAC, with a sensitivity of 65.8% and a specificity of 80.9%. The prevalence of CAC is high in non-dialysis CKD patients, with old age and male gender being traditional risk factors for CAC occurrence. HIF-1α positively correlate with both CAC and VC, which can provide certain diagnostic values for non-dialysis CAC.

Pathophysiology and clinical implications of coronary artery calcifications

PURPOSE OF REVIEW

To provide a summary of current understanding of coronary artery calcifications (CACs), outlining the role of calcium in atherosclerosis to comprehend the clinical implications of CAC.

RECENT FINDINGS

CAC serves as a reliable indicator of coronary artery disease (CAD) and it is associated with cardiovascular events. In recognition of its significance, recent global guidelines have integrated CAC assessment into risk evaluation protocols, highlighting its role as a noninvasive tool for evaluating and stratifying patients' risk for cardiovascular events. Beyond the amount of CAC values, also, calcium morphology had been linked to cardiovascular events.By leveraging CAC assessment, healthcare providers can effectively up or down reclassify patients' risk and tailor preventive strategies accordingly. This comprehensive approach may involve lifestyle modifications, meticulous management of risk factors, and judicious use of preventive medications to mitigate the likelihood of future cardiovascular events, or withhold treatments in those without signs of CAC, to optimize resource use.

SUMMARY

The identification of CAC burden and morphology through noninvasive imaging modalities can reclassify the prediction of future cardiovascular risk and serve as a risk modifier for atherosclerosis. These data underscore the utility of selectively using CAC assessment in both primary and secondary prevention strategies for atherosclerotic cardiovascular disease.

Exploring the Relationship Between Visceral Fat and Coronary Artery Calcification Risk Using Metabolic Score for Visceral Fat (METS-VF)

BACKGROUND

Metabolic Score for Visceral Fat (METS-VF) is a novel indicator for estimating intra-abdominal fat, yet its connection with coronary artery calcification (CAC) remains uncharted. Our research aims to explore the novel METS-VF indicator's link to CAC while comparing its performance against relevant anthropometric indices.

METHODS

This study enrolled participants who underwent health checkups and computed tomography scans for categorizing severity of CAC using the coronary artery calcium score. The METS-VF was calculated and compared with anthropometric indices in estimating the presence of CAC and different CAC severity using receiver operating characteristic curves.

RESULTS

Overall, 1217 participants (mean age 50.7 ± 9.9, 53.8% male) were included. METS-VF (odds ratio [OR], 1.506; 95% confidence interval [CI], 1.181-1.921; p = 0.001) was positively associated with the presence of CAC, even after accounting for cardiometabolic factors. Notably, METS-VF was positively associated with mild (OR, 1.450; 95% CI, 1.115-1.886; p = 0.006), moderate (OR, 1.865; 95% CI, 1.137-3.062; p = 0.014), and severe (OR, 2.316; 95% CI, 1.090-4.923; p = 0.029) CAC. Moreover, METS-VF yielded the highest area under curve (AUC) value in the estimation of the CAC presence (AUC = 0.710), mild (AUC = 0.682), moderate (AUC = 0.757), and severe (AUC = 0.807) CAC when compared with body mass index, waist circumference, visceral adiposity index, triglyceride-glucose index, and metabolic score for insulin resistance. The optimal METS-VF cut-off value was 6.4 for predicting CAC.

CONCLUSIONS

METS-VF emerged as a strong independent marker for detecting CAC presence across mild, moderate, and severe CAC categories, outperforming major anthropometric indices in accurately estimating the presence of CAC and different severity of CAC.

The triglyceride glucose: high-density lipoprotein cholesterol ratio is associated with coronary artery calcification evaluated via non-gated chest CT

BACKGROUND

Coronary artery calcification (CAC) is a common risk factor of cardiovascular disease. Although triglyceride glucose (TYG) index and high-density lipoprotein cholesterol (HDL-c) are both associated with CAC, no study has evaluated the correlation between the TYG/HDL-c ratio and CAC. In the present study, we investigated the relationships between CAC and the TYG index and the TYG/HDL-c ratio.

METHODS

A total of 9585 participants who underwent computed tomography (CT) screening for lung cancer from 2018 to 2020 were included in this cross-sectional study. Demographic data, laboratory test data and medical history data were collected from medical records. TYG = Ln[fasting glucose (mg/dL)×fasting TG (mg/dL/2]. The triglyceride glucose-HDL-c ratio was calculated as TYG/HDL-c. CAC was evaluated on chest CT images. Multivariate logistic regression analysis and restricted cubic splines were used to determine the relationships among the TYG index, TYG/HDL-c ratio and risk of CAC. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the TYG index and TYG/HDL-c ratio in identifying CACs in individuals aged 60 years and above.

RESULTS

CAC was detected in 2515 of 9585 participants (mean age 51.8 ± 15.5 years, 61.2% men). The prevalence of CAC was significantly greater in participants with a high TYG/HDL-c ratio (32.6% in the fourth quartile vs. 19.1% in the first quartile, p < 0.001). Multivariate logistic regression revealed that both the TYG index (odds ratio (OR) = 1.06, 95% confidence interval (CI): 1.02-1.10) and the TYG/HDL-c ratio were associated with coronary artery calcification (OR = 1.32, 95% CI: 1.14-1.51). No such association was observed between the TYG index and CAC when further adjusted for the serum lipid level (OR = 1.23, 95% CI: 0.99-1.54). The TYG/HDL-c ratio was still associated with CAC after further adjustment for low-density lipoprotein cholesterol and total cholesterol (OR = 1.21, 95% CI: 1.09-1.35). TYG/HDL-c ratio was associated both with single vessel and multivessel calcification (OR = 1.14, 95%CI:1.05-1.23; OR = 1.15, 95%CI: 1.05-1.21). Similar trends were observed when we categorized individuals by TYG index and TYG/HDL-c quartiles and in subjects older than 60 years. Restricted cubic splines revealed that the TYG/HDL ratio had a better dose‒responsive relationship than did the TYG index. Subgroup analysis revealed that the association between the TYG/HDL-c ratio and coronary artery calcification was mainly observed in nondiabetic or nonhypertensive participants, regardless of low-density lipoprotein cholesterol levels. The ROC curve also revealed that the TYG/HDL-c ratio was better able to identify CAC than the TYG index was (area under the curve = 0.54 vs. 0.52, p < 0.01) in subjects older than 60 years.

CONCLUSION

An increase in the TYG/HDL-c ratio is significantly positively associated with the risk of CAC, and the TYG/HDL-c ratio has a more stable association with CAC than TYG.

Exploring the Association of Smoking and Alcohol Consumption with Presence of and Severe Coronary Artery Calcification

Background

Despite the majority of studies have identified smoking as a risk factor for coronary artery calcification (CAC), some studies have not identified this relationship. Differences on results reached by studies on the association of alcohol consumption with CAC exist. Moreover, studies have almost exclusively investigated the association between smoking and alcohol consumption independently. Whether an interaction effect of alcohol on the association of smoking and CAC exists has hardly been investigated.

Methods

The data of 2431 adult patients who visited Fuwai Hospital, Chinese Academy of Medical Sciences from September, 2001 to December, 2023 and had Agaston coronary artery calcification score (CACS) reported were utilized. Patients who (1) underwent percutaneous coronary intervention, coronary bypass graft and heart transplantation, or (2) were complicated by acute medical conditions, chronic kidney disease or malignant neoplasms were excluded. Data from 1528 patients were eventually analyzed. Logistic regression was employed to investigate the association of smoking and alcohol consumption with presence of CAC and severe CAC. Interaction effects of alcohol consumption history on the association of current smoking and both presence of and severe CAC were examined.

Results

Smoking history was significantly associated with presence of CAC and severe CAC. Current alcohol consumption was also significantly associated with presence of CAC and severe CAC. After adjusting for confounders, alcohol consumption history demonstrated an interaction effect on the association of current smoking with both presence of and severe CAC. Using non-alcohol consumers not smoking at the time of the study as reference, current smokers with an alcohol consumption history suffered from an increased risk of presence of CAC and severe CAC.

Conclusions

Both smoking history and current alcohol consumption were associated with presence of and severe CAC. Alcohol consumption history demonstrated an interaction effect on the association of current smoking with both presence of and severe CAC.

Comparative Prognostic Value of Coronary Calcium Score and Perivascular Fat Attenuation Index in Coronary Artery Disease

Coronary artery disease (CAD) is the leading global cause of mortality, accounting for approximately 30% of all deaths. It is primarily characterized by the accumulation of atherosclerotic plaques within the coronary arteries, leading to reduced blood flow to the heart muscle. Early detection of atherosclerotic plaques is crucial to prevent major adverse cardiac events. Notably, recent studies have shown that 15% of myocardial infarctions occur in patients with non-obstructive CAD, underscoring the importance of comprehensive plaque assessment beyond merely identifying obstructive lesions. Cardiac Computed Tomography Angiography (CCTA) has emerged as a cost-effective and efficient technique for excluding obstructive CAD, particularly in patients with a low-to-intermediate clinical likelihood of the disease. Recent advancements in CCTA technology, such as improved resolution and reduced scan times, have mitigated many technical challenges, allowing for precise quantification and characterization of both calcified and non-calcified atherosclerotic plaques. This review focuses on two critical physiological aspects of atherosclerotic plaques: the burden of calcifications, assessed via the coronary artery calcium score (CACs), and perivascular fat attenuation index (pFAI), an emerging marker of vascular inflammation. The CACs, obtained through non-contrast CT scans, quantifies calcified plaque burden and is widely used to stratify cardiovascular risk, particularly in asymptomatic patients. Despite its prognostic value, the CACs does not provide information on non-calcified plaques or inflammatory status. In contrast, the pFAI, derived from CCTA, serves as an indirect marker of coronary inflammation and has shown potential in predicting adverse cardiac events. Combining both CACs and pFAI assessment could offer a comprehensive risk stratification approach, integrating the established calcification burden with novel inflammatory markers to enhance CAD prevention and management strategies.

Non-invasive surrogate markers of pulmonary hypertension are associated with poor survival in patients with cancer

BACKGROUND

Cancer is one of the leading causes of death worldwide, and cardiopulmonary comorbidities may further adversely affect cancer prognosis. We recently described lung cancer-associated pulmonary hypertension (PH) as a new form of PH and comorbidity of lung cancer. While patients with lung cancer with PH had significantly reduced overall survival compared with patients without PH, the prevalence and impact of PH in other cancers remain unclear.

METHODS

In this retrospective, observational cohort study, we analysed the prevalence and impact of PH on clinical outcomes in 1184 patients with solid tumours other than lung cancer, that is, colorectal, head and neck, urological, breast or central nervous system tumours, using surrogate markers for PH determined by CT.

RESULTS

PH prevalence in this cohort was 10.98%. A Cox proportional hazard model revealed a significant reduction in the median survival time of patients with cancer with PH (837 vs 2074 days; p<0.001). However, there was no correlation between pulmonary metastases and PH. A subgroup analysis showed that PH was linked to decreased lung and cardiac function. Additionally, PH was associated with systemic arterial hypertension (p<0.001) and coronary artery disease (p=0.014), but not emphysema.

CONCLUSIONS

In this study, fewer patients with cancer had surrogate parameters for PH compared with previously published results among patients with lung cancer. Consequently, the prevalence of PH in other cancers might be lower compared with lung cancer; however, PH still has a negative impact on prognosis. Furthermore, our data does not provide evidence that lung metastases cause PH. Thus, our results support the idea that lung cancer-associated PH represents a new category of PH. Our results also highlight the importance of further studies in the field of cardio-oncology.

Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis

OBJECTIVES

Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC.

METHODS

Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model.

RESULTS

A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports.

CONCLUSION

CAC is a common, but underreported, finding on non-gated CT with important prognostic implications.

CLINICAL RELEVANCE STATEMENT

Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT.

KEY POINTS

• Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.

Opportunistic Screening for Coronary Artery Disease: An Untapped Population Health Resource

BACKGROUND

Coronary artery disease is the leading cause of death in the United States. At-risk asymptomatic adults are eligible for screening with electrocardiogram-gated coronary artery calcium (CAC) CT, which aids in risk stratification and management decision-making. Incidental CAC (iCAC) is easily quantified on chest CT in patients imaged for noncardiac indications; however, radiologists do not routinely report the finding.

OBJECTIVE

To determine the clinical significance of CAC identified incidentally on routine chest CT performed for noncardiac indications.

DESIGN

An informationist developed search strategies in MEDLINE, Embase, and SCOPUS, and two reviewers independently screened results at both the abstract and full text levels. Data extracted from eligible articles included age, rate of iCAC identification, radiologist reporting frequency, impact on downstream medical management, and association of iCAC with patient outcomes.

RESULTS

From 359 unique citations, 83 research publications met inclusion criteria. The percentage of patients with iCAC ranged from 9% to 100%. Thirty-one investigations measured association(s) between iCAC and cardiovascular morbidity and mortality, and 29 identified significant correlations, including nonfatal myocardial infarction, fatal myocardial infarction, major adverse cardiovascular event, cardiovascular death, and all-cause death. iCAC was present in 20% to 100% of the patients in these cohorts, but when present, iCAC was reported by radiologists in only 31% to 44% of cases. Between 18% and 77% of patients with iCAC were not on preventive medications in studies that reported these data. Seven studies measured the effect of reporting on guideline directed medical therapy, and 5 (71%) reported an increase in medication prescriptions after diagnosis of iCAC, with one confirming reductions in low-density lipoprotein levels. Twelve investigations reported good concordance between CAC grade on noncardiac CT and Agatston score on electrocardiogram-gated cardiac CT, and 10 demonstrated that artificial intelligence tools can reliably calculate an Agatston score on noncardiac CT.

CONCLUSION

A body of evidence demonstrates that patients with iCAC on routine chest CT are at risk for cardiovascular disease events and death, but they are often undiagnosed. Uniform reporting of iCAC in the chest CT impression represents an opportunity for radiology to contribute to early identification of high-risk individuals and potentially reduce morbidity and mortality. AI tools have been validated to calculate Agatston score on routine chest CT and hold the best potential for facilitating broad adoption.

Coronary artery calcium score: we know where we are but not where we may be

Cardiac computed tomography angiography (CCTA) has emerged as a cost-effective and time-saving technique for excluding coronary artery disease. One valuable tool obtained by CCTA is the coronary artery calcium (CAC) score. The use of CAC scoring has shown promise in the risk assessment and stratification of cardiovascular disease. CAC scores can be complemented by plaque analysis to assess vulnerable plaque characteristics and further refine risk assessment. This paper aims to provide a comprehensive understanding of the value of the CAC as a prognostic tool and its implications for patient risk assessment, treatment strategies, and outcomes. CAC scoring has demonstrated superior ability in stratifying patients, especially asymptomatic individuals, compared to traditional risk factors and scoring systems. The main evidence suggests that individuals with a CAC score of 0 have a good long-term prognosis, while an elevated CAC score is associated with increased cardiovascular risk. Finally, the clinical power of CAC scoring and the development of new models for risk stratification could be enhanced by machine learning algorithms.