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Ahmed AI, Saad JM, Han Y, Alfawara MS, Soliman A, Nabi F, Zoghbi WA, Al-Mallah MH. Prognostic Interplay Between Coronary Artery Calcium Scoring and Cardiorespiratory FItness: The CAC-FIT Study. Mayo Clin Proc 2022; 97:1269-1281. [PMID: 35787855 DOI: 10.1016/j.mayocp.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/04/2022] [Accepted: 03/31/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the incremental prognostic role of coronary artery calcium score (CACS) and exercise capacity (EC), two independent prognostic tests in the assessment of patients with coronary artery disease. METHODS The cohort consisted of patients who had clinically indicated exercise stress testing and CACS assessment from January 1, 2015, to September 30, 2021, with a median of 27 days between each other. Exercise capacity was defined by peak metabolic equivalents of task (METs) achieved during exercise stress test. The CACS was determined by the Agatston method. Patients were observed from the latest test date to incident major adverse cardiac events (inclusive of all-cause death, nonfatal myocardial infarction, late revascularization, and admission for heart failure). RESULTS There were a` total of 1932 patients in the study population (mean age, 56±12 years; 42% female, 48% hypertension, 21% diabetes, 48% dyslipidemia). Peak METs below 6 was achieved in 8% of patients, and the median (interquartile range) CACS was 9 (0-203). In multivariable Cox regression models, both CACS (1 unit increase in log CACS: hazard ratio, 1.19; 95% CI, 1.06 to 1.34; P=.003;) and EC (1 unit increase in peak METs: hazard ratio, 0.89; 95% CI, 0.81 to 0.97; P=.01) were independently associated with outcomes. Using CACS+EC added incremental prognostic value over clinical and fitness models (C index increase from 0.68 to 0.75; P=.015). Incident event rates increased across categories of CACS and EC. CONCLUSION Our analysis found that CACS and EC have complementary risk-stratifying roles in coronary artery disease.
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Affiliation(s)
| | | | - Yushui Han
- Houston Methodist DeBakey Heart & Vascular Center
| | | | | | - Faisal Nabi
- Houston Methodist DeBakey Heart & Vascular Center
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2
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De Bosscher R, Dausin C, Claus P, Bogaert J, Dymarkowski S, Goetschalckx K, Ghekiere O, Belmans A, Van De Heyning CM, Van Herck P, Paelinck B, El Addouli H, La Gerche A, Herbots L, Heidbuchel H, Willems R, Claessen G. Endurance exercise and the risk of cardiovascular pathology in men: a comparison between lifelong and late-onset endurance training and a non-athletic lifestyle - rationale and design of the Master@Heart study, a prospective cohort trial. BMJ Open Sport Exerc Med 2021; 7:e001048. [PMID: 33927885 PMCID: PMC8055127 DOI: 10.1136/bmjsem-2021-001048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction Low and moderate endurance exercise is associated with better control of cardiovascular risk factors, a decreased risk of coronary artery disease and atrial fibrillation (AF). There is, however, a growing proportion of individuals regularly performing strenuous and prolonged endurance exercise in which the health benefits have been challenged. Higher doses of endurance exercise have been associated with a greater coronary atherosclerotic plaque burden, risk of AF and myocardial fibrosis (MF). Methods and analysis Master@Heart is a multicentre prospective cohort study aiming to assess the incidence of coronary atherosclerosis, AF and MF in lifelong endurance athletes compared to late-onset endurance athletes (initiation of regular endurance exercise after the age of 30 years) and healthy non-athletes. The primary endpoint is the incidence of mixed coronary plaques. Secondary endpoints include coronary calcium scores, coronary stenosis >50%, the prevalence of calcified and soft plaques and AF and MF presence. Tertiary endpoints include ventricular arrhythmias, left and right ventricular function at rest and during exercise, arterial stiffness and carotid artery intima media thickness. Two hundred male lifelong athletes, 200 late-onset athletes and 200 healthy non-athletes aged 45–70 will undergo comprehensive cardiovascular phenotyping using CT, coronary angiography, echocardiography, cardiac MRI, 12-lead ECG, exercise ECG and 24-hour Holter monitoring at baseline. Follow-up will include online tracking of sports activities, telephone calls to assess clinical events and a 7-day ECG recording after 1 year. Ethics and dissemination Local ethics committees approved the Master@Heart study. The trial was launched on 18 October 2018, recruitment is complete and inclusions are ongoing. Trial registration number NCT03711539.
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Affiliation(s)
- Ruben De Bosscher
- Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Christophe Dausin
- Movement Sciences, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Piet Claus
- Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jan Bogaert
- Radiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Steven Dymarkowski
- Radiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Kaatje Goetschalckx
- Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Olivier Ghekiere
- Radiology, Jessa Ziekenhuis Campus Virga Jesse, Hasselt, Limburg, Belgium
| | - Ann Belmans
- Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Flanders, Belgium
| | | | - Paul Van Herck
- Cardiology, University Hospital Antwerp, Edegem, Belgium
| | | | | | - André La Gerche
- Cardiology, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Lieven Herbots
- Cardiology, Jessa Ziekenhuis Campus Virga Jesse, Hasselt, Limburg, Belgium
| | | | - Rik Willems
- Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Guido Claessen
- Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
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3
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Aengevaeren VL, Mosterd A, Sharma S, Prakken NHJ, Möhlenkamp S, Thompson PD, Velthuis BK, Eijsvogels TMH. Exercise and Coronary Atherosclerosis: Observations, Explanations, Relevance, and Clinical Management. Circulation 2020; 141:1338-1350. [PMID: 32310695 PMCID: PMC7176353 DOI: 10.1161/circulationaha.119.044467] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Physical activity and exercise training are effective strategies for reducing the risk of cardiovascular events, but multiple studies have reported an increased prevalence of coronary atherosclerosis, usually measured as coronary artery calcification, among athletes who are middle-aged and older. Our review of the medical literature demonstrates that the prevalence of coronary artery calcification and atherosclerotic plaques, which are strong predictors for future cardiovascular morbidity and mortality, was higher in athletes compared with controls, and was higher in the most active athletes compared with less active athletes. However, analysis of plaque morphology revealed fewer mixed plaques and more often only calcified plaques among athletes, suggesting a more benign composition of atherosclerotic plaques. This review describes the effects of physical activity and exercise training on coronary atherosclerosis in athletes who are middle-aged and older and aims to contribute to the understanding of the potential adverse effects of the highest doses of exercise training on the coronary arteries. For this purpose, we will review the association between exercise and coronary atherosclerosis measured using computed tomography, discuss the potential underlying mechanisms for exercise-induced coronary atherosclerosis, determine the clinical relevance of coronary atherosclerosis in middle-aged athletes and describe strategies for the clinical management of athletes with coronary atherosclerosis to guide physicians in clinical decision making and treatment of athletes with elevated coronary artery calcification scores.
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Affiliation(s)
- Vincent L Aengevaeren
- Department of Physiology (V.L.A., T.M.H.E.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Cardiology (V.L.A.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands (A.M.)
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's University of London, United Kingdom (S.S.)
| | - Niek H J Prakken
- Department of Radiology, University Medical Center Groningen, The Netherlands (N.H.J.P.)
| | - Stefan Möhlenkamp
- Clinic of Cardiology and Intensive Care Medicine, Bethanien Hospital Moers, Germany (S.M.)
| | | | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, The Netherlands (B.K.V.)
| | - Thijs M H Eijsvogels
- Department of Physiology (V.L.A., T.M.H.E.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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4
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Franklin BA, Thompson PD, Al-Zaiti SS, Albert CM, Hivert MF, Levine BD, Lobelo F, Madan K, Sharrief AZ, Eijsvogels TMH. Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e705-e736. [PMID: 32100573 DOI: 10.1161/cir.0000000000000749] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.
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5
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Beri N, Dang P, Bhat A, Venugopal S, Amsterdam EA. Usefulness of Excellent Functional Capacity in Men and Women With Ischemic Exercise Electrocardiography to Predict a Negative Stress Imaging Test and Very Low Late Mortality. Am J Cardiol 2019; 124:661-665. [PMID: 31300200 DOI: 10.1016/j.amjcard.2019.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.
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6
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Löffler AI, Perez MV, Nketiah EO, Bourque JM, Keeley EC. Usefulness of Achieving ≥10 METs With a Negative Stress Electrocardiogram to Screen for High-Risk Obstructive Coronary Artery Disease in Patients Referred for Coronary Angiography After Exercise Stress Testing. Am J Cardiol 2018; 121:289-293. [PMID: 29191566 DOI: 10.1016/j.amjcard.2017.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 02/03/2023]
Abstract
Functional capacity in exercise stress testing is an independent predictor of cardiac events. Routine use of nuclear perfusion imaging increases radiation burden and cost. Our goal was to assess the clinical utility of exercise functional capacity with stress electrocardiogram (ECG) as an adjunct in predicting the presence of high-risk obstructive coronary artery disease (CAD) on diagnostic coronary angiography. We performed a retrospective study of patients who underwent exercise stress testing for the evaluation of chest pain and underwent diagnostic coronary angiography within the subsequent 3 months. High-risk CAD was defined as coronary artery diameter stenosis of ≥70% in the proximal left anterior descending artery, ≥70% diameter stenosis in 3 major epicardial arteries, or ≥50% diameter stenosis in the left main artery. Univariable and multivariable analyses were performed to identify predictors of high-risk CAD. Of the 412 patients, 105 (25%) had high-risk CAD on coronary angiography. On multivariate logistic regression, we found that positive stress ECG, abnormal stress imaging, left ventricular ejection fraction, and male gender were independent predictors of high-risk CAD. The strongest predictor was positive stress ECG (hazard ratio 3.16, 95% confidence interval 1.90 to 5.27, p <0.001). Functional capacity measures alone were not independent predictors of high-risk CAD. Achieving ≥10 METs with a negative stress ECG resulted in 94% sensitivity and 97% negative predictive value in identifying high-risk CAD. This supports the strategy for provisional use of myocardial perfusion imaging in patients with low functional capacity and/or abnormal stress ECG to minimize cost and radiation exposure.
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Affiliation(s)
- Adrián I Löffler
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Margarita V Perez
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Emmanuel O Nketiah
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jamieson M Bourque
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Ellen C Keeley
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia.
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7
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Radford NB, DeFina LF, Leonard D, Barlow CE, Willis BL, Gibbons LW, Gilchrist SC, Khera A, Levine BD. Cardiorespiratory Fitness, Coronary Artery Calcium, and Cardiovascular Disease Events in a Cohort of Generally Healthy Middle-Age Men: Results From the Cooper Center Longitudinal Study. Circulation 2018; 137:1888-1895. [PMID: 29343464 DOI: 10.1161/circulationaha.117.032708] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 12/15/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND A robust literature demonstrates that coronary artery calcification (CAC) and cardiorespiratory fitness (CRF) are independent predictors of cardiovascular disease (CVD) events. Much less is known about the joint associations of CRF and CAC with CVD risk. In the setting of high CAC, high versus low CRF has been associated with decreased CVD events. The goal of this study was to assess the effect of continuous levels of CRF on CVD risk in the setting of increasing CAC burden. METHODS We studied 8425 men without clinical CVD who underwent preventive medicine examinations that included an objective measurement of CRF and CAC between 1998 and 2007. There were 383 CVD events during an average follow-up of 8.4 years. Parametric proportional hazards regression models based on a Gompertz mortality rule were used to estimate total CVD incidence rates at 70 years of age as well as hazard ratios for the included covariates. RESULTS CVD events increased with increasing CAC and decreased with increasing CRF. Adjusting for CAC level (scores of 0, 1-99, 100-399, and ≥400), for each additional MET of fitness, there was an 11% lower risk for CVD events (hazard ratio, 0.89; 95% confidence interval, 0.84-0.94). When CAC and CRF were considered together, there was a strong association between continuous CRF and CVD incidence rates in all CAC groups. CONCLUSIONS In a large cohort of generally healthy men, there is an attenuation of CVD risk at all CAC levels with higher CRF.
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Affiliation(s)
| | - Laura F DeFina
- Cooper Institute, Dallas, TX (L.F.D., D.L., C.E.B., B.L.W., L.W.G.)
| | - David Leonard
- Cooper Institute, Dallas, TX (L.F.D., D.L., C.E.B., B.L.W., L.W.G.)
| | - Carolyn E Barlow
- Cooper Institute, Dallas, TX (L.F.D., D.L., C.E.B., B.L.W., L.W.G.)
| | | | - Larry W Gibbons
- Cooper Institute, Dallas, TX (L.F.D., D.L., C.E.B., B.L.W., L.W.G.)
| | - Susan C Gilchrist
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston (S.C.G.)
| | - Amit Khera
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (A.K., B.D.L.)
| | - Benjamin D Levine
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (A.K., B.D.L.) .,Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (B.D.L.)
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8
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Laddu DR, Rana JS, Murillo R, Sorel ME, Quesenberry CP, Allen NB, Gabriel KP, Carnethon MR, Liu K, Reis JP, Lloyd-Jones D, Carr JJ, Sidney S. 25-Year Physical Activity Trajectories and Development of Subclinical Coronary Artery Disease as Measured by Coronary Artery Calcium: The Coronary Artery Risk Development in Young Adults (CARDIA) Study. Mayo Clin Proc 2017; 92:1660-1670. [PMID: 29050797 PMCID: PMC5679779 DOI: 10.1016/j.mayocp.2017.07.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/20/2017] [Accepted: 07/21/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate 25-year physical activity (PA) trajectories from young to middle age and assess associations with the prevalence of coronary artery calcification (CAC). PATIENTS AND METHODS This study includes 3175 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study who self-reported PA by questionnaire at 8 follow-up examinations over 25 years (from March 1985-June 1986 through June 2010-May 2011). The presence of CAC (CAC>0) at year 25 was measured using computed tomography. Group-based trajectory modeling was used to identify PA trajectories with increasing age. RESULTS We identified 3 distinct PA trajectories: trajectory 1, below PA guidelines (n=1813; 57.1%); trajectory 2, meeting PA guidelines (n=1094; 34.5%); and trajectory 3, 3 times PA guidelines (n=268; 8.4%). Trajectory 3 participants had higher adjusted odds of CAC>0 (adjusted odds ratio [OR], 1.27; 95% CI, 0.95-1.70) vs those in trajectory 1. Stratification by race showed that white participants who engaged in PA 3 times the guidelines had higher odds of developing CAC>0 (OR, 1.80; 95% CI, 1.21-2.67). Further stratification by sex showed higher odds for white males (OR, 1.86; 95% CI, 1.16-2.98), and similar but nonsignificant trends were noted for white females (OR, 1.71; 95% CI, 0.79-3.71). However, no such higher odds of CAC>0 for trajectory 3 were observed for black participants. CONCLUSION White individuals who participated in 3 times the recommended PA guidelines over 25 years had higher odds of developing coronary subclinical atherosclerosis by middle age. These findings warrant further exploration, especially by race, into possible biological mechanisms for CAC risk at very high levels of PA.
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Affiliation(s)
- Deepika R. Laddu
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL
| | - Jamal S. Rana
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, CA
| | - Rosenda Murillo
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX
| | - Michael E. Sorel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Norrina B. Allen
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kelley P. Gabriel
- Department of Epidemiology, Human Genetics and Environmental Sciences. University of Texas Health Science Center at Houston, School of Public Health – Austin Campus, Austin, TX
| | - Mercedes R. Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kiang Liu
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jared P. Reis
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Donald Lloyd-Jones
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Jeffrey Carr
- Departments of Radiology and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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9
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Arnson Y, Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Impact of Exercise on the Relationship Between CAC Scores and All-Cause Mortality. JACC Cardiovasc Imaging 2017; 10:1461-1468. [PMID: 28528154 DOI: 10.1016/j.jcmg.2016.12.030] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 11/22/2016] [Accepted: 12/06/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aims to assess the correlations among coronary artery calcium (CAC), self-reported exercise, and mortality in asymptomatic patients. BACKGROUND The interaction between reported exercise habits and CAC scores for predicting clinical risk is not yet well known. METHODS We followed 10,690 asymptomatic patients who underwent CAC scanning. Patients were divided into 4 groups based on a single-item self-reported exercise. Mean follow-up was 8.9 ± 3.5 years for the occurrence of all-cause mortality (ACM). RESULTS Annualized ACM progressively increased with increasing CAC score (p < 0.001) and decreasing exercise (p < 0.001). Among patients with CAC scores of 0, ACM was low regardless of the amount of exercise. Among patients with CAC scores from 1 to 399, there was a stepwise increase in ACM for each reported decrement in exercise, and this difference was markedly more pronounced among patients with CAC scores ≥400. Compared with highly active patients with a CAC score of 0, highly sedentary patients with CAC scores ≥400 had a 3.1-fold increase (95% confidence interval: 1.35 to 7.11) in adjusted ACM risk. Our single-item physical activity questionnaire was also predictive of risk factors and clinical and lipid profile measurements. CONCLUSIONS In asymptomatic patients, self-reported exercise is a significant predictor of long-term outcomes. Prognostic value of the reported exercise is additive to the increasing degree of underlying atherosclerosis. Among patients with high CAC scores, exercise may play a protective role, whereas reported minimal or no exercise substantially increases clinical risk. Our results suggest there is clinical utility for the use of a simple single-item exercise questionnaire for such assessments.
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Affiliation(s)
- Yoav Arnson
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Heidi Gransar
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sean W Hayes
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - John D Friedman
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Louise E J Thomson
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Berman
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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10
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Merghani A, Maestrini V, Rosmini S, Cox AT, Dhutia H, Bastiaenan R, David S, Yeo TJ, Narain R, Malhotra A, Papadakis M, Wilson MG, Tome M, AlFakih K, Moon JC, Sharma S. Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile. Circulation 2017; 136:126-137. [PMID: 28465287 DOI: 10.1161/circulationaha.116.026964] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/14/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies in middle-age and older (masters) athletes with atherosclerotic risk factors for coronary artery disease report higher coronary artery calcium (CAC) scores compared with sedentary individuals. Few studies have assessed the prevalence of coronary artery disease in masters athletes with a low atherosclerotic risk profile. METHODS We assessed 152 masters athletes 54.4±8.5 years of age (70% male) and 92 controls of similar age, sex, and low Framingham 10-year coronary artery disease risk scores with an echocardiogram, exercise stress test, computerized tomographic coronary angiogram, and cardiovascular magnetic resonance imaging with late gadolinium enhancement and a 24-hour Holter. Athletes had participated in endurance exercise for an average of 31±12.6 years. The majority (77%) were runners, with a median of 13 marathon runs per athlete. RESULTS Most athletes (60%) and controls (63%) had a normal CAC score. Male athletes had a higher prevalence of atherosclerotic plaques of any luminal irregularity (44.3% versus 22.2%; P=0.009) compared with sedentary males, and only male athletes showed a CAC ≥300 Agatston units (11.3%) and a luminal stenosis ≥50% (7.5%). Male athletes demonstrated predominantly calcific plaques (72.7%), whereas sedentary males showed predominantly mixed morphology plaques (61.5%). The number of years of training was the only independent variable associated with increased risk of CAC >70th percentile for age or luminal stenosis ≥50% in male athletes (odds ratio, 1.08; 95% confidence interval, 1.01-1.15; P=0.016); 15 (14%) male athletes but none of the controls revealed late gadolinium enhancement on cardiovascular magnetic resonance imaging. Of these athletes, 7 had a pattern consistent with previous myocardial infarction, including 3(42%) with a luminal stenosis ≥50% in the corresponding artery. CONCLUSIONS Most lifelong masters endurance athletes with a low atherosclerotic risk profile have normal CAC scores. Male athletes are more likely to have a CAC score >300 Agatston units or coronary plaques compared with sedentary males with a similar risk profile. The significance of these observations is uncertain, but the predominantly calcific morphology of the plaques in athletes indicates potentially different pathophysiological mechanisms for plaque formation in athletic versus sedentary men. Coronary plaques are more abundant in athletes, whereas their stable nature could mitigate the risk of plaque rupture and acute myocardial infarction.
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Affiliation(s)
- Ahmed Merghani
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Viviana Maestrini
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Stefania Rosmini
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Andrew T Cox
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Harshil Dhutia
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Rachel Bastiaenan
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Sarojini David
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Tee Joo Yeo
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Rajay Narain
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Aneil Malhotra
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Michael Papadakis
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Mathew G Wilson
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Maite Tome
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Khaled AlFakih
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - James C Moon
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.)
| | - Sanjay Sharma
- From Cardiology Clinical and Academic Group, St Georges, University of London, UK (A.M., A.T.C., H.D., R.B., R.N., A.M., M.P., M.T., S.S.); The Barts Heart Centre, University College London, UK (V.M., J.C.M.); Department of Cardiovascular, Respiratory, Geriatric, Anesthesiologic, and Nephrologic Sciences, Sapienza University of Rome, Italy (V.M., K.A.); University Hospital Lewisham, London, UK (S.R., S.D.); National University Heart Centre, Singapore (T.J.Y.); and Orthopaedic and Sports Medicine Hospital, Aspetar, Qatar (M.G.W.).
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11
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Rozanski A, Uretsky S, Berman DS. Use of coronary artery calcium scanning as a triage for cardiac ischemia testing. J Nucl Cardiol 2017; 24:502-506. [PMID: 26846368 DOI: 10.1007/s12350-016-0405-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/03/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mt Sinai St. Lukes and Roosevelt Hospitals, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Seth Uretsky
- The Department of Cardiovascular Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Daniel S Berman
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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12
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Bourque JM, Beller GA. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies. JACC Cardiovasc Imaging 2016; 8:1309-21. [PMID: 26563861 DOI: 10.1016/j.jcmg.2015.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023]
Abstract
Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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13
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Rozanski A, Slomka P, S Berman D. Extending the Use of Coronary Calcium Scanning to Clinical Rather Than Just Screening Populations: Ready for Prime Time? Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.116.004876. [PMID: 27165701 DOI: 10.1161/circimaging.116.004876] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Alan Rozanski
- From the Division of Cardiology, Mt Sinai St. Luke's and Roosevelt Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY (A.R.); and Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.S., D.B.)
| | - Piotr Slomka
- From the Division of Cardiology, Mt Sinai St. Luke's and Roosevelt Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY (A.R.); and Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.S., D.B.)
| | - Daniel S Berman
- From the Division of Cardiology, Mt Sinai St. Luke's and Roosevelt Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY (A.R.); and Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.S., D.B.).
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14
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Zafrir B, Azaiza M, Gaspar T, Dobrecky-Mery I, Azencot M, Lewis BS, Rubinshtein R, Halon DA. Low cardiorespiratory fitness and coronary artery calcification: Complementary cardiovascular risk predictors in asymptomatic type 2 diabetics. Atherosclerosis 2015; 241:634-40. [PMID: 26117400 DOI: 10.1016/j.atherosclerosis.2015.06.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 06/01/2015] [Accepted: 06/16/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Despite its well-established prognostic value, cardiorespiratory fitness (CRF) is not incorporated routinely in risk assessment tools. Whether low CRF provides additional predictive information in asymptomatic type 2 diabetics beyond conventional risk scores and coronary artery calcification (CAC) is unclear. METHODS We studied 600 type 2 diabetics aged 55-74 years without known coronary heart disease. CRF was quantified in metabolic equivalents (METs) by maximal treadmill testing and categorized as tertiles of percent predicted METs (ppMETs) achieved. CAC was calculated by non-enhanced computed tomography scans. The individual and joint association of both measures with an outcome event of all-cause mortality, myocardial infarction or stroke, was determined over a mean follow-up period of 80 ± 16 months. RESULTS There were 72 (12%) events during follow-up. Low CRF was independently associated with event risk after adjustment for traditional risk factors and CAC (HR 2.25, 95% CI 1.41-3.57, p = 0.001). CRF (unfit/fit) allowed further outcome discrimination both amongst diabetics with low CAC scores (9.5% versus 2.0% event rate), and amongst diabetics with high CAC scores (23.5% versus 12.4% event rate), p < 0.001. The addition of CRF to a model comprising UKPDS and CAC scores improved the area under the curve for event prediction from 0.66 to 0.71, p = 0.03, with a positive continuous net reclassification improvement (NRI) of 0.451, p = 0.002. CONCLUSIONS CRF, quantified by ppMETs, provided independent prognostic information which was additive to CAC. Low CRF may identify asymptomatic diabetic subjects at higher risk for all-cause mortality, myocardial infarction or stroke, despite low CAC.
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Affiliation(s)
- Barak Zafrir
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Mohanad Azaiza
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tamar Gaspar
- Department of Radiology, Lady Davis Carmel Medical Center, Israel
| | - Idit Dobrecky-Mery
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mali Azencot
- Department of Radiology, Lady Davis Carmel Medical Center, Israel
| | - Basil S Lewis
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronen Rubinshtein
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - David A Halon
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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15
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Levine BD. Going High with Heart Disease: The Effect of High Altitude Exposure in Older Individuals and Patients with Coronary Artery Disease. High Alt Med Biol 2015; 16:89-96. [DOI: 10.1089/ham.2015.0043] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Benjamin D. Levine
- Institute for Exercise and Environmental Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
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16
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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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17
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Preventive Cardiology: The Effects of Exercise. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Levine BD. Can intensive exercise harm the heart? The benefits of competitive endurance training for cardiovascular structure and function. Circulation 2014; 130:987-91. [PMID: 25223769 DOI: 10.1161/circulationaha.114.008142] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Benjamin D Levine
- From the University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
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19
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Cardiorespiratory fitness and cardiovascular burden in chronic kidney disease. J Sci Med Sport 2014; 18:492-7. [PMID: 25127529 DOI: 10.1016/j.jsams.2014.07.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/04/2014] [Accepted: 07/10/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Reduced functional capacity is associated with poor prognosis. In patients with chronic kidney disease the factors that contribute to low cardiorespiratory fitness are unclear. The objective of this study was to evaluate the cardiorespiratory and cardiovascular response to exercise in chronic kidney disease patients, and secondly investigate the relationships between cardiorespiratory fitness and cardiovascular burden. DESIGN Cross-sectional analysis. METHODS Baseline demographic, anthropometric and biochemical data were examined in 136 patients with moderate chronic kidney disease (age 59.7±9.6yrs, eGFR 40±9ml/min/1.73m(2), 55% male, 39% with a history of cardiovascular disease, 38% diabetic and 17% current smokers). Cardiorespiratory fitness was measured as peak VO2, left ventricular morphology and function using echocardiography, central arterial stiffness by aortic pulse wave velocity and left ventricular afterload using augmentation index. Physical activity levels were assessed using the Active Australia questionnaire. RESULTS Peak VO2 (22.9±6.5ml/kg/min) and peak heart rate (148±22bpm) were 17% and 12% lower than the age-predicted values, respectively. The low fit group were significantly older, and were more likely to have type II diabetes, cardiovascular disease, a higher BMI and be less active than the high fit group (P<0.05). The independent predictors of peak VO2 were age, type II diabetes, hemoglobin level, physical activity, aortic pulse wave velocity, augmentation index, and global longitudinal strain. CONCLUSIONS In patients with chronic kidney disease, the peak VO2 and heart rate response is markedly impaired. Reduced cardiorespiratory fitness is independently associated with increased aortic stiffness, increased left ventricle afterload, poor left ventricle function and higher burden of cardiovascular risk.
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20
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Duvall WL, Parker MW, Henzlova MJ. Improving Nuclear Cardiology Practice. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Ruiz JR, Joyner M, Lucia A. Rebuttal from Jonatan R. Ruiz, Michael Joyner and Alejandro Lucia. J Physiol 2013; 591:4949. [PMID: 24130316 DOI: 10.1113/jphysiol.2013.260026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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22
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Rozanski A, Cohen R, Uretsky S. The coronary calcium treadmill test: a new approach to the initial workup of patients with suspected coronary artery disease. J Nucl Cardiol 2013; 20:719-30. [PMID: 23975601 DOI: 10.1007/s12350-013-9763-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Due to the growth of cardiac testing and increasing cost of cardiovascular healthcare, the development of more cost-effective strategies has now become a dominant issue regarding future utilization of cardiac imaging procedures. To that end, we review the potential of combining two relatively inexpensive tests, the coronary artery calcium (CAC) scan and exercise electrocardiography (ECG), as a first-line test for the workup of patients with suspected coronary artery disease (CAD). The CAC scan was initially introduced as a screening test for CAD, based on data indicating that it is a specific marker for atherosclerosis, predicts clinical risk in accordance with the magnitude of CAC, and provides incremental information for prognostic risk compared to more readily available clinical data. However, CAC scores also predict the likelihood of observing myocardial ischemia among patients undergoing exercise myocardial perfusion SPECT imaging. Exercise ECG predicts clinical events according to the ST-segment response and according to functional exercise capacity, with the latter parameter as a stronger predictor of clinical outcomes. Like CAC scores, exercise functional capacity can also be used to predict the likelihood of ischemia since ischemia diminishes proportionally with increasing exercise capacity. Recent work indicates that when patients are designated by Bayesian analyses into low, intermediate, and high likelihood categories for CAD based on clinical data and the response to exercise ECG, the frequency of inducible myocardial ischemia is very low among both low and intermediate CAD likelihood patients who have a CAC score <400. Future studies are needed to investigate what clinical factors might further modify the CAC-ischemia relationship. On the basis of current data, an initial testing strategy that employs the combined calcium treadmill test has the inherent ability to designate a substantial number of intermediate likelihood patients who would not require further testing due to relatively low CAC scores and reasonable functional capacity.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, St. Lukes Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY, 10025, USA,
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Taraboanta C, Hague CJ, Mancini GBJ, Forster BB, Frohlich J. Coronary artery calcium findings in asymptomatic subjects with family history of premature coronary artery disease. BMC Cardiovasc Disord 2012; 12:53. [PMID: 22805651 PMCID: PMC3521199 DOI: 10.1186/1471-2261-12-53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 06/28/2012] [Indexed: 01/07/2023] Open
Abstract
Background To evaluate the frequency of positive coronary arteries calcium (CAC) scores in a unique population of asymptomatic first degree relatives (FDRs) of patients with angiographically confirmed early onset of coronary artery disease (CAD) and to assess their association with carotid ultrasound findings and other cardiovascular risk factors. Method and results We scanned, using 64-slice multi-detector computed tomography, 57 asymptomatic FDRs (47 ± 9 years old; 44% male, 56% female), out of the 111 FDRs previously phenotyped for cardiovascular (CV) risk factors. The controls were 616 individuals (57 ± 10 years old; 76% male, 24% female) with no family history of cardiovascular disease, chest pain or diabetes selected out of the 3500 subjects scanned between 2002 and 2007. FDRs had higher risk of abnormal CAC scores compared to controls; odds ratio (OR) for the 75th percentile was 1.96 (95% CI 1.04 – 3.67, p < 0.05). Conclusion The frequency of abnormal CAC scores is two-fold higher in asymptomatic FDRs than in controls. CAC scan provides additional information on CV risk assessment in asymptomatic FDRs, particularly for those in the intermediate risk category. Clinical trial registration NCT00387595
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Affiliation(s)
- Catalin Taraboanta
- Department of Pathology and Laboratory medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Mulders TA, Sivapalaratnam S, Stroes ES, Kastelein JJ, Guerci AD, Pinto-Sietsma SJ. Asymptomatic Individuals With a Positive Family History for Premature Coronary Artery Disease and Elevated Coronary Calcium Scores Benefit From Statin Treatment. JACC Cardiovasc Imaging 2012; 5:252-60. [DOI: 10.1016/j.jcmg.2011.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 11/21/2011] [Indexed: 02/08/2023]
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25
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Bourque JM, Holland BH, Watson DD, Beller GA. Achieving an exercise workload of > or = 10 metabolic equivalents predicts a very low risk of inducible ischemia: does myocardial perfusion imaging have a role? J Am Coll Cardiol 2009; 54:538-45. [PMID: 19643316 DOI: 10.1016/j.jacc.2009.04.042] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 04/08/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES We sought to identify prospectively the prevalence of significant ischemia (> or =10% of the left ventricle [LV]) on exercise single-photon emission computed tomography (SPECT) imaging relative to workload achieved in consecutive patients referred for myocardial perfusion imaging (MPI). BACKGROUND High exercise capacity is a strong predictor of a good prognosis, and the role of MPI in patients achieving high workloads is questionable. METHODS Prospective analysis was performed on 1,056 consecutive patients who underwent quantitative exercise gated (99m)Tc-SPECT MPI, of whom 974 attained > or =85% of their maximum age-predicted heart rate. These patients were further divided on the basis of attained exercise workload (<7, 7 to 9, or > or =10 metabolic equivalents [METs]) and were compared for exercise test and imaging outcomes, particularly the prevalence of > or =10% LV ischemia. Individuals reaching > or =10 METs but <85% maximum age-predicted heart rate were also assessed. RESULTS Of these 974 subjects, 473 (48.6%) achieved > or =10 METs. This subgroup had a very low prevalence of significant ischemia (2 of 473, 0.4%). Those attaining <7 METs had an 18-fold higher prevalence (7.1%, p < 0.001). Of the 430 patients reaching > or =10 METs without exercise ST-segment depression, none had > or =10% LV ischemia. In contrast, the prevalence of > or =10% LV ischemia was highest in the patients achieving <10 METs with ST-segment depression (14 of 70, 19.4%). CONCLUSIONS In this referral cohort of patients with an intermediate-to-high clinical risk of coronary artery disease, achieving > or =10 METs with no ischemic ST-segment depression was associated with a 0% prevalence of significant ischemia. Elimination of MPI in such patients, who represented 31% (430 of 1,396) of all patients undergoing exercise SPECT in this laboratory, could provide substantial cost-savings.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Internal Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Metrikat J, Albrecht M, Maya-Pelzer P, Ortlepp JR. Physical fitness is associated with lower inflammation, even in
individuals with high cholesterol – An alternative to statin
therapy? Glob Heart 2009. [DOI: 10.1016/j.cvdpc.2009.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bhat A, Desai A, Amsterdam EA. Usefulness of high functional capacity in patients with exercise-induced ST-depression to predict a negative result on exercise echocardiography and low prognostic risk. Am J Cardiol 2008; 101:1541-3. [PMID: 18489930 DOI: 10.1016/j.amjcard.2008.01.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 01/21/2008] [Accepted: 01/21/2008] [Indexed: 10/22/2022]
Abstract
Although exercise electrocardiography (ExECG) is commonly used to detect coronary artery disease, the diagnostic accuracy and reliability of positive (ischemic) results of ExECG in low- and intermediate-risk populations are limited. Accordingly, many patients with positive results of ExECG undergo secondary evaluation using noninvasive stress imaging such as exercise echocardiography. Functional capacity is a strong predictor of prognosis and, indirectly, of high-risk coronary artery disease. It was hypothesized that high functional capacity in patients with positive results of ExECG would predict (1) negative results on subsequent exercise echocardiography and (2) a low risk for late mortality. Results were analyzed in 104 consecutive patients (79 men, 25 women; mean age 49 years, range 27 to 76) referred for exercise echocardiography after positive results of ExECG with a treadmill workload of > or =10 METs. Late all-cause mortality was also determined in these patients. Exercise echocardiographic results were negative in 93% of patients (97 of 104; 92% of men [73 of 79] and 100% of women [25 of 25]) and positive in 7% (7 of 104). During a mean follow-up period of 7.2 +/- 1.9 years, there was 1 death. In conclusion, high functional capacity in patients with positive results of ExECG is associated with negative exercise echocardiographic results in most patients and very low late mortality. Patients with ischemic ST-segment response on ExECG who achieve workloads of > or =10 METs infrequently require additional noninvasive or invasive evaluation.
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Abstract
Maximal oxygen uptake (.VO(2,max)) is a physiological characteristic bounded by the parametric limits of the Fick equation: (left ventricular (LV) end-diastolic volume--LV end-systolic volume) x heart rate x arterio-venous oxygen difference. 'Classical' views of .VO(2,max) emphasize its critical dependence on convective oxygen transport to working skeletal muscle, and recent data are dispositive, proving convincingly that such limits must and do exist. 'Contemporary' investigations into the mechanisms underlying peripheral muscle fatigue due to energetic supply/demand mismatch are clarifying the local mediators of fatigue at the skeletal muscle level, though the afferent signalling pathways that communicate these environmental conditions to the brain and the sites of central integration of cardiovascular and neuromotor control are still being worked out. Elite endurance athletes have a high .VO(2,max) due primarily to a high cardiac output from a large compliant cardiac chamber (including the myocardium and pericardium) which relaxes quickly and fills to a large end-diastolic volume. This large capacity for LV filling and ejection allows preservation of blood pressure during extraordinary rates of muscle blood flow and oxygen transport which support high rates of sustained oxidative metabolism. The magnitude and mechanisms of cardiac phenotype plasticity remain uncertain and probably involve underlying genetic factors, as well as the length, duration, type, intensity and age of initiation of the training stimulus.
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Affiliation(s)
- Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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Khera A, Mitchell JH, Levine BD. Preventive Cardiology: The Effects of Exercise. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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