Polypill therapy, subclinical atherosclerosis, and cardiovascular events-implications for the use of preventive pharmacotherapy: MESA (Multi-Ethnic Study of Atherosclerosis)

Growth differentiation factor-15 predicts all-cause death and major adverse cardiovascular events in patients with coronary heart disease: a prospective cohort study

The prognostic value of growth differentiation factor-15 (GDF-15) in predicting long-term adverse outcomes in coronary heart disease (CHD) patients remains limited. Our study examines the association between GDF-15 and adverse outcomes over an extended period in CHD patients and firstly assesses the incremental prognostic effect of incorporating GDF-15 into the Framingham risk score (FRS)-based model. This single-center prospective cohort study included 3,321 patients with CHD categorized into 2,479 acute coronary syndrome (ACS) (74.6%) and 842 non-ACS (25.4%) groups. The median age was 61.0 years (range: 53.0-70.0), and 917 (27.6%) were females. Mortality and major adverse cardiovascular events (MACEs) included cardiovascular mortality, myocardial infarction (MI), stroke, and heart failure (HF) (inclusive of HF episodes requiring outpatient treatment and/or hospital admission). Cox regression models assessed the associations between GDF-15 and the incidence of all-cause mortality and MACEs. Patients were stratified into three groups based on GDF-15 levels: the first tertile group (< 1,370 ng/L), the second tertile group (1,370-2,556 ng/L), and the third tertile group (> 2,556 ng/L). The C-index, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA) were used to assess incremental value. Over a median 9.4-year follow-up, 759 patients (22.9%) died, and 1,291 (38.9%) experienced MACEs. The multivariate Cox model indicated that GDF-15 was significantly associated with all-cause mortality (per ln unit increase, HR = 1.49, 95% CI: 1.36-1.64) and MACEs (per ln unit increase, HR = 1.29, 95% CI: 1.20-1.38). These associations persisted when GDF-15 was analyzed as an ordinal variable (p for trend < 0.05). Subgroup analysis of ACS and non-ACS for the components of MACEs separately showed a significant association between GDF-15 and both cardiovascular mortality and HF, but no association was observed between GDF-15 and MI /stroke in both ACS and non-ACS patients. The addition of GDF-15 to the FRS-based model enhanced the discrimination for both all-cause mortality (∆ C-index = 0.009, 95% CI: 0.005-0.014; IDI = 0.030, 95% CI: 0.015-0.047; continuous NRI = 0.631, 95% CI: 0.569-0.652) and MACEs (∆ C-index = 0.009, 95% CI: 0.006-0.012; IDI = 0.026, 95% CI: 0.009-0.042; continuous NRI = 0.593, 95% CI: 0.478-0.682). DCA suggested that incorporating GDF-15 into the FRS-based model demonstrated higher net benefits compared to FRS-based models alone (All-cause mortality: FRS-based model: area under the curve of DCA (AUDC) = 0.0903, FRS-based model + GDF-15: AUDC = 0.0908; MACEs: FRS-based model: AUDC = 0.1806, FRS-based model + GDF-15: AUDC = 0.1833). GDF-15 significantly associates with the long-term prognosis of all-cause mortality and MACEs in CHD patients and significantly improves the prognostic accuracy of the FRS-based model for both outcomes.

Frontiers of cardiovascular polypills: From atherosclerosis and beyond

Fixed-dose combination (FDC) therapies (also known as polypills) remain underutilized in clinical practice despite over two decades of evidence from randomized controlled trials demonstrating increased adherence to multidrug therapy, improved cardiovascular disease (CVD) risk factor control, and lower incidence of cardiovascular events. Evidence demonstrates that FDC-based implementation strategies can substantially complement and augment current strategies for CVD risk prevention globally. The next decade is likely to extend the frontier of cardiovascular FDC therapies, particularly given expected advances in FDC manufacturing technology and accessibility. FDC-based anti-hypertensive therapies are emerging as integral components of a pragmatic blood pressure lowering strategy. Cardiovascular FDCs are rapidly approaching its coming of age, transforming from heavily hyped research tools to pragmatic clinical instruments. This review evaluates the current evidence for cardiovascular FDCs, barriers to current use, and potential next generation advances.

Earlier treatment in adults with high lifetime risk of cardiovascular diseases: What prevention trials are feasible and could change clinical practice? Report of a National Heart, Lung, and Blood Institute (NHLBI) Workshop

More than half of U.S. young adults have low ten-year but high lifetime risk of cardiovascular disease (CVD). Improving primary prevention in young adulthood may help reduce persistent CVD disparities and overall CVD morbidity and mortality. The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop in 2021 to identify potential trial opportunities in CVD prevention in young adults. The workshop identified promising interventions that could be tested, including interventions that focus on a single cardiovascular risk factor (e.g., lipids or inflammation) to multiple risk factor interventions (e.g., multicomponent lifestyle interventions or fixed-low dose combination of medications). Given the sample size and duration for a trial with hard endpoints, more research is needed on the utility of intermediate endpoints identified noninvasively such as subclinical coronary atherosclerosis as a surrogate endpoint. For now, clinical outcomes trials with hard endpoints will more likely change clinical practice. Trial efficiency depends on accurate identification of high-risk young adults, which can potentially be done using traditional risk equations, coronary artery calcium screening, computerized tomography coronary angiography, and polygenic risk scores. Trials in young adults should include enhanced recruitment strategies with intense community engagement to enroll a trial population that is racially, ethnically, geographically, and socially diverse. Despite the challenges in conducting large prevention trials in young adults, recent advances including innovation in clinical trial conduct, new therapies and successful interventions in older populations, and an increasing recognition of a lifespan approach to risk assessment have made such trials more feasible than ever.

Disclosures

The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.

Myocardial Radiomics Texture Features Associated with Increased Coronary Calcium Score—First Results of a Photon-Counting CT

The coronary artery calcium score is an independent risk factor of the development of adverse cardiac events. The severity of coronary artery calcification may influence the myocardial texture. Due to higher spatial resolution and signal-to-noise ratio, new CT technologies such as PCCT may improve the detection of texture alterations depending on the severity of coronary artery calcification. In this retrospective, single-center, IRB-approved study, left ventricular myocardium was segmented and radiomics features were extracted using pyradiomics. The mean and standard deviation with the Pearson correlation coefficient for correlations of features were calculated and visualized as boxplots and heatmaps. Random forest feature selection was performed. Thirty patients (26.7% women, median age 58 years) were enrolled in the study. Patients were divided into two subgroups depending on the severity of coronary artery calcification (Agatston score 0 and Agatston score ≥ 100). Through random forest feature selection, a set of four higher-order features could be defined to discriminate myocardial texture between the two groups. When including the additional Agatston 1–99 groups as a validation, a severity-associated change in feature intensity was detected. A subset of radiomics features texture alterations of the left ventricular myocardium was associated with the severity of coronary artery calcification estimated by the Agatston score.

Impact of Adaptive Statistical Iterative Reconstruction-V on Coronary Artery Calcium Scores Obtained From Low-Tube-Voltage Computed Tomography - A Patient Study

OBJECTIVE

To evaluate the impact of adaptive statistical iterative reconstruction-V (ASIR-V) on the accuracy of ultra-low-dose coronary artery calcium (CAC) scoring.

MATERIALS AND METHOD

One-hundred-and-three patients who underwent computed tomography (CT) for CAC scoring were prospectively included. All underwent standard scanning with 120-kilovolt-peak (kVp) and with 80- and 70-kVp tube voltage. ASiR-V was applied to the 80- and 70-kVp scans at different levels. The 120-kVp scans reconstructed with filtered back projection served as the standard of reference. Recently published novel kVp-adapted thresholds were used for calculation of CAC scores from 80- and 70-kVp scans and the resulting CAC scores were compared against the standard of reference. Patients were stratified into six CAC score risk categories: 0, 1-10, 11-100, 101-400, 401-1000, and >1000.

RESULTS

Increasing levels of ASIR-V led to an increasing underestimation of CAC scores with bias ranging from -128 to -118 and from -205 to -198 for the 80- and 70-kVp scans, respectively, when compared with the standard of reference. Reconstruction with 20% and 40% ASIR-V for the 80- and 70-kVp scans, respectively, yielded noise levels comparable to the standard of reference. Nevertheless, a change in risk-class was observed in 29 (28.6%) and 46 (44.7%) patients, exclusively to a lower risk-class, when CAC scores were derived from these reconstructions.

CONCLUSION

ASIR-V leads to noise reduction in CT scans acquired with low tube-voltages. However, ASIR-V introduces substantial inaccuracies and marked underestimation of ultra-low-dose CAC scoring as compared with standard-dose CAC scoring despite normalization of noise.

Accurate Measurement of Agatston Score Using kVp-Independent Reconstruction Algorithm for Ultra-High-Pitch Sn150 kVp CT

OBJECTIVE

To investigate the accuracy of the Agatston score obtained with the ultra-high-pitch (UHP) acquisition mode using tin-filter spectral shaping (Sn150 kVp) and a kVp-independent reconstruction algorithm to reduce the radiation dose.

MATERIALS AND METHODS

This prospective study included 114 patients (mean ± standard deviation, 60.3 ± 9.8 years; 74 male) who underwent a standard 120 kVp scan and an additional UHP Sn150 kVp scan for coronary artery calcification scoring (CACS). These two datasets were reconstructed using a standard reconstruction algorithm (120 kVp + Qr36d, protocol A; Sn150 kVp + Qr36d, protocol B). In addition, the Sn150 kVp dataset was reconstructed using a kVp-independent reconstruction algorithm (Sn150 kVp + Sa36d, protocol C). The Agatston scores for protocols A and B, as well as protocols A and C, were compared. The agreement between the scores was assessed using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. The radiation doses for the 120 kVp and UHP Sn150 kVp acquisition modes were also compared.

RESULTS

No significant difference was observed in the Agatston score for protocols A (median, 63.05; interquartile range [IQR], 0-232.28) and C (median, 60.25; IQR, 0-195.20) (p = 0.060). The mean difference in the Agatston score for protocols A and C was relatively small (-7.82) and with the limits of agreement from -65.20 to 49.56 (ICC = 0.997). The Agatston score for protocol B (median, 34.85; IQR, 0-120.73) was significantly underestimated compared with that for protocol A (p < 0.001). The UHP Sn150 kVp mode facilitated an effective radiation dose reduction by approximately 30% (0.58 vs. 0.82 mSv, p < 0.001) from that associated with the standard 120 kVp mode.

CONCLUSION

The Agatston scores for CACS with the UHP Sn150 kVp mode with a kVp-independent reconstruction algorithm and the standard 120 kVp demonstrated excellent agreement with a small mean difference and narrow agreement limits. The UHP Sn150 kVp mode allowed a significant reduction in the radiation dose.

Multi-Ethnic Study of Atherosclerosis (MESA): JACC Focus Seminar 5/8

The MESA (Multi-Ethnic Study of Atherosclerosis) is a National Heart, Lung, and Blood Institute-sponsored prospective study aimed at studying the prevalence, progression, determinants, and prognostic significance of subclinical cardiovascular disease in a sex-balanced, multiethnic, community-dwelling U.S. cohort. MESA helped usher in an era of noninvasive evaluation of subclinical atherosclerosis presence, burden, and progression for the evaluation of atherosclerotic cardiovascular disease risk, beyond what could be predicted by traditional risk factors alone. Concepts developed in MESA have informed international patient care guidelines, providing new tools to effectively guide public health policy, population screening, and clinical decision-making. MESA is grounded in an open science model that continues to be a beacon for collaborative science. In this review, we detail the original goals of MESA, and describe how the scope of MESA has evolved over time. We highlight 10 significant MESA contributions to cardiovascular medicine, and chart the path forward for MESA in the year 2021 and beyond.

Role of coronary artery calcium score in the primary prevention of cardiovascular disease

First developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called "power of zero"), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to de-risk individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.

Polypills in Cardiovascular Disease Prevention: Mass-Strategy Approach, Precision Medicine, or an Essential Intertwine Between Them?

PURPOSE OF REVIEW

This review considers the framework of high-risk vs. population approaches as proposed in the Rose's axiom within the context of cardiovascular diseases, including its benefits and limitations. We also contextualize the use of precision medicine in primary prevention therapy and contrast that with population approach.

RECENT FINDINGS

Although the high-risk strategy aims at individualized care, the complexity of pharmacologic regimens and other limitations reduces its real-life impact. On the other hand, broad population strategies include treatment of a substantial number of low-risk individuals who are unlikely to benefit from treatment. The use of additional strategies to identify those low-risk individuals, instead of targeting at identifying the high-risk population, is and alternative strategy to be considered. Evidence of the potential use of coronary artery calcium score and polypills for this strategy is discussed. A more targeted population approach to primary prevention in cardiovascular diseases with the use of polypills and coronary artery calcium score might be considered in a structured mass-strategy approach to risk reduction.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Evaluation of an AI-based, automatic coronary artery calcium scoring software

Objectives

To evaluate an artificial intelligence (AI)–based, automatic coronary artery calcium (CAC) scoring software, using a semi-automatic software as a reference.

Methods

This observational study included 315 consecutive, non-contrast-enhanced calcium scoring computed tomography (CSCT) scans. A semi-automatic and an automatic software obtained the Agatston score (AS), the volume score (VS), the mass score (MS), and the number of calcified coronary lesions. Semi-automatic and automatic analysis time were registered, including a manual double-check of the automatic results. Statistical analyses were Spearman’s rank correlation coefficient (⍴), intra-class correlation (ICC), Bland Altman plots, weighted kappa analysis (κ), and Wilcoxon signed-rank test.

Results

The correlation and agreement for the AS, VS, and MS were ⍴ = 0.935, 0.932, 0.934 (p < 0.001), and ICC = 0.996, 0.996, 0.991, respectively (p < 0.001). The correlation and agreement for the number of calcified lesions were ⍴ = 0.903 and ICC = 0.977 (p < 0.001), respectively. The Bland Altman mean difference and 1.96 SD upper and lower limits of agreements for the AS, VS, and MS were − 8.2 (− 115.1 to 98.2), − 7.4 (− 93.9 to 79.1), and − 3.8 (− 33.6 to 25.9), respectively. Agreement in risk category assignment was 89.5% and κ = 0.919 (p < 0.001). The median time for the semi-automatic and automatic method was 59 s (IQR 35–100) and 36 s (IQR 29–49), respectively (p < 0.001).

Conclusions

There was an excellent correlation and agreement between the automatic software and the semi-automatic software for three CAC scores and the number of calcified lesions. Risk category classification was accurate but showing an overestimation bias tendency. Also, the automatic method was less time-demanding.

Key Points

• Coronary artery calcium (CAC) scoring is an excellent candidate for artificial intelligence (AI) development in a clinical setting.

• An AI-based, automatic software obtained CAC scores with excellent correlation and agreement compared with a conventional method but was less time-consuming.

Association of mineral content outside of bone with coronary artery calcium and 1-year cardiovascular prognosis in maintenance hemodialysis patients

Coronary artery calcifications (CACs) are common among maintenance hemodialysis (MHD) patients and associated with increased morbidity and mortality due to cardiovascular events. The insight into chronic kidney disease‐mineral and bone disorder (CKD‐MBD) established a correlation between dysregulated mineral metabolism and CACs. This study aimed to identify the association of mineral content outside of bone (MCOB) with CACs and cardiovascular events in MHD patients. In the pilot prospective study with no intervention, patients underwent body composition assessment by body composition monitor after hemodialysis and computed tomography examination using the Agatston scoring method simultaneously within a week. The primary end point included cardiovascular events and cardiovascular death. Correlations and receiver operating characteristic analysis elucidated the associations of MCOB with CACs; multivariate analysis assessed the cardiovascular risk for groups with different MCOB. One hundred three eligible patients with an average age of 48 (35‐63) years old were enrolled and followed up to 12 (11‐12.5) months, among which 52.4% had detectable CACs at baseline. MCOB showed an inverse correlation with Agatston score and significantly discriminated the patients with Agatston score > 0 (AUC = 0.737; P < 0.001) and 400 (AUC = 0.733; P < 0.001). MCOB ≤ 9.2657 mg/kg was an independent risk factor for CACs (OR = 4.853; P = 0.044) and strong predictor for cardiovascular morbidity and mortality (HR = 10.108; P = 0.042), as well as rehospitalization (HR = 2.689; P = 0.004). MCOB inversely correlated with the presence and extent of CACs, and could discriminate Agatston score > 0 and 400, which also presented as an independent indicator for CKD‐MBD and 1‐year cardiovascular prognosis in adult MHD patients. Additional studies are required for identifying this issue.

Statin Trials, Cardiovascular Events, and Coronary Artery Calcification: Implications for a Trial-Based Approach to Statin Therapy in MESA

OBJECTIVES

This study sought to determine whether coronary artery calcium (CAC) could be used to optimize statin allocation among individuals for whom trial-based evidence supports efficacy of statin therapy.

BACKGROUND

Recently, allocation of statins was proposed for primary prevention of atherosclerotic cardiovascular disease (ASCVD) based on proven efficacy from randomized controlled trials (RCTs) of statin therapy, a so-called trial-based approach.

METHODS

The study used data from MESA (Multi-Ethnic Study of Atherosclerosis) with 5,600 men and women, 45 to 84 years of age, and free of clinical ASCVD, lipid-lowering therapy, or missing information for risk factors at baseline examination.

RESULTS

During 10 years' follow-up, 354 ASCVD and 219 hard coronary heart disease (CHD) events occurred. Based on enrollment criteria for 7 RCTs of statin therapy in primary prevention, 73% of MESA participants (91% of those >55 years of age) were eligible for statin therapy according to a trial-based approach. Among those individuals, CAC = 0 was common (44%) and was associated with low rates of ASCVD and CHD (3.9 and 1.7, respectively, per 1,000 person-years). There was a graded increase in event rates with increasing CAC score, and in individuals with CAC >100 (27% of participants) the rates of ASCVD and CHD were 18.9 and 12.7, respectively. Consequently, the estimated number needed to treat (NNT) in 10 years to prevent 1 event varied greatly according to CAC score. For ASCVD events, the NNT was 87 for CAC = 0 and 19 for CAC >100. For CHD events, the NNT was 197 for CAC = 0 and 28 for CAC >100.

CONCLUSIONS

Most MESA participants qualified for trial-based primary prevention with statins. Among the individuals for whom trial-based evidence supports efficacy of statin therapy, CAC = 0 and CAC >100 were common and associated with low and high cardiovascular risks, respectively. This information may guide shared decision making aimed at targeting evidence-based statins to those who are likely to benefit the most.

Providing Evidence for Subclinical CVD in Risk Assessment

When the MESA (Multi-Ethnic Study of Atherosclerosis) began, the Framingham risk score was the preferred tool for 10-year global coronary heart disease risk assessment; however, the Framingham risk score had limitations including derivation in a homogenous population lacking racial and ethnic diversity and exclusive reliance on traditional risk factors without consideration of most subclinical disease measures. MESA was designed to study the prognostic value of subclinical atherosclerosis and other risk markers in a multiethnic population. In a series of landmark publications, MESA demonstrated that measures of subclinical cardiovascular disease add significant prognostic value to the traditional Framingham risk variables. In head-to-head studies comparing these markers, MESA established that the coronary artery calcium score may be the single best predictor of coronary heart disease risk. Results from MESA have directly influenced recent prevention guidelines including the recommendations on risk assessment and cholesterol-lowering therapy. The MESA study has published its own risk score, which allows for the calculation of 10-year risk of coronary heart disease before and after knowledge of a coronary artery calcium score.

Strengths and Limitations of Using the Polypill in Cardiovascular Prevention

Purpose of Review

Polypill and its role in cardiovascular disease (CVD) prevention has been extensively discussed and debated since the inception of the concept in 2003. This article reviews the subsequent accumulated research in this area.

Recent Findings

Several short and intermediate to long-term studies with different brands of polypills have analysed the impact of polypill in phase II and III trials. The strengths of polypill that have emerged include better adherence, equivalent or better risk factor control and quality of life among polypill users as compared to usual care. The lurking limitations include difficulty with dose adjustment to targets, fear of mass medicalisation and low acceptability among physicians.

Summary

The current literature supports polypill use in reducing blood pressure and cholesterol levels for CVD prevention with improvement in adherence to medication. However, the long-term outcome of polypill on CVD events and mortality are unavailable and are currently being studied in clinical trials.

Coronary artery calcification and cognitive function: cross-sectional results from the ELSA-Brasil study

OBJECTIVES

We examined the relationship between coronary artery calcification (CAC) score and performance in cognitive tests in a large Brazilian sample.

METHODS

In this cross-sectional study, 4104 participants (mean age = 50.9 ± 8.8 years old, 54% female) from the Brazilian Longitudinal Study of Adult Health had complete information for CAC and cognitive tests. We used linear regression models adjusted for sociodemographics, cardiovascular risk factors (hypertension, diabetes, smoking, alcohol use, physical activity, and body mass index), depression, and thyroid function. To investigate potential different associations for middle-aged and older adults, we stratified the analysis by age groups.

RESULTS

Participants with CAC ≥ 100 Agatston score had poorer performance in the trail making test compared to those with CAC < 100 Agatston score (β = -0.101, 95% CI = -0.194; -0.010, p = 0.03). We did not find any other association between CAC and cognitive tests. When we investigated the effect modification between CAC and age on cognitive tests, only the effect modification on global cognition (p = 0.02) and trail making test was significant (p = 0.0003).

CONCLUSIONS

Higher CAC was weakly associated with poorer performance in an executive function test in a large sample from the Brazilian Longitudinal Study of Adult Health. Copyright © 2017 John Wiley & Sons, Ltd.

Coronary Artery Calcium Score for Long-term Risk Classification in Individuals With Type 2 Diabetes and Metabolic Syndrome From the Multi-Ethnic Study of Atherosclerosis

Importance

Although the risk of type 2 diabetes is considered to be equivalent to coronary heart disease (CHD) risk, there is considerable heterogeneity among individuals for CHD and atherosclerotic cardiovascular disease (ASCVD) risk. It is not known whether coronary artery calcium (CAC) assessment at baseline in individuals with established metabolic syndrome (MetS) or diabetes identifies CHD and ASCVD prognostic indicators during a long follow-up period.

Objective

To compare improvement in long-term prognostication of incident CHD and ASCVD using CAC scores among those with diabetes, MetS, or neither condition.

Design, Setting, and Participants

This study included participants from the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study of 6814 males and females aged 45 to 84 years without known CVD from 4 race/ethnicity groups (white [38.5%], African American [27.5%], Hispanic [22.1%], and Chinese [11.9%]) recruited from 6 US communities from July 2000 through August 2002. Follow-up for each participant extended to the first occurrence of an incident event, other death, loss to follow-up, or the last follow-up call through December 31, 2013. Data analysis was performed from June 1, 2016, to September 12, 2017. Cox proportional hazards regression models were used to estimate hazard ratios (HRs). Area under the receiver operator characteristic curve and net reclassification improvement were used to compare incremental contributions of CAC score when added to the Framingham risk score, ethnicity/race, and socioeconomic status.

Main Outcomes and Measures

CHD events, including myocardial infarction, resuscitated cardiac arrest, or CHD death.

Results

Of 6814 MESA participants, 6751 had complete risk factor and follow-up data and were included in this study (mean [SD] age, 62.2 [10.2] years; 3186 [47.2%] male). A total of 881 (13.0%) had diabetes, 1738 (25.7%) had MetS, and 4132 (61.2%) had neither condition. After 11.1 mean years of follow-up, CHD events occurred in 84 participants with diabetes (135 ASCVD events), 115 with MetS (175 ASCVD events), and 157 with neither (250 ASCVD events). The CAC score was independently associated with incident CHD in multivariable analyses in those with diabetes (HR, 1.30; 95% CI, 1.19-1.43), MetS (HR, 1.30; 95% CI, 1.20-1.41), and neither condition (HR, 1.37; 95% CI, 1.27-1.47). For incident CHD, net reclassification improvement with addition of CAC score was 0.23 (95% CI, 0.10-0.37) in those with diabetes, 0.22 (95% CI, 0.09-0.35) in those with MetS, and 0.25 (95% CI, 0.15-0.35) in those with neither condition. The CAC score was also a prognostic indicator of CHD and ASCVD after controlling for diabetes duration of 10 years or longer at baseline, insulin use, and glycemic control.

Conclusions and Relevance

In a large multiethnic cohort, the addition of CAC score to global risk assessment was associated with significantly improved risk classification in those with MetS and diabetes, even if diabetes duration was longer than a decade, suggesting a role for the CAC score in risk assessment in such patients.

Comparative analysis of high-sensitivity cardiac troponin I and T for their association with coronary computed tomography-assessed calcium scoring represented by the Agatston score

Background

This study evaluates the association between high-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) and coronary calcium concentration (CAC) detected by coronary computed tomography (CCT) and evaluated with the Agatston score in patients with suspected coronary artery disease (CAD).

Methods

Patients undergoing CCT during routine clinical care were enrolled prospectively. CCT was indicated for patients with a low to intermediate pretest probability for CAD. Within 24 h of CCT examination, peripheral blood samples were taken to measure cardiac biomarkers hs-cTnI and hs-cTnT.

Results

A total of 76 patients were enrolled including 38% without detectable CAC, 36% with an Agatston score from 1 to 100, 17% from 101 to 400, and 9% with values ≥ 400. hs-cTnI was increasing alongside Agatston score and was able to differentiate between different groups of Agatston scores. Both hs-cTn discriminated values greater than 100 (hs-cTnI, AUC = 0.663; p = 0.032; hs-cTnT, AUC = 0.650; p = 0.048). In univariate and multivariate logistic regression models, hs-cTnT and hs-cTnI were significantly associated with increased Agatston scores. Patients with hs-cTnT ≥ 0.02 µg/l and hs-cTnI ≥ 5.5 ng/l were more likely to reveal values ≥ 400 (hs-cTnT; OR = 13.4; 95% CI 1.545–116.233; p = 0.019; hs-cTnI; OR = 8.8; 95% CI 1.183–65.475; p = 0.034).

Conclusion

The present study shows that the Agatston score was significantly correlated with hs cardiac troponins, both in univariable and multivariable linear regression models. Hs-cTnI is able to discriminate between different Agatston values. The present results might reveal potential cut-off values for hs cardiac troponins regarding different Agatston values.

Trial registration Cardiovascular Imaging and Biomarker Analyses (CIBER), NCT03074253 https://clinicaltrials.gov/ct2/show/record/NCT03074253

Coronary Plaque Morphology and the Anti-Inflammatory Impact of Atorvastatin: A Multicenter 18F-Fluorodeoxyglucose Positron Emission Tomographic/Computed Tomographic Study

Supplemental Digital Content is available in the text.

Background—

Nonobstructive coronary plaques manifesting high-risk morphology (HRM) associate with an increased risk of adverse clinical cardiovascular events. We sought to test the hypothesis that statins have a greater anti-inflammatory effect within coronary plaques containing HRM.

Methods and Results—

In this prospective multicenter study, 55 subjects with or at high risk for atherosclerosis underwent ¹⁸F-fluorodeoxyglucose positron emission tomographic/computed tomographic imaging at baseline and after 12 weeks of treatment with atorvastatin. Coronary arterial inflammation (¹⁸F-fluorodeoxyglucose uptake, expressed as target-to-background ratio) was assessed in the left main coronary artery (LMCA). While blinded to the PET findings, contrast-enhanced computed tomographic angiography was performed to characterize the presence of HRM (defined as noncalcified or partially calcified plaques) in the LMCA. Arterial inflammation (target-to-background ratio) was higher in LMCA segments with HRM than those without HRM (mean±SEM: 1.95±0.43 versus 1.67±0.32 for LMCA with versus without HRM, respectively; P=0.04). Moreover, atorvastatin treatment for 12 weeks reduced target-to-background ratio more in LMCA segments with HRM than those without HRM (12 week-baseline Δtarget-to-background ratio [95% confidence interval]: −0.18 [−0.35 to −0.004] versus 0.09 [−0.06 to 0.26]; P=0.02). Furthermore, this relationship between coronary plaque morphology and change in LMCA inflammatory activity remained significant after adjusting for baseline low-density lipoprotein and statin dose (β=−0.27; P=0.038).

Conclusions—

In this first study to evaluate the impact of statins on coronary inflammation, we observed that the anti-inflammatory impact of statins is substantially greater within coronary plaques that contain HRM features. These findings suggest an additional mechanism by which statins disproportionately benefit individuals with more advanced atherosclerotic disease.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00703261.

Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability worldwide, yet ASCVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure- and cholesterol-lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of ASCVD.

OBJECTIVES

To determine the effect of fixed-dose combination therapy on all-cause mortality, fatal and non-fatal ASCVD events, and adverse events. We also sought to determine the effect of fixed-dose combination therapy on blood pressure, lipids, adherence, discontinuation rates, health-related quality of life, and costs.

SEARCH METHODS

We updated our previous searches in September 2016 of CENTRAL, MEDLINE, Embase, ISI Web of Science, and DARE, HTA, and HEED. We also searched two clinical trials registers in September 2016. We used no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure-lowering and one lipid-lowering component versus usual care, placebo, or an active drug comparator for any treatment duration in adults 18 years old or older, with no restrictions on presence or absence of pre-existing ASCVD.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies for inclusion and extracted the data for this update. We evaluated risk of bias using the Cochrane 'Risk of bias' assessment tool. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I2 < 50%) and random-effects models when heterogeneity was high (I2 ≥ 50%). We used the GRADE approach to evaluate the quality of evidence.

MAIN RESULTS

In the initial review, we identified nine randomised controlled trials with a total of 7047 participants and four additional trials (n = 2012 participants; mean age range 62 to 63 years; 30% to 37% women) were included in this update. Eight of the 13 trials evaluated the effects of fixed-dose combination (FDC) therapy in populations without prevalent ASCVD, and the median follow-up ranged from six weeks to 23 months. More recent trials were generally larger with longer follow-up and lower risk of bias. The main risk of bias was related to lack of blinding of participants and personnel, which was inherent to the intervention. Compared with the comparator groups (placebo, usual care, or active drug comparator), the effects of the fixed-dose combination treatment on mortality (FDC = 1.0% versus control = 1.0%, RR 1.10, 95% CI 0.64 to 1.89,  I2 = 0%, 5 studies, N = 5300) and fatal and non-fatal ASCVD events (FDC = 4.7% versus control = 3.7%, RR 1.26, 95% CI 0.95 to 1.66, I2 = 0%, 6 studies, N = 4517) were uncertain (low-quality evidence). The low event rates for these outcomes and indirectness of evidence for comparing fixed-dose combination to usual care versus individual drugs suggest that these results should be viewed with caution. Adverse events were common in both the intervention (32%) and comparator (27%) groups, with participants randomised to fixed-dose combination therapy being 16% (RR 1.16, 95% CI 1.09 to 1.25, 11 studies, 6906 participants, moderate-quality evidence) more likely to report an adverse event . The mean differences in systolic blood pressure between the intervention and control arms was -6.34 mmHg (95% CI -9.03 to -3.64, 13 trials, 7638 participants, moderate-quality evidence). The mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.61 mmol/L (95% CI -0.88 to -0.35, 11 trials, 6565 participants, low-quality evidence) and -0.70 mmol/L (95% CI -0.98 to -0.41, 12 trials, 7153 participants, moderate-quality evidence), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I2 ≥ 80% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multidrug strategy by 44% (26% to 65%) compared with usual care (4 trials, 3835 participants, moderate-quality evidence).

AUTHORS' CONCLUSIONS

The effects of fixed-dose combination therapy on all-cause mortality or ASCVD events are uncertain. A limited number of trials reported these outcomes, and the included trials were primarily designed to observe changes in ASCVD risk factor levels rather than clinical events, which may partially explain the observed differences in risk factors that were not translated into differences in clinical outcomes among the included trials. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, active comparator, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing, longer-term trials of fixed-dose combination therapy will help demonstrate whether short-term changes in risk factors might be maintained and lead to expected differences in clinical events based on these changes.

Assessment of Coronary Artery Calcium Scoring for Statin Treatment Strategy according to ACC/AHA Guidelines in Asymptomatic Korean Adults

PURPOSE

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines advocate the use of statin treatment for prevention of cardiovascular disease. We aimed to assess the usefulness of coronary artery calcium (CAC) for stratifying potential candidates of statin use among asymptomatic Korean individuals.

MATERIALS AND METHODS

A total of 31375 subjects who underwent CAC scoring as part of a general health examination were enrolled in the current study. Statin eligibility was categorized as statin recommended (SR), considered (SC), and not recommended (SN) according to ACC/AHA guidelines. Cox regression analysis was employed to estimate hazard ratios (HR) with 95% confidential intervals (CI) after stratifying the subjects according to CAC scores of 0, 1-100, and >100. Number needed to treat (NNT) to prevent one mortality event during study follow up was calculated for each group.

RESULTS

Mean age was 54.4±7.5 years, and 76.3% were male. During a 5-year median follow-up (interquartile range; 3-7), there were 251 (0.8%) deaths from all-causes. A CAC >100 was independently associated with mortality across each statin group after adjusting for cardiac risk factors (e.g., SR: HR, 1.60; 95% CI, 1.07-2.38; SC: HR, 2.98; 95% CI, 1.09-8.13, and SN: HR, 3.14; 95% CI, 1.08-9.17). Notably, patients with CAC >100 displayed a lower NNT in comparison to the absence of CAC or CAC 1-100 in SC and SN groups.

CONCLUSION

In Korean asymptomatic individuals, CAC scoring might prove useful for reclassifying patient eligibility for receiving statin therapy based on updated 2013 ACC/AHA guidelines.

2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology

The Society of Cardiovascular Computed Tomography (SCCT) and the Society of Thoracic Radiology (STR) have jointly produced this document. Experts in this subject have been selected from both organizations to examine subject-specific data and write this guideline in partnership. A formal literature review, weighing the strength of evidence has been performed. When available, information from studies on cost was considered. Computed tomography (CT) acquisition, CAC scoring methodologies and clinical outcomes are the primary basis for the recommendations in this guideline. This guideline is intended to assist healthcare providers in clinical decision making. The recommendations reflect a consensus after a thorough review of the best available current scientific evidence and practice patterns of experts in the field and are intended to improve patient care while acknowledging that situations arise where additional information may be needed to better inform patient care.

CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines

OBJECTIVES

The aim of this study was to assess the difference in indication for statin therapy by European Society of Cardiology (ESC) versus American Heart Association/American College of Cardiology (AHA/ACC) guidelines and to quantify the potential additional role of coronary artery calcification (CAC) score over updated guidelines in a primary prevention cohort.

BACKGROUND

Recently, ESC and AHA/ACC updated the guidelines regarding statin therapy in primary prevention.

METHODS

In 3,745 subjects (59 ± 8 years of age, 47% men) from the population based longitudinal Heinz Nixdorf Recall cohort study without cardiovascular disease or lipid-lowering therapy at baseline CAC score was assessed between 2000 and 2003. Subjects remained unaware of their initial CAC score. Statin indication was determined according to 2012 ESC and 2013 AHA/ACC guidelines based on subjects individual baseline characteristics.

RESULTS

The frequency of statin recommendation was lower according to ESC compared to AHA/ACC guidelines (34% vs. 56%; p < 0.0001), whereas low CAC score (<100) was common in subjects with statin indication by both guidelines (59% for ESC, 62% for AHA/ACC). During 10.4 ± 2.0 years of follow-up, 131 myocardial infarctions occurred. For ESC recommendations, CAC score differentiated risk for subjects without (1.0 [95% confidence interval (CI): 0.4 to 1.5] vs. 6.5 [95% CI: 4.1 to 8.9] coronary events per 1,000 person-years for CAC 0 vs. ≥100) and with statin indication (2.6 [95% CI: 0.6 to 4.7] vs. 9.9 [95% CI: 7.3 to 12.5] per 1,000 person-years for CAC 0 vs. ≥100). Likewise, CAC score stratified proportions experiencing events subjects with statin indication according to AHA/ACC (2.7 [95% CI: 1.1 to 4.2] vs. 9.1 [95% CI: 7.0 to 11.0] per 1,000 person-years for CAC 0 vs. ≥100), whereas event rate in subjects without statin indication was low (1.1 [95% CI: 0.65 to 1.68] per 1,000 person-years).

CONCLUSIONS

Current ESC and AHA/ACC guidelines lead to markedly different recommendation regarding statin therapy in a German primary prevention cohort. Quantification of CAC score in addition to the guidelines improves stratification between subjects at high versus low risk for coronary events, indicating that CAC scoring may help to match intensified risk factor modification to atherosclerotic plaque burden as well as actual risk while avoiding therapy in subjects with low coronary atherosclerosis that have low 10-year event rate.

Usefulness of the Polypill for the Prevention of Cardiovascular Disease and Hypertension

Cardiovascular disease (CVD) remains the leading cause of death in the developed countries and is estimated to be the leading cause of death in the developing countries by the year 2030. The cause for this rise in CVD is the increase in the major CVD risk factors (CVRFs) like hypertension, obesity, diabetes, and hyperlipidemia, which account for 80 % of all CVD deaths worldwide. In order to prevent the increase in CVD, it has been proposed to develop a low-cost polypill containing four to five generic drugs with known effectiveness in the reduction of the CVRFs. This polypill has now been tested in several recent studies for the primary and secondary prevention of CVD and stroke with fairly good results. A Medline search of the English language literature between 2011 and 2015 resulted in the identification of 15 studies with pertinent findings. These findings together with collateral literature will be discussed in this review.

Multimodality Imaging in Coronary Artery Disease: Focus on Computed Tomography

Coronary artery disease (CAD) is the leading cause of mortality worldwide, and various cardiovascular imaging modalities have been introduced for the purpose of diagnosing and determining the severity of CAD. More recently, advances in computed tomography (CT) technology have contributed to the widespread clinical application of cardiac CT for accurate and noninvasive evaluation of CAD. In this review, we focus on imaging assessment of CAD based upon CT, which includes coronary artery calcium screening, coronary CT angiography, myocardial CT perfusion, and fractional flow reserve CT. Further, we provide a discussion regarding the potential implications, benefits and limitations, as well as the possible future directions according to each modality.

Use of imaging and clinical data to screen for cardiovascular disease in asymptomatic diabetics

Background

There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches.

Methods

98 asymptomatic individuals with T2DM without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA).

Results

Of 98 subjects (average age 55 ± 6, 64 % female), 43 (44 %) had coronary plaque detectable on CTA, and 38 (39 %) had CAC score >0. By CTA, 16 (16 %) had coronary stenosis ≥50 %, including three subjects with CAC = 0. Subjects with coronary plaque had greater prevalence of carotid plaque (58 % vs. 38 %, p = 0.01) and greater carotid intima media thickness (0.80 ± 0.20 mm vs. 0.70 ± 0.11 mm, p = 0.02). Notably, 18 of 55 subjects (33 %) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom five had ≥ 50 % coronary stenosis, two had <50 % stenosis, and one had no CAD. Among these tests, CAC scoring had the highest sensitivity and specificity for prediction of CAD.

Conclusion

Among asymptomatic subjects with T2DM, a majority (56 %) had no CAD by CTA. When compared to CTA, CAC was the most accurate screening modality for detection of CAD, while ETT and carotid ultrasound were less sensitive and specific. However, 33 % of subjects with normal coronary CTA had carotid plaque, suggesting that screening for carotid plaque might better characterize stroke risk in such patients.

Coronary artery calcium scanning: past, present, and future

Coronary artery calcium scanning (CAC) has emerged as the most robust predictor of coronary events in the asymptomatic primary prevention population, particularly in the intermediate-risk cohort. Every study has demonstrated its superiority to risk factor-based paradigms, e.g., the Framingham Risk Score, with outcome-based net reclassification indexes ranging from 52.0% to 65.6% in the intermediate-risk, 34.0% to 35.8% in the high-risk, and 11.6% to 15.0% in the low-risk cohorts. CAC improves medication and lifestyle adherence and is cost-effective in specified populations, with the ability to effectively stratify the number needed to treat and scan for different therapeutic strategies and patient cohorts. Data have emerged clearly demonstrating the worse prognosis associated with increasing CAC on serial scans, suggesting a potential role for evaluating residual risk and treatment success or failure. CAC is also strongly associated with the development of stroke and congestive heart failure.

Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis)

BACKGROUND

The American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy.

OBJECTIVES

This study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not.

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis.

RESULTS

The study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years.

CONCLUSIONS

Significant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy.

2013 ACC/AHA versus 2004 NECP ATP III Guidelines in the Assignment of Statin Treatment in a Korean Population with Subclinical Coronary Atherosclerosis

Background

The usefulness of the 2013 ACC/AHA guidelines for the management of blood cholesterol in the Asian population remains controversial. In this study, we investigated whether eligibility for statin therapy determined by the 2013 ACC/AHA guidelines is better aligned with the presence of subclinical coronary atherosclerosis detected by CCTA (coronary computed tomography angiography) compared to the previously recommended 2004 NCEP ATP III guidelines.

Methods

We collected the data from 5,837 asymptomatic subjects who underwent CCTA using MDCT during routine health examinations. Based on risk factor assessment and lipid data, we determined guideline-based eligibility for statin therapy according to the 2013 ACC/AHA and 2004 NCEP ATP III guidelines. We defined the presence and severity of subclinical coronary atherosclerosis detected in CCTA according to the presence of significant coronary artery stenosis (defined as >50% stenosis), plaques, and the degree of coronary calcification.

Results

As compared to the 2004 ATP III guidelines, a significantly higher proportion of subjects with significant coronary stenosis (61.8% vs. 33.8%), plaques (52.3% vs. 24.7%), and higher CACS (CACS >100, 63.6% vs. 26.5%) was assigned to statin therapy using the 2013 ACC/AHA guidelines (P < .001 for all variables). The area under the curves of the pooled cohort equation of the new guidelines in detecting significant stenosis, plaques, and higher CACS were significantly higher than those of the Framingham risk calculator.

Conclusions

Compared to the previous ATP III guidelines, the 2013 ACC/AHA guidelines were more sensitive in identifying subjects with subclinical coronary atherosclerosis detected by CCTA in an Asian population.

Liver fat, statin use, and incident diabetes: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

To balance competing cardiovascular benefits and metabolic risks of statins, markers of type 2 diabetes (T2D) susceptibility are needed. We sought to define a competing risk/benefit of statin therapy on T2D and cardiovascular disease (CVD) events using liver attenuation and coronary artery calcification (CAC).

METHODS AND RESULTS

3153 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA) without CVD, T2D/impaired fasting glucose, or baseline statin therapy had CT imaging for CAC and hepatic attenuation (hepatic steatosis). Cox models and rates of CVD and T2D were calculated to assess the role of liver attenuation in T2D and the relative risks/benefits of statins on CVD and T2D. 216 T2D cases were diagnosed at median 9.1 years follow-up. High liver fat and statin therapy were associated with diabetes (HR 2.06 [95%CI 1.52-2.79, P < 0.0001] and 2.01 [95%CI 1.46-2.77, P < 0.0001], respectively), after multivariable adjustment. With low liver fat and CAC = 0, the number needed to treat (NNT) for statin to prevent one CVD event (NNT 218) was higher than the number needed to harm (NNH) with an incident case of T2D (NNH 68). Conversely, those with CAC >100 and low liver fat were more likely to benefit from statins for CVD reduction (NNT 29) relative to T2D risk (NNH 67). Among those with CAC >100 and fatty liver, incremental reduction in CVD with statins (NNT 40) was less than incremental risk increase for T2D (NNH 24).

CONCLUSIONS

Liver fat is associated with incident T2D and stratifies competing metabolic/CVD risks with statin therapy. Hepatic fat may inform T2D surveillance and lipid therapeutic strategies.

Automatic Coronary Calcium Scoring in Non-Contrast-Enhanced ECG-Triggered Cardiac CT With Ambiguity Detection

The amount of coronary artery calcification (CAC) is a strong and independent predictor of cardiovascular events. We present a system that automatically quantifies total patient and per coronary artery CAC in non-contrast-enhanced, ECG-triggered cardiac CT. The system identifies candidate calcifications that cannot be automatically labeled with high certainty and optionally presents these to an expert for review. Candidates were extracted by intensity-based thresholding and described by location features derived from estimated coronary artery positions, as well as size, shape and intensity features. Next, a two-class classifier distinguished between coronary calcifications and negatives or a multiclass classifier labeled CAC per coronary artery. Candidates that could not be labeled with high certainty were identified by entropy-based ambiguity detection and presented to an expert for review and possible relabeling. The system was evaluated with 530 test images. Using the two-class classifier, the intra-class correlation coefficient (ICC) between reference and automatically determined total patient CAC volume was 0.95. Using the multiclass classifier, the ICC between reference and automatically determined per artery CAC volume was 0.98 (LAD), 0.69 (LCX), and 0.95 (RCA). In 49% of CTs, no ambiguous candidates were identified, while review of the remaining CTs increased the ICC for total patient CAC volume to 1.00, and per artery CAC volume to 1.00 (LAD), 0.95 (LCX), and 0.99 (RCA). In conclusion, CAC can be automatically identified in non-contrast-enhanced ECG-triggered cardiac CT. Ambiguity detection with expert review may enable the application of automatic CAC scoring in the clinic with a performance comparable to that of a human expert.

Pathways Forward in Cardiovascular Disease Prevention One and a Half Years After Publication of the 2013 ACC/AHA Cardiovascular Disease Prevention Guidelines

The 2013 American College of Cardiology/American Heart Association cardiovascular disease prevention guidelines represent an important step forward in the risk assessment and management of atherosclerotic cardiovascular disease in clinical practice. Differentiated risk prediction equations for women and black individuals were developed, and convenient 10-year and lifetime risk assessment tools were provided, facilitating their implementation. Lifestyle modification was portrayed as the foundation of preventive therapy. In addition, based on high-quality evidence from randomized controlled trials, statins were prioritized as the first lipid-lowering pharmacologic treatment, and a shared decision-making model between the physician and the patient was emphasized as a key feature of personalized care. After publication of the guidelines, however, important limitations were also identified. This resulted in a constructive scientific debate yielding valuable insights into potential opportunities to refine recommendations, fill gaps in guidance, and better harmonize recommendations within and outside the United States. The latter point deserves emphasis because when guidelines are in disagreement, this may result in nonaction on the part of professional caregivers or nonadherence by patients. In this review, we discuss the key scientific literature relevant to the guidelines published in the year and a half after their release. We aim to provide cohesive, evidence-based views that may offer pathways forward in cardiovascular disease prevention toward greater consensus and benefit the practice of clinical medicine.

Is the association of hypertension with cardiovascular events stronger among the lean and normal weight than among the overweight and obese? The multi-ethnic study of atherosclerosis

Previous studies that suggest the association of hypertension with cardiovascular disease (CVD) events is stronger in the lean/normal weight than in the obese have either included smokers, diabetics, or cancer patients, or did not account for central obesity. This study examines the interaction of adiposity with hypertension on CVD events using body mass index (BMI)-based definitions of overweight and obesity, as well as waist circumference (WC) to assess adiposity. In the Multi-Ethnic Study of Atherosclerosis, we classified 3657 nonsmoking men and women, free of baseline clinical CVD, diabetes mellitus and cancer, into 7 BMI-WC combinations defined by ethnicity-specific BMI (normal, overweight, class 1 obese, and class 2/3 obese) and ethnicity- and sex-specific WC categories (optimal or nonoptimal). Adjusted absolute event rates per 1000 person-years and relative risks (95% confidence intervals) for CVD events for hypertension (blood pressure ≥140/90 or taking medication) versus no hypertension computed within adiposity categories were 9.3 versus 1.9 and 4.96 (2.56-9.60) for normal BMI/optimal WC, 13.2 versus 4.2 and 3.13 (0.99-9.86) for normal BMI/nonoptimal WC, 9.0 versus 4.5 and 2.00 (1.19-3.36) for overweight BMI/optimal WC, 8.4 versus 5.6 and 1.50 (0.88-2.54) for overweight BMI/nonoptimal WC,14.1 versus 2.1 and 6.75 (0.69-65.57) for class 1 obese/optimal WC, 10.1 versus 3.7 and 2.69 (1.41-5.16) for class 1 obese/nonoptimal WC, and 9.9 versus 6.9 and 1.45(0.60-3.52) for class 2/3 obese/WC pooled. This study found a large relative risk of CVD events associated with hypertension for normal BMI participants and more importantly similarly high absolute risks for both normal and obese BMI with hypertension.

Heterogeneity in statin indications within the 2013 american college of cardiology/american heart association guidelines

A standard ("core") implementation of American College of Cardiology/American Heart Association 2013 lipid guidelines (based on 10-year risk) dramatically increases the statin-eligible population in older Americans, raising controversy in the cardiovascular community. The guidelines also endorse a more "comprehensive" risk approach based in part on lifetime risk. The impact of this broader approach on statin eligibility remains unclear. We studied the impact of 2 different implementations of the new guidelines ("core" and "comprehensive") using the National Health and Nutrition Examination Survey. Although "core" guidelines led to 72.0 million subjects qualifying for statin therapy, the broader "comprehensive" application led to nearly a twofold greater estimate for statin-eligible subjects (121.2 million), with the greatest impact among those aged 21 to 45 years. Subjects indicated for statin therapy under comprehensive guidelines had a greater burden of cardiovascular risk factors and a higher lifetime risk of cardiovascular disease than those not indicated for statins. In particular, men aged 21 to 45 years had a 3.13-fold increased odds of being eligible for statin therapy only under the "comprehensive" guidelines (vs standard "core" guidelines; 95% confidence interval 2.82 to 3.47, p <0.0001). There were no racial differences. In conclusion, the "comprehensive" approach to statin eligibility espoused by the American College of Cardiology/American Heart Association 2013 guidelines would increase the statin-eligible population to over 120 million Americans, particularly targeting younger men with high-risk factor burden.