1
|
Williams KJ. Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late. Arterioscler Thromb Vasc Biol 2024; 44:48-64. [PMID: 37970716 DOI: 10.1161/atvbaha.123.320065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.
Collapse
Affiliation(s)
- Kevin Jon Williams
- Department of Cardiovascular Sciences, Department of Medicine, Lewis Katz School of Medicine at Temple University, PA
| |
Collapse
|
2
|
Leiknes JB, Hiorth A, Havnen J, Greve OJ, Kurz KD, Larsen AI. Estimating cardiac output from coronary CT angiography: an individualized compartment model in comparison to the Stewart-Hamilton method. Front Cardiovasc Med 2023; 10:1156332. [PMID: 38054087 PMCID: PMC10694230 DOI: 10.3389/fcvm.2023.1156332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/10/2023] [Indexed: 12/07/2023] Open
Abstract
Background Attenuation is correlated with the concentration of contrast medium (CM) in the arteries. The cardiac output (CO) affects the concentration of CM in the circulatory system; therefore, CO affects the time-density curve (TDC). Thus, estimating CO using TDC from test-bolus images acquired in computed tomography (CT) is possible. In this study, we compare two methods of estimating CO, namely, an individualized mathematical compartment model, integrating patient, contrast, and scanning factors with TDC, and the Stewart-Hamilton method based on the area under the curve of the TDC. Materials and methods Attenuation in the aorta was measured during test-bolus in 40 consecutive patients with a clinical indication for coronary CT angiography (CCTA). Each participant underwent cardiac magnetic resonance imaging following CCTA to validate the estimated CO. The individual compartment model used TDC in conjunction with scanning and patient-specific parameters to estimate the concentration of CM and CO over time. This was compared to the CO calculated from the area under the curve using the Stewart-Hamilton method. Results Both CO estimated with our individualized compartment model (r = 0.66, p < 0.01) and the Stewart-Hamilton method (r = 0.53, p < 0.01) were moderately correlated with CO measured with cardiac MRI. Body surface area (BSA) and time to peak (TTP) affected the accuracy of our model. Lower BSA resulted in overestimation, and lower TTP resulted in CO underestimation, respectively. We found no gender-specific difference in the accuracy of our model when correcting for BSA. The Stewart-Hamilton method performed better with a more complete TDC, whereas the compartment model performed better overall with a partial TDC. Conclusion The TDC acquired in CCTA allows for CO estimation. Both the Stewart-Hamilton method and our mathematical compartment model show moderate correlation when applied to our data, although each method has its strengths and limitations. If the majority of the TDC is known, the Stewart-Hamilton method may be more reliable, but an individual compartment model is preferable when there are insufficient data points in the TDC. Regardless, both methods can potentially increase the diagnostic information acquired from a CCTA, which is increasingly recommended in clinical guidelines.
Collapse
Affiliation(s)
- Jon Bjarne Leiknes
- Stavanger Medical Imaging Laboratory, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Aksel Hiorth
- Department of Energy Resources, University of Stavanger, Stavanger, Norway
| | - Jorunn Havnen
- Stavanger Medical Imaging Laboratory, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
| | - Ole Jacob Greve
- Stavanger Medical Imaging Laboratory, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
| | - Kathinka Dæhli Kurz
- Stavanger Medical Imaging Laboratory, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
- Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
| | - Alf Inge Larsen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| |
Collapse
|
3
|
Budoff MJ, Lakshmanan S, Toth PP, Hecht HS, Shaw LJ, Maron DJ, Michos ED, Williams KA, Nasir K, Choi AD, Chinnaiyan K, Min J, Blaha M. Cardiac CT angiography in current practice: An American society for preventive cardiology clinical practice statement ✰. Am J Prev Cardiol 2022; 9:100318. [PMID: 35146468 PMCID: PMC8802838 DOI: 10.1016/j.ajpc.2022.100318] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
Abstract
In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention - applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.
Collapse
Affiliation(s)
- Matthew J. Budoff
- Division of Cardiology, Lundquist Institute at Harbor-UCLA, Torrance CA, USA
| | - Suvasini Lakshmanan
- Division of Cardiology, Lundquist Institute at Harbor-UCLA, Torrance CA, USA
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harvey S. Hecht
- Department of Medicine, Mount Sinai Medical Center, New York, NY
| | - Leslee J. Shaw
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J. Maron
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kim A. Williams
- Division of Cardiology, Rush University Medical Center, Chicago IL
| | - Khurram Nasir
- Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Andrew D. Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Kavitha Chinnaiyan
- Division of Cardiology, Department of Medicine, Beaumont Hospital, Royal Oak, MI
| | - James Min
- Chief Executive Officer Cleerly Inc., New York, NY
| | - Michael Blaha
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
4
|
Coronary computed tomography angiography in patients with stable coronary artery disease. Trends Cardiovasc Med 2021; 32:421-428. [PMID: 34454051 DOI: 10.1016/j.tcm.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 01/07/2023]
Abstract
The treatment of coronary artery disease (CAD), which is defined by stable anatomical atherosclerotic and functional alterations of epicardial vessels or microcirculation, focuses on managing intermittent angina symptoms and preventing major adverse cardiovascular events with optimal medical therapy. When patients with known CAD present with angina and no acute coronary syndrome, they have historically been evaluated with a variety of noninvasive stress tests that utilize electrocardiography, radionuclide scintigraphy, echocardiography, or magnetic resonance imaging for determining the presence and extent of inducible myocardial ischemia. Patient event-free survival, however, is largely driven by the coronary atherosclerotic disease burden, which is not directly assessed by functional testing. Direct evaluation of coronary atherosclerotic disease by coronary computed tomography angiography (coronary CTA) has emerged as the first line noninvasive imaging modality as it improves diagnostic accuracy and positively influences clinical management. Compared to functional assessment of CAD, coronary CTA-guided management results in improved patient outcomes by facilitating prevention of myocardial infarction. Other strengths of coronary CTA include detailed atherosclerotic plaque characterization and the ability to assess functional significance of specific lesions, which may further improve risk assessment and prognosis and lead to more appropriate referrals for additional testing, such as invasive coronary angiography.
Collapse
|
5
|
Cardoso R, Dudum R, Ferraro RA, Bittencourt M, Blankstein R, Blaha MJ, Nasir K, Rajagopalan S, Michos ED, Blumenthal RS, Cainzos-Achirica M. Cardiac Computed Tomography for Personalized Management of Patients With Type 2 Diabetes Mellitus. Circ Cardiovasc Imaging 2020; 13:e011365. [DOI: 10.1161/circimaging.120.011365] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.
Collapse
Affiliation(s)
- Rhanderson Cardoso
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.C., R.B.)
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Ramzi Dudum
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA (R.D.)
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Richard A. Ferraro
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Marcio Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital, University of Sao Paulo, Brazil (M.B.)
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.C., R.B.)
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (K.N., M.C.-A.)
- Center for Outcomes Research, The Houston Methodist Research Institute, Houston, TX (K.N., M.C.-A.)
| | - Sanjay Rajagopalan
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH (S.R.)
| | - Erin D. Michos
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (R.C., R.D., R.A.F., M.J.B., E.D.M., R.S.B., M.C.-A.)
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (K.N., M.C.-A.)
- Center for Outcomes Research, The Houston Methodist Research Institute, Houston, TX (K.N., M.C.-A.)
| |
Collapse
|
6
|
Lakshmanan S, Budoff MJ. Where ISCHEMIA fails, coronary CTA shines. Int J Cardiol 2020; 322:40-42. [PMID: 32871187 DOI: 10.1016/j.ijcard.2020.08.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/26/2020] [Accepted: 08/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Suvasini Lakshmanan
- Lundquist Institute for Biomedical Innovation and Research at Harbor UCLA Medical Center, Torrance, CA, USA
| | - Matthew J Budoff
- Lundquist Institute for Biomedical Innovation and Research at Harbor UCLA Medical Center, Torrance, CA, USA.
| |
Collapse
|
7
|
Oikonomou EK, Desai MY, Marwan M, Kotanidis CP, Antonopoulos AS, Schottlander D, Channon KM, Neubauer S, Achenbach S, Antoniades C. Perivascular Fat Attenuation Index Stratifies Cardiac Risk Associated With High-Risk Plaques in the CRISP-CT Study. J Am Coll Cardiol 2020; 76:755-757. [DOI: 10.1016/j.jacc.2020.05.078] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 12/30/2022]
|
8
|
van Rosendael AR, Bax JJ, Arbab-Zadeh A. Noninvasive assessment of coronary atherosclerosis by cardiac computed tomography for risk stratifying patients with suspected coronary heart disease. J Cardiovasc Comput Tomogr 2019; 13:235-241. [PMID: 31563581 DOI: 10.1016/j.jcct.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Alexander R van Rosendael
- From the Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; The Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jeroen J Bax
- From the Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; The Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Armin Arbab-Zadeh
- The Department of Medicine-Division of Cardiology Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|