Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring

Bridging Prevention and Imaging: The Influence of Statins on CAC and CCTA Findings

To evaluate the impact of statins on CHD prevention, role of CAC scoring and CCTA in guiding statin therapy for both primary and secondary prevention in ASCVD. Coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA) have emerged as vital non-invasive imaging tools for refining cardiovascular risk assessment and guiding statin therapy in patients with atherosclerotic cardiovascular disease (ASCVD). CAC scoring helps stratify patients based on subclinical atherosclerosis burden, while CCTA provides detailed insights into plaque composition and distribution. Multiple studies, including the Multi-Ethnic Study of Atherosclerosis (MESA) and the CONFIRM registry, have demonstrated the utility of CAC scoring in identifying individuals at risk of major adverse cardiovascular events (MACE) and guiding personalized statin therapy. CAC scores, categorized into risk-based thresholds, enable clinicians to determine when statins should be initiated or deferred. CCTA complements CAC scoring by assessing plaque characteristics, including non-calcified plaque (NCP), calcified plaque, and high-risk features such as low-attenuation plaques, spotty calcifications, and positive remodeling. Serial CCTA imaging has further highlighted the effect of high-intensity statin therapy on plaque progression, demonstrating reductions in NCP and stabilization through increased calcification. CAC scoring effectively identifies patients with subclinical atherosclerosis who would benefit from statin therapy, particularly those with CAC scores > 100 or in the ≥ 75th percentile for age and sex. Statin therapy has been shown to promote plaque stabilization by increasing calcified plaque volume while reducing the progression of non-calcified plaques, thereby mitigating the risk of plaque rupture. CCTA provides additional value by identifying vulnerable plaque features and monitoring the impact of statin therapy over time. Studies have demonstrated significant reductions in total plaque volume and low-attenuation plaques in patients undergoing intensive lipid-lowering therapy, reinforcing the role of CCTA in guiding statin decisions for patients with established ASCVD. CAC scoring serves as a powerful tool to refine risk stratification and guide statin therapy initiation, particularly in asymptomatic individuals. CCTA enhances this approach by providing comprehensive plaque assessment and monitoring the response to statin therapy. Integrating CAC scoring and CCTA into clinical practice allows for a personalized approach to ASCVD management, improving patient outcomes through optimized statin therapy and targeted risk reduction.

Tripeptide DT-109 (Gly-Gly-Leu) attenuates atherosclerosis and vascular calcification in nonhuman primates

Advanced atherosclerotic lesions and vascular calcification substantially increase the risk of cardiovascular events. However, effective strategies for preventing or treating advanced atherosclerosis and calcification are currently lacking. This study investigated the efficacy of DT-109 (Gly-Gly-Leu) in attenuating atherosclerosis and calcification in nonhuman primates, exploring its broader therapeutic potential. In this study, twenty male cynomolgus monkeys were administered a cholesterol-rich diet ad libitum for 10 months. Then, the animals were treated either orally with DT-109 (150 mg/kg/day) or a vehicle (H2O) for 5 months while continuing on the same diet. Plasma lipid levels were measured monthly and at the end of the experiment, pathological examinations of the aortas and coronary arteries and RNA sequencing of the coronary arteries were performed. To explore possible molecular mechanisms, the effects of DT-109 on smooth muscle cells (SMCs) were examined in vitro. We found that DT-109 administration significantly suppressed atherosclerotic lesion formation in both the aorta and coronary arteries. Pathological examinations revealed that DT-109 treatment reduced lesional macrophage content and calcification. RNA sequencing analysis showed that DT-109 treatment significantly downregulated the pro-inflammatory factors NLRP3, AIM2, and CASP1, the oxidative stress factors NCF2 and NCF4, and the osteogenic factors RUNX2, COL1A1, MMP2, and MMP9, while simultaneously upregulating the expression of the SMCs contraction markers ACTA2, CNN1, and TAGLN. Furthermore, DT-109 inhibited SMC calcification and NLRP3 inflammasome activation in vitro. These results demonstrate that DT-109 effectively suppresses both atherosclerosis and calcification. These findings, in conjunction with insights from our previous studies, position DT-109 as a novel multifaceted therapeutic agent for cardiovascular diseases.

Resource Efficient Screening for Primary Prevention of Coronary Heart Disease: A Proof-of-Concept Test in the MESA Cohort

BACKGROUND

The best use of cardiac imaging to guide preventive coronary heart disease (CHD) treatment is debated. Current guidelines recommend the pooled cohort equation, followed by computed tomography for coronary artery calcification (CAC) assessment. We evaluated if this approach could be simplified using a self-report risk algorithm instead of the pooled cohort equation.

METHODS

A gradient boosting machine model was trained on self-reported factors to calculate the probability of a high CAC score (≥100). This model was part of a self-report-based CHD preventive strategy with 3 steps: (1) calculate the probability of having a high CAC; (2) perform computed tomography for high-risk individuals; and (3) assign treatment eligibility with lipid-lowering therapy if CAC score exceeds a designated threshold. This strategy was tested using data from the MESA (Multi-Ethnic Study of Atherosclerosis) cohort (n=4564) and compared with guidelines recommending CAC scanning for intermediate-risk individuals (pooled cohort equation, 7.5% to <20%) by evaluating CHD events over 10-year follow-up in the group defined as treatment eligible by either strategy.

RESULTS

The pooled cohort equation identified 33% of the MESA population as eligible for a CAC scan and 19% as treatment eligible, capturing 48% of all CHD events (103 of 216). The self-report strategy identified 56% of CHD events (120 of 216; P=0.02) with the same number of CAC scans and treatments but required health care visits for only 33% of the population.

CONCLUSIONS

A self-report screening strategy, combined with CAC scoring, is more resource efficient and better discriminates high-risk individuals suitable for lipid-lowering therapy compared with current guidelines.

Comparison of cardiac computed tomography recommendations in recent ESC vs. ACC/AHA guidelines

Cardiac computed tomography (CCT) continues to expand with increasing applications and technological advancements. Growing evidence on the clinical utility of CCT necessitates evaluating how this knowledge is incorporated into European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. We aimed to provide a comprehensive comparison of CCT indications between ESC and ACC/AHA guidelines to identify areas of consensus and divergence in the current landscape of CCT utilization. ESC and ACC/AHA guidelines were systematically reviewed for CCT recommendations. The class of recommendation (COR) and level of evidence (LOE) were compared using χ2 or Fisher exact tests. The latest ESC guidelines included 40 recommendations regarding CCT: 18 (45%) COR-I, 14 (35%) COR-IIa, 6 (15%) COR-IIb, and 2 (5%) COR-III. Two (5%) recommendation had LOE-A, 20 (50%) had LOE-B, and 18 (45%) had LOE-C. The latest ACC/AHA guidelines consisted of 54 recommendations: 18 (33.3%) COR-I, 28 (51.9%) COR-IIa, 6 (11.1%) COR-IIb, and 2 (3.7%) COR-III. Two recommendations were assigned LOE-A (3.7%), 30 (55.6%) were classified as LOE-B, and 22 (40.7%) as LOE-C. ACC/AHA guidelines had a significantly higher proportion of COR-IIa recommendations (P = 0.04) and similar proportions of COR-I and COR-IIb recommendations (P = 0.28; P = 0.76), compared to ESC guidelines. The proportion of LOE-B and LOE-C recommendations weren't statistically different (P = 0.54; P = 0.84). ACC/AHA guidelines included more CCT recommendations with a higher COR and LOE than ESC guidelines. These findings highlight the need for continued research and consensus-building to establish standardized, evidence-based CCT recommendations in clinical practice.

Effects of Combining Coronary Calcium Score With Treatment on Plaque Progression in Familial Coronary Artery Disease: A Randomized Clinical Trial

Importance

Coronary artery calcium (CAC) scoring provides prognostic information, especially in patients at intermediate risk for coronary artery disease (CAD). However, the benefit of combining CAC score with a primary prevention strategy has not been tested in a randomized trial.

Objective

To assess whether combining the CAC score with a prevention strategy can be used to limit plaque progression in intermediate-risk patients with a family history of premature CAD.

Design, Setting, and Participants

Prospective, randomized, open-blinded end point clinical trial in 7 hospitals across Australia (between 2013 and 2020; the last date of follow-up was June 5, 2021). Asymptomatic people aged 40 to 70 years with a first-degree relative with CAD onset at younger than 60 years old or second-degree relative with onset at younger than 50 years old were recruited from the community.

Interventions

Intermediate-risk participants underwent CAC scoring. Those with a CAC score greater than 0 but less than 400 underwent coronary computed tomography angiography (CCTA) and were randomized to CAC score-informed prevention or usual care.

Main Outcomes and Measures

Follow-up CCTA was obtained at 3 years, with plaque volume measured by an independent core laboratory. The primary outcome was total plaque volume, with further analysis for calcified and noncalcified plaque volume.

Results

This study included 365 participants (mean [SD] age, 58 [6] years; 57.5% male); 179 in the CAC score-informed and 186 in the usual care groups. Compared with usual care, the CAC score-informed group showed a sustained reduction in total (mean [SD], -3 [31] mg/dL vs -56 [38] mg/dL; P < .001) and LDL (mean [SD], -2 [31] vs -51 [36] mg/dL; P < .001) cholesterol levels at 3 years, which was associated with a reduction in pooled cohort equation risk calculation (mean [SD], 2.1% [2.9%] vs 0.5% [2.9%]; P < .001). Plaque progression was greater in usual care than CAC score-informed participants for total plaque volume (mean [SD], 24.9 [37.7] mm3 vs 15.4 [30.9] mm3; P = .009), noncalcified plaque volume (mean [SD], 15.7 [32.2] mm3 vs 5.6 [28.5] mm3; P = .002), and fibrofatty and necrotic core plaque volume (mean [SD], 4.5 [25.8] mm3 vs -0.8 [12.6] mm3; P = .02). These plaque volume changes were independent of other risk factors including baseline plaque volume, blood pressure, and lipid profile.

Conclusions and Relevance

The combination of CAC score with a primary prevention strategy in intermediate-risk patients with a family history of CAD was associated with reduction of atherogenic lipids and slower plaque progression compared with usual care. These data support the use of CAC score to assist intensive preventive strategies in intermediate-risk patients.

Trial Registration

anzctr.org.au Identifier: ACTRN12614001294640.

Exposure to Lead and Coronary Artery Atherosclerosis: A Swedish Cross-Sectional Population-Based Study

BACKGROUND

Lead is an established causal risk factor for coronary heart disease. Atherosclerosis may be the key mediator for this association, but evidence from studies in humans is limited. Our objective was to test the hypothesis that environmental lead exposure is associated with coronary atherosclerosis.

METHODS

We used cross-sectional data from the SCAPIS (Swedish Cardiopulmonary Bioimage Study), including 5627 men and women aged 50 to 64 years. Coronary artery calcium score (CACS), measured using computed tomography, was used as a marker of atherosclerosis, and blood lead was used as a biomarker of lead exposure. The prevalence ratio (PR) of positive (>0) and high (≥100) CACSs in relation to blood lead (continuous variable) was modeled using Poisson regression with robust SEs, adjusted for age, sex, smoking, low-density lipoprotein/high-density lipoprotein ratio, waist circumference, heredity for cardiovascular diseases, statin use, diabetes, blood cadmium, low physical activity, and educational level.

RESULTS

Median blood lead was 14.2 μg/L. Positive CACS (prevalence, 41%) was not significantly associated with blood lead (PR per Δ10 μg/L, 1.02 [95% CI, 0.99-1.04]), whereas the association was stronger for high CACS (prevalence, 13%; and PR per Δ10 μg/L, 1.05 [95% CI, 1.00-1.11]). The estimate for high CACS was stronger in men (PR per Δ10 μg/L, 1.07 [95% CI, 1.01-1.13]) than among women (PR per Δ10 μg/L, 1.01 [95% CI, 0.85-1.20]).

CONCLUSIONS

Our study, which found that lead is associated with coronary artery calcification in men, provides further evidence that lead is a risk factor for atherosclerosis and coronary heart disease.

Factorial Mendelian randomization of lipoprotein (a) lowering, low-density lipoprotein cholesterol lowering, and lifestyle improvements: joint associations with cardiovascular risk

BACKGROUND

High levels of lipoprotein(a) [Lp(a)] have been associated with an increased risk of cardiovascular disease (CVD); however, the effects of Lp(a)-lowering therapy in combination with low-density lipoprotein cholesterol (LDL-C)-lowering treatment or lifestyle improvements on CVD risk remain unexplored.

METHODS

We conducted a factorial Mendelian randomization study among 385 917 participants in the UK Biobank. Separate genetic scores were constructed to proxy the effects of Lp(a) lowering, LDL-C lowering through different targets [HMG-CoA reductase, NPC1-like intracellular cholesterol transporter 1, proprotein convertase subtilisin/kexin Type 9, and low-density lipoprotein receptor (LDLR)], as well as improvements in body mass index (BMI), systolic blood pressure (SBP), and lifestyle factors (cigarette smoking, alcohol consumption, and physical activity).

RESULTS

Genetically predicted lower Lp(a) levels were associated with a decreased risk of CVD and CVD-specific mortality. Per 50-mg/dl, the hazard ratio ranged from 0.73 [95% confidence interval (CI): 0.73, 0.73] for peripheral artery disease (PAD) to 0.95 (95% CI: 0.92, 0.99) for venous thromboembolism. In factorial analyses exploring combined exposure to low-level Lp(a) and low-level LDL-C, there was no consistent evidence for departure from an additive model for any outcome (Pinteraction > .05), with the exception of the analysis using the LDLR score and PAD (Pinteraction = .006). In factorial analyses exploring combination therapies integrating Lp(a) lowering with interventions on BMI, SBP, and lifestyle factors, there was no evidence for departure from an additive model in any analysis (Pinteraction > .05).

CONCLUSIONS

Our study suggests that Lp(a) lowering will have a similar magnitude for reducing cardiovascular events whether it is considered alone, or in conjunction with LDL-C reduction or lifestyle improvements.

PET/CT-derived coronary calcium score may predict cardiac complications in anthracycline-treated patients with lymphoma

ABSTRACT

Anthracycline-mediated cardiotoxicity is a common concern after lymphoma therapy, particularly in patients with high cardiovascular risk (CVR). In noncancer populations, coronary artery calcium scoring (CACS) effectively identifies individuals who may benefit from aggressive CVR modification to lower the risk of cardiovascular events. Emerging evidence suggests that CACS can also predict cancer therapy-related cardiotoxicity, potentially identifying candidates for cardioprotective strategies. Our study aimed to evaluate whether CACS obtained from pretreatment positron emission tomography (PET)/computed tomography (CT) scans could stratify cardiac event risk in patients with lymphoma receiving anthracycline-based chemotherapy. We enrolled 358 consecutive patients with lymphoma treated between 2012 and 2022, calculating the CACS from their pretreatment PET/CT. We reviewed medical records to identify pre-existing cardiac conditions, CVR, and posttreatment cardiac events, including coronary events, heart failure (HF), and arrhythmias. Logistic and Cox regression models were used to assess associations between CVR, CACS categories (CACS = 0, CACS 1-400, CACS >400), and new cardiac events. At a median follow-up of 27 months (95% confidence interval [CI], 22.3-31.7) in patients without cardiac history, 10% experienced posttreatment cardiac events (HF, 14; arrhythmias, 9; coronary event, 1; combination, 8). Patients with a CACS >0 had more events (21 total, 20% vs 11 total, 5.4% for CACS = 0; P < .001). Elevated CACS was independently associated with HF (CACS 1-400: odds ratio [OR], 3.73; 95% CI, 1.21-11.43; P = .022; CACS >400: OR, 5.43; 95% CI, 1.47-20.03; P = .011) and any cardiac event (CACS 1-400: OR, 2.48; 95% CI, 1.02-6.04; P = .045; CACS >400: OR, 3.28; 95% CI, 0.91-10.68; P = .029). CACS may effectively stratify patients with lymphoma at risk of cardiac complications, thereby identifying a group poised to benefit from targeted preventive strategies.

Hybrid cardiovascular imaging. A clinical consensus statement of the european association of nuclear medicine (EANM) and the european association of cardiovascular imaging (EACVI) of the ESC

Hybrid imaging consists of a combination of two or more imaging modalities, which equally contribute to image information. To date, hybrid cardiovascular imaging can be performed by either merging images acquired on different scanners, or with truly hybrid PET/CT and PET/MR scanners. The European Association of Nuclear Medicine (EANM), and the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC) aim to review clinical situations that may benefit from the use of hybrid cardiac imaging and provide advice on acquisition protocols providing the most relevant information to reach diagnosis in various clinical situations.

Coronary artery calcification detected on low-dose computed tomography in high-risk participants of an Australian lung cancer screening program: A prospective observational study

BACKGROUND AND OBJECTIVES

Coronary artery calcification (CAC) is a frequent additional finding on lung cancer screening (LCS) low-dose computed tomography (LDCT). Cardiovascular disease (CVD) is a major cause of death in LCS participants. We aimed to describe prevalence of incidental CAC detected on LDCT in LCS participants without prior history of coronary artery disease (CAD), evaluate their CVD risk and describe subsequent investigation and management.

METHODS

Prospective observational nested cohort study including all participants enrolled at a single Australian site of the International Lung Screen Trial. Baseline LDCTs were reviewed for CAC, and subsequent information collected regarding cardiovascular health. 5-year CVD risk was calculated using the AusCVD risk calculator.

RESULTS

55% (226/408) of participants had CAC on LDCT and no prior history of CAD, including 23% with moderate-severe CAC. Mean age of participants with CAC was 65 years, 68% were male. 53% were currently smoking. Majority were high risk (51%) or intermediate risk (32%) of a cardiovascular event in 5 years. 21% of participants were re-stratified to a higher CVD risk group when CAC detected on LCS was incorporated. Only 10% of participants with CAC received lifestyle advice (only 3% currently smoking received smoking cessation advice). 80% of participants at high-risk did not meet guideline recommendations, with 47% of this group remaining without cholesterol lowering therapy.

CONCLUSION

LCS with LDCT offers the potential to identify and communicate CVD risk in this population. This may improve health outcomes for high-risk LCS participants and further personalize management once screening results are known.

Lipid-Lowering Medication and Outcomes After Anatomical and Functional Imaging in Suspected Coronary Artery Disease

BACKGROUND

Anatomical and functional imaging identify different phenotypes of coronary artery disease (CAD) that may have implications for lipid-lowering medication (LLM).

OBJECTIVES

The aim of this study was to assess the associations between LLM and long-term outcomes after combined anatomical and functional imaging in patients with suspected obstructive CAD.

METHODS

Consecutive patients (n = 1,973; 41% men; median age: 63 years) underwent coronary computed tomography angiography (CTA) because of suspected CAD. Patients in whom obstructive CAD was not ruled out by CTA underwent ischemia testing by positron emission tomography. Data on LLM purchases were collected until 2 years, and the combined endpoints of death, myocardial infarction, and unstable angina pectoris were assessed at a median of 6.7 years.

RESULTS

After imaging, LLM was used by 24% of patients with no CAD, 51% of patients with nonobstructive CAD, 72% of patients with obstructive CAD on CTA without myocardial ischemia, and 91% of patients with myocardial ischemia. The use of LLM decreased during follow-up, with 77% of patients with myocardial ischemia using LLM for 2 years. The use of LLM was associated with a lower annual rate of adverse events in patients with myocardial ischemia (6.1% vs 2.8%; P = 0.032) or obstructive CAD without myocardial ischemia (2.9% vs 1.4%; P = 0.004) but not in patients with nonobstructive CAD (1.5% vs 1.4%; P = 0.89) or no CAD (0.3% vs 0.3%; P = 0.68).

CONCLUSIONS

The CAD phenotype defined by anatomical and functional imaging guides the use of LLM. The presence of myocardial ischemia and anatomical obstructive coronary lesions were associated with a long-term outcome benefit from LLM.

Coronary artery calcium on lung cancer radiation planning CT aids cardiovascular risk assessment

BACKGROUND

Patients with non-small cell lung cancer (NSCLC) undergoing thoracic radiation are at high cardiovascular risk. Semiquantitative assessment of coronary artery calcification (CAC) on baseline planning non-gated chest computed tomography (CT) scans may help further risk stratify patients.

OBJECTIVES

This study aimed to characterize the association between CAC and major adverse cardiovascular events (MACE; myocardial infarction or stroke) and assess the utility of semiquantitative assessment of CAC.

METHODS

Patients with NSCLC with non-contrast planning chest CT scans were evaluated for CAC. Planning scans were visually graded using the CAC-DRS method, stratifying patients into no, mild, moderate, and severe CAC groups. Demographics, comorbidities, and radiation treatment characteristics were gathered, and CAC groups were assessed for the incidence of MACE after initiation of radiation therapy.

RESULTS

Out of 137 patients, 39 patients had no CAC, and 98 patients had any CAC (38 with mild CAC, 34 with moderate CAC, and 26 with severe CAC). There was 1 MACE event in the no CAC group and 11 in patients with any CAC. The presence of CAC was associated with increased MACE compared to no CAC (p = 0.034). Semiquantitative CAC analysis correlated with formal CAC scoring.

CONCLUSION

There is a significantly lower incidence of MACE in patients with no CAC on planning CT compared to patients with higher burdens of CAC. CAC burden is an important risk factor for adverse cardiovascular events in patients with NSCLC undergoing thoracic radiation. Semiquantitative CAC scoring may be a useful proxy when formal CAC scoring is unavailable.

Eligibility for lipid-lowering therapy when applying systemic coronary risk estimation 2 according to guidelines on apparently healthy middle-aged individuals

AIMS

To estimate the proportion eligible for lipid-lowering therapy (LLT) when using the systemic coronary risk estimation 2 (SCORE2) on apparently healthy individuals.

METHODS AND RESULTS

Individuals aged 50-64 years were randomly invited to The Swedish Cardiopulmonary Bioimage Study (n = 30 154). Participants with previous atherosclerotic cardiovascular disease (CVD), diabetes mellitus, or chronic kidney disease were excluded. The 10-year risk of CVD was estimated using the SCORE2 equation and the multicell chart. Eligibility for LLT was estimated according to the 2021 European Society of Cardiology CVD prevention guidelines. Presence of coronary atherosclerosis was determined using coronary computed tomography angiography (CCTA). Among 26 570 apparently healthy individuals, 32% had high and 4% had very high 10-year CVD risk, according to the SCORE2 equation. Among high- and very-high-risk individuals, 99% had low-density lipoprotein cholesterol levels above guideline goals making 35% of the total population eligible for LLT. Of those eligible, undergoing imaging, 38% had no signs of coronary atherosclerosis according to CCTA. Using the SCORE2 chart, 52% of the population were eligible for LLT, of which 44% had no signs of coronary atherosclerosis. In those with high or very high risk, ongoing LLT was reported in 7% and another 11% received LLT within 6 months after study participation.

CONCLUSION

Nearly all apparently healthy individuals with high and very high CVD risk, or 35% of the total population, were eligible for LLT according to guidelines, and a large proportion had no signs of atherosclerosis. Compared with the SCORE2 equation, the SCORE2 chart resulted in more individuals being eligible for LLT.

Incidental Coronary Artery Calcification and the Risk of Major Adverse Cardiovascular Outcomes

Background Incidental findings of coronary artery calcifications (CACs) are not consistently reported, and the clinical significance relating to cardiovascular outcomes remains to be established. In this single-center cross-sectional study, we assessed the association between incidental coronary artery calcification documented on formal chest CT reports and the incidence of major adverse cardiovascular events (MACE). Methods A MACE was defined as the occurrence of stroke or transient ischemic attack or ST-segment elevation myocardial infarction, non-ST-elevation myocardial infarction, or undergoing coronary artery bypass grafting. A composite endpoint included either MACE or the occurrence of cardiovascular death. We assessed the predictors of the composite outcome and the effect of lipid-lowering therapy on the composite outcome in the studied cohort.  Results The composite outcome occurred in 39.1% of the 1,354 subjects studied. Peripheral arterial disease was the only comorbid condition associated with increased odds (adjusted odds ratio (aOR) 2.6, p < 0.001, 95% CI: 1.9 - 3.56). The average treatment effect of lipid-lowering therapy was 0.11 (p = 0.002, 95% CI: 0.04 - 0.17). At 10 years after the first CAC report, the presence of peripheral artery disease appears to present the lowest odds of survival, which is <50% (hazard ratio (HR) 2.44, p < 0.001, 95% CI: 1.67 - 3.56). Conclusion In patients with CAC on incidental chest CT scans, the presence of peripheral arterial disease is associated with increased odds of MACE and/or cardiovascular death. In those with incidental CAC on non-gated chest CT scans, the residual risk for MACE remains high despite lipid-lowering therapy and antiplatelet agents.

Added prognostic value of visually estimated coronary artery calcium among heart transplant recipients

BACKGROUND

Cardiac hybrid positron emission tomography/computed tomography (PET/CT) has become a valid screening modality for cardiac allograft vasculopathy (CAV) following heart transplantation (HT). Visually estimated coronary artery calcium (VECAC) can be quantified from CT images obtained as part of PET/CT and has been shown to be associated with adverse cardiovascular outcomes in coronary artery disease. We investigated the prognostic value of VECAC following HT.

METHODS

A retrospective analysis of 430 consecutive adult HT patients who underwent 13N-ammonia cardiac PET/CT from 2016 to 2019 with follow-up through October 15, 2022, was performed. VECAC categories included: VECAC 0, VECAC 1-9, VECAC 10-99, and VECAC 100+. The association between VECAC categories and outcomes was assessed using univariable and multivariable proportional hazards regression. The primary outcome was death/retransplantation.

RESULTS

The cohort was 73% male, 33% had diabetes, 67% had estimated glomerular filtration rate <60 ml/min, median age was 61 years, and median time since HT was 7.5 years. VECAC alone was insufficiently sensitive to screen for CAV. During a median follow-up of 4.2 years ninety patients experienced death or retransplantation. Compared with those with VECAC 0, patients VECAC 10-99 (HR 2.25, 95% CI 1.23-4.14, p = 0.009) and VECAC 100+ (HR 3.42, 95% CI 1.96-5.99, p < 0.001) experienced an increased risk of death/retransplantation. The association was similar for cardiovascular death and cardiovascular hospitalization. After adjusting for other predictors of death/retransplantation, VECAC 10-99 (VECAC 10-99: aHR 1.95, 95% CI 1.03-3.71 p = 0.04) and VECAC 100+ (VECAC 100+: aHR 2.33, 95% CI 1.17-4.63, p = 0.02) remained independently associated with death/retransplantation.

CONCLUSIONS

VECAC is an independent prognostic marker of death/retransplantation following HT and merits inclusion as a part of post-HT surveillance PET/CT.

The functions of apolipoproteins and lipoproteins in health and disease

Lipoproteins and apolipoproteins are crucial in lipid metabolism, functioning as essential mediators in the transport of cholesterol and triglycerides and being closely related to the pathogenesis of multiple systems, including cardiovascular. Lipoproteins a (Lp(a)), as a unique subclass of lipoproteins, is a low-density lipoprotein(LDL)-like particle with pro-atherosclerotic and pro-inflammatory properties, displaying high heritability. More and more strong evidence points to a possible link between high amounts of Lp(a) and cardiac conditions like atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis (AS), making it a risk factor for heart diseases. In recent years, Lp(a)'s role in other diseases, including neurological disorders and cancer, has been increasingly recognized. Although therapies aimed at low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) have achieved significant success, elevated Lp(a) levels remain a significant clinical management problem. Despite the limited efficacy of current lipid-lowering therapies, major clinical advances in new Lp(a)-lowering therapies have significantly advanced the field. This review, grounded in the pathophysiology of lipoproteins, seeks to summarize the wide-ranging connections between lipoproteins (such as LDL-C and HDL-C) and various diseases, alongside the latest clinical developments, special emphasis is placed on the pivotal role of Lp(a) in cardiovascular disease, while also examining its future potential and mechanisms in other conditions. Furthermore, this review discusses Lp(a)-lowering therapies and highlights significant recent advances in emerging treatments, advocates for further exploration into Lp(a)'s pathogenic mechanisms and its potential as a therapeutic target, proposing new secondary prevention strategies for high-risk individuals.

Coronary artery calcification is prevalent in systemic sclerosis and is associated with adverse prognosis

Objective

Coronary artery calcification assessed on thoracic computed tomography represents the calcific component of established coronary artery disease, is a biomarker of total atheromatous plaque burden and predicts mortality. Systemic sclerosis is a pro-inflammatory condition, and inflammation is also a driver of coronary artery disease. We assessed coronary artery calcification prevalence, mortality risk and potential clinical impact on primary prevention in a cohort of patients with systemic sclerosis, differentiated by clinical phenotype including the presence of interstitial lung disease and pulmonary arterial hypertension.

Methods

Retrospective analysis of 258 computed tomographies in systemic sclerosis patients from three prospectively maintained clinical and research databases at a single tertiary rheumatology/pulmonary hypertension (PH) service between March 2007 and September 2020 (mean age = 65 ± 12, 14% male). Co-morbidities, statin prescription and all-cause mortality were recorded. Patients were subtyped according to underlying systemic sclerosis complications. Computed tomographies were re-reviewed for coronary artery calcification; severity was graded using a 4-point scale per vessel and summed for total coronary artery calcification score. The impact of reporting coronary artery calcification was assessed against pre-existing statin prescriptions.

Results

Coronary artery calcification was present in 58% (149/258). Coronary artery calcification was more prevalent in systemic sclerosis-pulmonary arterial hypertension than in systemic sclerosis subgroups with interstitial lung disease or without pulmonary arterial hypertension, controlling for age, sex, co-morbidities and smoking status (71%; χ 2(13) = 81.4; p < 0.001). The presence and severity of coronary artery calcification were associated with increased risk of mortality independently of age and co-morbidities (hazard ratio = 2.8; 95% confidence interval = 1.2-6.6; p = 0.018). The 'number needed to report' coronary artery calcification presence to potentially impact management was 3.

Conclusions

Coronary artery calcification is common in systemic sclerosis. Coronary artery calcification predicts mortality independently of age and confounding co-morbidities which suggests this finding has clinical relevance and is a potential target for screening and therapeutic intervention.

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

Background

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

Methods

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

Results

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

Conclusions

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

Current and Emerging Approaches for Primary Prevention of Coronary Artery Disease Using Cardiac Computed Tomography

PURPOSE OF REVIEW

To summarize the current use of cardiac computed tomography (CT) technologies as well as their pertinent evidence in regards to prevention of coronary artery disease (CAD).

RECENT FINDINGS

Cardiac CTA has now become a main non-invasive method for the evaluation of symptomatic CAD. In addition to coronary calcium score, other CT technologies such as atherosclerotic plaque analysis, fractional flow reserve estimation by CT, pericoronary fat attenuation, and endothelial wall shear stress have emerged. Whether the use of CT modalities can enhance risk prediction and prevention in CAD has not been fully answered. We discuss the evidence for coronary artery calcium scoring and coronary CT angiography in primary prevention and the current barriers to their use. We attempt to delineate what can be done to expand use and what studies are needed to broaden adoption in the future. We also examine the potential roles of emerging CT technologies. Finally, we describe potential clinical approaches to prevention that would incorporate cardiac CT technologies.

Patient-Specific Myocardial Infarction Risk Thresholds From AI-Enabled Coronary Plaque Analysis

BACKGROUND

Plaque quantification from coronary computed tomography angiography has emerged as a valuable predictor of cardiovascular risk. Deep learning can provide automated quantification of coronary plaque from computed tomography angiography. We determined per-patient age- and sex-specific distributions of deep learning-based plaque measurements and further evaluated their risk prediction for myocardial infarction in external samples.

METHODS

In this international, multicenter study of 2803 patients, a previously validated deep learning system was used to quantify coronary plaque from computed tomography angiography. Age- and sex-specific distributions of coronary plaque volume were determined from 956 patients undergoing computed tomography angiography for stable coronary artery disease from 5 cohorts. Multicenter external samples were used to evaluate associations between coronary plaque percentiles and myocardial infarction.

RESULTS

Quantitative deep learning plaque volumes increased with age and were higher in male patients. In the combined external sample (n=1847), patients in the ≥75th percentile of total plaque volume (unadjusted hazard ratio, 2.65 [95% CI, 1.47-4.78]; P=0.001) were at increased risk of myocardial infarction compared with patients below the 50th percentile. Similar relationships were seen for most plaque volumes and persisted in multivariable analyses adjusting for clinical characteristics, coronary artery calcium, stenosis, and plaque volume, with adjusted hazard ratios ranging from 2.38 to 2.50 for patients in the ≥75th percentile of total plaque volume.

CONCLUSIONS

Per-patient age- and sex-specific distributions for deep learning-based coronary plaque volumes are strongly predictive of myocardial infarction, with the highest risk seen in patients with coronary plaque volumes in the ≥75th percentile.

Clinical Advances in Cardiovascular Computed Tomography: From Present Applications to Promising Developments

PURPOSE OF THE REVIEW

This review aims to provide a profound overview on most recent studies on the clinical significance of Cardiovascular Computed Tomography (CCT) in diagnostic and therapeutic pathways. Herby, this review helps to pave the way for a more extended but yet purposefully use in modern day cardiovascular medicine.

RECENT FINDINGS

In recent years, new clinical applications of CCT have emerged. Major applications include the assessment of coronary artery disease and structural heart disease, with corresponding recommendations by major guidelines of international societies. While CCT already allows for a rapid and non-invasive diagnosis, technical improvements enable further in-depth assessments using novel imaging parameters with high temporal and spatial resolution. Those developments facilitate diagnostic and therapeutic decision-making as well as improved prognostication. This review determined that recent advancements in both hardware and software components of CCT allow for highly advanced examinations with little radiation exposure. This particularly strengthens its role in preventive care and coronary artery disease. The addition of functional analyses within and beyond coronary artery disease offers solutions in wide-ranging patient populations. Many techniques still require improvement and validation, however, CCT possesses potential to become a "one-stop-shop" examination.

Addressing residual risk beyond statin therapy: New targets in the management of dyslipidaemias-A report from the European Society of Cardiology Cardiovascular Round Table

Cardiovascular (CV) disease is the most common cause of death in Europe. Despite proven benefits, use of lipid-lowering therapy remains suboptimal. Treatment goals are often not achieved, even in patients at high risk with atherosclerotic CV disease (ASCVD). The occurrence of CV events in patients on lipid-lowering drugs is defined as "residual risk", and can result from inadequate control of plasma lipids or blood pressure, inflammation, diabetes, and environmental hazards. Assessment of CV risk factors and vascular imaging can aid in the evaluation and management decisions for individual patients. Lifestyle measures remain the primary intervention for lowering CV risk. Where drug therapies are required to reach lipid treatment targets, their effectiveness increases when they are combined with lifestyle measures delivered through formal programs. However, lipid drug dosage and poor adherence to treatment remain major obstacles to event-free survival. This article discusses guideline-supported treatment algorithms beyond statin therapy that can help reduce residual risk in specific patient profiles while also likely resulting in substantial healthcare savings through better patient management and treatment adherence.

Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence?

PURPOSE OF REVIEW

Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies.

RECENT FINDINGS

The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.

Combining anatomical and biochemical markers in the detection and risk stratification of coronary artery disease

AIMS

We aimed to test the hypothesis if combining coronary artery calcium score (Ca-score) as a quantitative anatomical marker of coronary atherosclerosis with high-sensitivity cardiac troponin as a quantitative biochemical marker of myocardial injury provided incremental value in the detection of functionally relevant coronary artery disease (fCAD) and risk stratification.

METHODS AND RESULTS

Consecutive patients undergoing myocardial perfusion single-photon emission computed tomography (MPS) without prior CAD were enrolled. The diagnosis of fCAD was based on the presence of ischaemia on MPS and coronary angiography; fCAD was centrally adjudicated in the diagnostic and prognostic domain. Diagnostic accuracy was evaluated using the area under the receiver-operating characteristic curve (AUC). The composite of cardiovascular death and non-fatal acute myocardial infarction (AMI) within 730 days was the primary prognostic endpoint. Among 1715 patients eligible for the diagnostic analysis, 399 patients had fCAD. The combination of Ca-score and high-sensitivity cardiac troponin T (hs-cTnT) had good diagnostic accuracy for the diagnosis of fCAD (AUC 0.79, 95% confidence interval (CI) 0.77-0.81), but no incremental value compared with the Ca-score alone (AUC 0.79, 95% CI 0.77-0.81, P = 0.965). Similar results were observed using high-sensitivity cardiac troponin I (AUC 0.80, 95% CI 0.77-0.82) instead of hs-cTnT. Among 1709 patients (99.7%) with available follow-up, 59 patients (3.5%) suffered the composite primary prognostic endpoint (non-fatal AMI, n = 34; CV death, n = 28). Both Ca-score and hs-cTnT had independent prognostic value. Increased risk was restricted to patients with elevation in both markers.

CONCLUSION

The combination of the Ca-score with hs-cTnT increases the prognostic accuracy for future events but does not provide incremental value vs. the Ca-score alone for the diagnosis of fCAD.

STUDY REGISTRATION

Clinical trial registration: NCT00470587.

Personalizing cardiovascular risk prediction for patients with systemic lupus erythematosus

OBJECTIVE

Cardiovascular disease (CVD) risk is increased in SLE and underestimated by general population prediction algorithms. We aimed to develop a novel SLE-specific prediction tool, SLECRISK, to provide a more accurate estimate of CVD risk in SLE.

METHODS

We studied patients in the Brigham and Women's Hospital SLE cohort. We collected one-year baseline data including the presence of traditional CVD factors and SLE-related features at cohort enrollment. Ten-year follow-up for the first major adverse cardiovascular event (MACE; myocardial infarction (MI), stroke, or cardiac death) began at day +1 following the baseline period (index date). ICD-9/10 codes identified MACE were adjudicated by board-certified cardiologists. Least absolute shrinkage and selection operator regression selected SLE-related variables to add to the American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equations 10-year risk Cox regression model. Model fit statistics and performance (sensitivity, specificity, positive/negative predictive value, c-statistic) for predicting moderate/high 10-year risk (≥7.5 %) of MACE were assessed and compared to ACC/AHA, Framingham risk score (FRS), and modified FRS (mFRS). Optimism adjustment internal validation was performed using bootstrapping.

RESULTS

We included 1,243 patients with 90 MACEs (46 MIs, 36 strokes, 19 cardiac deaths) over 8946.5 person-years of follow-up. SLE variables selected for the new prediction algorithm (SLECRISK) were SLE activity (remission/mild vs. moderate/severe), disease duration (years), creatinine (mg/dL), anti-dsDNA, anti-RNP, lupus anticoagulant, anti-Ro positivity, and low C4. The sensitivity for detecting moderate/high-risk (≥7.5 %) of MACE using SLECRISK was 0.74 (95 %CI: 0.65, 0.83), which was better than the sensitivity of the ACC/AHA model (0.38 (95 %CI: 0.28, 0.48)). It also identified 3.4-fold more moderate/high-risk patients than the ACC/AHA. Patients who were moderate/high-risk according to SLECRISK but not ACC/AHA, were more likely to be young women with severe SLE and few other traditional CVD risk factors. Model performance between SLECRISK, FRS, and mFRS were similar.

CONCLUSION

The novel SLECRISK tool is more sensitive than the ACC/AHA for predicting moderate/high 10-year risk for MACE and may be particularly useful in predicting risk for young females with severe SLE. Future external validation studies utilizing cohorts with more severe SLE are needed.

Associations of Dietary Calcium and Phosphorus With Vascular and Valvular Calcification: The ARIC Study

Background

High dietary calcium and phosphorus may accelerate vascular calcification, but epidemiological data are inconsistent. Most of those studies assessed diet at one point and have not been systematically evaluated.

Objectives

The purpose of this study was to assess the associations of dietary calcium and phosphorus intakes in middle age with coronary artery and extra-coronary calcification at older age.

Methods

We studied 1,914 participants from the ARIC (Atherosclerosis Risk In Communities) study (mean age 80.5 years) without coronary heart disease who underwent chest computed tomography scans at visit 7 (2018-2019) and completed a 66-item food frequency questionnaire at 2 earlier visits (visit 1 [1987-1989] and visit 3 [1993-1995]). Dietary calcium and phosphorus intakes were averaged between these 2 visits. Calcification was quantified by the Agatston score in coronary artery, ascending aorta, descending aorta, aortic valve ring, aortic valve, and mitral valve.

Results

Dietary calcium intake was inversely associated with coronary artery and ascending aorta calcification, whereas the association was not significant for other measures of extra-coronary calcification. For example, the highest vs lowest quartile of calcium intake showed an adjusted OR of 0.66 (95% CI: 0.45-0.98) for coronary artery calcification (Agatston score ≥75th percentile). Dietary phosphorus intake demonstrated similar results, but the magnitude of the association was weaker than dietary calcium intake.

Conclusions

Dietary calcium and phosphorus intakes at middle age were not positively associated with vascular and valvular calcification at over 75 years old. Our findings did not support the link between a calcium or phosphorus-rich diet and vascular and valvular calcification.

Chemotherapy Related Cardiotoxicity Evaluation-A Contemporary Review with a Focus on Cardiac Imaging

The long-term survivorship of patients diagnosed with cancer has improved due to accelerated detection and rapidly evolving cancer treatment strategies. As such, the evaluation and management of cancer therapy related complications has become increasingly important, including cardiovascular complications. These have been captured under the umbrella term "cardiotoxicity" and include left ventricular dysfunction and heart failure, acute coronary syndromes, valvular abnormalities, pericardial disease, arrhythmia, myocarditis, and vascular complications. These complications add to the burden of cardiovascular disease (CVD) or are risk factors patients with cancer treatment are presenting with. Of note, both pre- and newly developing CVD is of prognostic significance, not only from a cardiovascular perspective but also overall, potentially impacting the level of cancer therapy that is possible. Currently, there are varying recommendations and practices regarding CVD risk assessment and mitigating strategies throughout the cancer continuum. This article provides an overview on this topic, in particular, the role of cardiac imaging in the care of the patient with cancer. Furthermore, it summarizes the current evidence on the spectrum, prevention, and management of chemotherapy-related adverse cardiac effects.

Coronary artery calcium and cardiovascular outcomes in patients with lymphoma undergoing autologous hematopoietic cell transplantation

BACKGROUND

Patients undergoing autologous hematopoietic cell transplantation (HCT) have a >2-fold risk of developing cardiovascular disease (CVD; heart failure, myocardial infarction, and stroke), compared to the general population. Coronary artery calcium (CAC) is predictive of CVD in nononcology patients but is not as well studied in patients who underwent HCT and survivors of HCT.The objective of this study was to examine the association between CAC and CVD risk and outcomes after HCT in patients with lymphoma.

METHODS

This was a retrospective cohort study of 243 consecutive patients who underwent a first autologous HCT for lymphoma between 2009 and 2014. CAC (Agatston score) was determined from chest computed tomography obtained <60 days from HCT. Multivariable Cox regression analysis was used to calculate hazard ratio (HR) estimates and 95% confidence intervals (CIs), adjusted for covariates (age, conventional risk factors [e.g., hypertension and dyslipidemia], and cancer treatment).

RESULTS

The median age at HCT was 55.7 years (range, 18.5-75.1 years), 59% were male, and 60% were non-Hispanic White. The prevalence of CAC was 37%. The 5-year CVD incidence for the cohort was 12%, and there was an incremental increase in the incidence according to CAC score: 0 (6%), 1-100 (20%), and >100 (32%) (p = .001). CAC was significantly associated with CVD risk (HR, 3.0; 95% CI, 1.2-7.5) and worse 5-year survival (77% vs. 50%; p < .001; HR, 2.0; 95% CI, 1.1-3.4), compared to those without CAC.

CONCLUSIONS

CAC is independently associated with CVD and survival after HCT. This highlights the importance of integrating readily available imaging information in risk stratification and decision-making in patients undergoing HCT, which sets the stage for strategies to optimize outcomes after HCT.

Influence of Deep Learning Based Image Reconstruction on Quantitative Results of Coronary Artery Calcium Scoring

RATIONALE AND OBJECTIVES

To assess the impact of deep learning-based imaging reconstruction (DLIR) on quantitative results of coronary artery calcium scoring (CACS) and to evaluate the potential of DLIR for radiation dose reduction in CACS.

METHODS

For a retrospective cohort of 100 consecutive patients (mean age 62 ±10 years, 40% female), CACS scans were reconstructed with filtered back projection (FBP), adaptive statistical iterative reconstruction (ASiR-V in 30%, 60% and 90% strength) and DLIR in low, medium and high strength. CACS was quantified semi-automatically and compared between image reconstructions. In a phantom study, a cardiac calcification insert was scanned inside an anthropomorphic thorax phantom at standard dose, 50% dose and 25% dose. FBP reconstructions at standard dose served as the reference standard.

RESULTS

In the patient study, DLIR led to a mean underestimation of Agatston score by 3.5, 6.4 and 11.6 points at low, medium and high strength, respectively. This underestimation of Agatston score was less pronounced for DLIR than for ASiR-V. In the phantom study, quantitative CACS results increased with reduced radiation dose and decreased with increasing strength of DLIR. Medium strength DLIR reconstruction at 50% dose reduction and high strength DLIR reconstruction at 75% dose reduction resulted in quantitative CACS results that were comparable to FBP reconstructions at standard dose.

CONCLUSION

Compared to FBP as the historical reference standard, DLIR leads to an underestimation of CACS but this underestimation is more moderate than with ASiR-V. DLIR can offset the increase in image noise and calcium score at reduced dose and may thus allow for substantial radiation dose reductions in CACS studies.

Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography

Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.

Measurement and Application of Incidentally Detected Coronary Calcium: JACC Review Topic of the Week

Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease risk stratification. The nongated, noncontrast chest computed tomography scan (NCCT) has emerged as a source of CAC characterization with tremendous potential due to the high volume of NCCT scans. Application of incidental CAC characterization from NCCT has raised questions around score accuracy, standardization of methodology including the possibility of deep learning to automate the process, and the risk stratification potential of an NCCT-derived score. In this review, the authors aim to summarize the role of NCCT-derived CAC in preventive cardiovascular health today as well as explore future avenues for eventual clinical applicability in specific patient populations and broader health systems.

Comparison of Coronary Artery Calcium and Quantitative Coronary Plaque in Predicting Obstructive Coronary Artery Disease: Subgroup Analysis of the CLARIFY Study

Background: Agatston coronary artery calcium (CAC) score is a strong predictor of mortality. However, the relationship between CAC and quantitative calcified plaque volume (CPV), which is measured on coronary computed tomography angiography (CCTA), is not well understood. Furthermore, there is limited evidence evaluating the difference between CAC versus CPV and CAC versus total plaque volume (TPV) in predicting obstructive coronary artery disease (CAD). Methods: This study included 147 subjects from the CLARIFY registry, a multicentered study of patients undergoing assessment using CCTA and CAC score as part of acute and stable chest pain evaluation. Automated software service (Cleerly.Inc, Denver, CO, USA) was used to evaluate the degree of vessel stenosis and plaque quantification on CCTA. CAC was measured using the standard Agatston method. Spearman correlation and receiver operating characteristic curve analysis was performed to evaluate the diagnostic ability of CAC, CPV and TPV in detecting obstructive CAD. Results: Results demonstrated a very strong positive correlation between CAC and CPV (r=0.76, p=0.0001) and strong correlation between CAC and TPV (r=0.72, p<0.001) at per-patient level analysis. At per-patient level analysis, the sensitivity of CAC (68%) is lower than CPV (77%) in predicting >50% stenosis, but negative predictive value is comparable. However, the sensitivity of TPV is higher compared with CAC in predicting >50% stenosis, and the negative predictive value of TPV is also higher. Conclusion: CPV and TPV are more sensitive in predicting the severity of obstructive CAD compared with the CAC score. However, the negative predictive value of CAC is comparable to CPV, but is lower than TPV. This study elucidates the relationship between CAC and quantitative plaque types, and especially emphasizes the differences between CAC and CPV which are two distinct plaque measurement techniques that are utilized in predicting obstructive CAD.

Impact of myocardial perfusion and coronary calcium on medical management for coronary artery disease

AIMS

Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with computed tomography (CT) attenuation correction and prescription of acetylsalicylic acid (ASA) and statins.

METHODS AND RESULTS

We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single centre between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression. In total, 9908 patients were included, with a mean age 66.8 ± 11.7 years and 5337 (53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2 vs. 12.0%, P < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared with no calcium (increase 12.1 vs. 7.8%, P < 0.001). In multivariable analyses, ischaemia and coronary artery calcium were independently associated with ASA and statin prescription.

CONCLUSION

Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.

Fully Automated Agatston Score Calculation From Electrocardiography-Gated Cardiac Computed Tomography Using Deep Learning and Multi-Organ Segmentation: A Validation Study

To evaluate deep learning-based calcium segmentation and quantification on ECG-gated cardiac CT scans compared with manual evaluation. Automated calcium quantification was performed using a neural network based on mask regions with convolutional neural networks (R-CNNs) for multi-organ segmentation. Manual evaluation of calcium was carried out using proprietary software. This is a retrospective study of archived data. This study used 40 patients to train the segmentation model and 110 patients were used for the validation of the algorithm. The Pearson correlation coefficient between the reference actual and the computed predictive scores shows high level of correlation (0.84; P < .001) and high limits of agreement (±1.96 SD; -2000, 2000) in Bland-Altman plot analysis. The proposed method correctly classifies the risk group in 75.2% and classifies the subjects in the same group. In total, 81% of the predictive scores lie in the same categories and only seven patients out of 110 were more than one category off. For the presence/absence of coronary artery calcifications, the deep learning model achieved a sensitivity of 90% and a specificity of 94%. Fully automated model shows good correlation compared with reference standards. Automating process reduces evaluation time and optimizes clinical calcium scoring without additional resources.

Use of coronary artery calcium score and coronary CT angiography to guide cardiovascular prevention and treatment

Currently, cardiovascular risk stratification to guide preventive therapy relies on clinical scores based on cardiovascular risk factors. However, the discriminative power of these scores is relatively modest. The use of coronary artery calcium score (CACS) and coronary CT angiography (CCTA) has surfaced as methods for enhancing the estimation of risk and potentially providing insights for personalized treatment in individual patients. CACS improves overall cardiovascular risk prediction and may be used to improve the yield of statin therapy in primary prevention, and possibly identify patients with a favorable risk/benefit relationship for antiplatelet therapies. CCTA holds promise to guide anti-atherosclerotic therapies and to monitor individual response to these treatments by assessing individual plaque features, quantifying total plaque volume and composition, and assessing peri-coronary adipose tissue. In this review, we aim to summarize current evidence regarding the use of CACS and CCTA for guiding lipid-lowering and antiplatelet therapy and discuss the possibility of using plaque burden and plaque phenotyping to monitor response to anti-atherosclerotic therapies.

Vendor Independent Coronary Calcium Scoring Improves Individual Risk Assessment: MESA (Multi-Ethnic Study of Atherosclerosis)

BACKGROUND

Substantial variation in Agatston scores (AS) acquired with different computed tomography (CT) scanners may influence patient risk classification.

OBJECTIVES

This study sought to develop a calibration tool for state-of-the-art CT systems resulting in vendor-neutral AS (vnAS), and to assess the impact of vnAS on coronary heart disease (CHD) event prediction.

METHODS

The vnAS calibration tool was derived by imaging 2 anthropomorphic calcium containing phantoms on 7 different CT and 1 electron beam tomography system, which was used as the reference system. The effect of vnAS on CHD event prediction was analyzed with data from 3,181 participants from MESA (Multi-Ethnic Study on Atherosclerosis). Chi-square analysis was used to compare CHD event rates between low (vnAS <100) and high calcium groups (vnAS ≥100). Multivariable Cox proportional hazard regression models were used to assess the incremental value of vnAS.

RESULTS

For all CT systems, a strong correlation with electron beam tomography-AS was found (R2 >0.932). Of the MESA participants originally in the low calcium group (n = 781), 85 (11%) participants were reclassified to a higher risk category based on the recalculated vnAS. For reclassified participants, the CHD event rate of 15% was significantly higher compared with participants in the low calcium group (7%; P = 0.008) with a CHD HR of 3.39 (95% CI: 1.82-6.35; P = 0.001).

CONCLUSIONS

The authors developed a calibration tool that enables calculation of a vnAS. MESA participants who were reclassified to a higher calcium category by means of the vnAS experienced more CHD events, indicating improved risk categorization.

Activation of the Nrf-2/HO-1 signalling axis can alleviate metabolic syndrome in cardiovascular disease

Background: Cardiovascular disease (CVD) is widely observed in modern society. CVDs are responsible for the majority of fatalities, with heart attacks and strokes accounting for approximately 80% of these cases. Furthermore, a significant proportion of these deaths, precisely one-third, occurs in individuals under 70. Metabolic syndrome encompasses a range of diseases characterized by various physiological dysfunctions. These include increased inflammation in adipose tissue, enhanced cholesterol synthesis in the liver, impaired insulin secretion, insulin resistance, compromised vascular tone and integrity, endothelial dysfunction, and atheroma formation. These factors contribute to the development of metabolic disorders and significantly increase the likelihood of experiencing cardiovascular complications.Method: We selected studies that proposed hypotheses regarding metabolic disease syndrome and cardiovascular disease (CVD) and the role of Nrf2/HO-1 and factor regulation in CVD research investigations based on our searches of Medline and PubMed.Results: A total of 118 articles were included in the review, 16 of which exclusively addressed hypotheses about the role of Nrf2 on Glucose regulation, while 16 involved Cholesterol regulation. Likewise, 14 references were used to prove the importance of mitochondria on Nrf2. Multiple studies have provided evidence suggesting the involvement of Nrf2/HO-1 in various physiological processes, including metabolism and immune response. A total of 48 research articles and reviews have been used to highlight the role of metabolic syndrome and CVD.Conclusion: This review provides an overview of the literature on Nrf2/HO-1 and its role in metabolic disease syndrome and CVD.

Predicting Adverse Cardiac Events After Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer

Background

Radiotherapy may cause grade ≥3 cardiac events, necessitating a better understanding of risk factors. The potential predictive role of imaging biomarkers with radiotherapy doses for cardiac event occurrence has not been studied.

Objectives

The aim of this study was to establish the associations between cardiac substructure dose and coronary artery calcium (CAC) scores and cardiac event occurrence.

Methods

A retrospective cohort analysis included patients with locally advanced non-small cell lung cancer treated with radiotherapy (2006-2018). Cardiac substructures, including the left anterior descending coronary artery, left main coronary artery, left circumflex coronary artery, right coronary artery, and TotalLeft (left anterior descending, left main, and left circumflex coronary arteries), were contoured. Doses were measured in 2-Gy equivalent units, and visual CAC scoring was compared with automated scoring. Grade ≥3 adverse cardiac events were recorded. Time-dependent receiver-operating characteristic modeling, the log-rank statistic, and competing-risk models were used to measure prediction performance, threshold modeling, and the cumulative incidence of cardiac events, respectively.

Results

Of the 233 eligible patients, 61.4% were men, with a median age of 68.1 years (range: 34.9-90.7 years). The median follow-up period was 73.7 months (range: 1.6-153.9 months). Following radiotherapy, 22.3% experienced cardiac events, within a median time of 21.5 months (range: 1.7-118.9 months). Visual CAC scoring showed significant correlation with automated scoring (r = 0.72; P < 0.001). In a competing-risk multivariable model, TotalLeft volume receiving 15 Gy (per 1 cc; HR: 1.38; 95% CI: 1.11-1.72; P = 0.004) and CAC score >5 (HR: 2.51; 95% CI: 1.08-5.86; P = 0.033) were independently associated with cardiac events. A model incorporating age, TotalLeft CAC (score >5), and volume receiving 15 Gy demonstrated a higher incidence of cardiac events for a high-risk group (28.9%) compared with a low-risk group (6.9%) (P < 0.001).

Conclusions

Adverse cardiac events associated with radiation occur in more than 20% of patients undergoing thoracic radiotherapy within a median time of <2 years. The present findings provide further evidence to support significant associations between TotalLeft radiotherapy dose and cardiac events and define CAC as a predictive risk factor.

Efficacy and Safety of Single-Pill Combination of Rosuvastatin and Ezetimibe in Chinese Patients with Primary Hypercholesterolemia Inadequately Controlled by Statin Treatment (ROZEL): A Randomized, Double-Blind, Double Dummy, Active-Controlled Phase 3 Clinical Trial

INTRODUCTION

Many patients with primary hypercholesterolemia do not achieve their plasma low-density lipoprotein cholesterol (LDL-C) goals with statin alone under a recommended dose of statin (e.g., 10 mg rosuvastatin) in China. The objective of this phase III study was to evaluate the efficacy and safety of a new single-pill combination (SPC) of rosuvastatin 10 mg/ezetimibe 10 mg (R10/E10) in this population.

METHODS

This was a randomized, double-blind, double-dummy, active-controlled study in patients with primary hypercholesterolemia inadequately controlled with statin alone. The participants were randomized 1:1 to receive SPC R10/E10 or R10. The primary objective was to demonstrate the superiority of SPC R10/E10 vs. R10 in reducing the LDL-C levels after 8 weeks.

RESULTS

This trial randomized 305 participants to SPC R10/E10 (n = 153) and R10 (n = 152). The superiority of SPC R10/E10 over R10 was demonstrated with the least square (LS) mean difference of percent change in LDL-C from baseline to week 8: - 13.85% (95% confidence interval [CI] - 20.15% to - 7.56%, P < 0.0001). The proportion of participants who achieved the LDL-C target (< 2.6 mmol/l) at week 8 was larger with SPC R10/E10 (n = 80, 54.1%) than with R10 (n = 42, 29.2%) (Odds ratio = 2.80, 95% CI 1.70 to 4.61, P < 0.0001). No unexpected safety findings were reported.

CONCLUSION

The results suggest that SPC R10/E10 improve LDL-C reduction and goal achievement in Chinese patients with primary hypercholesterolemia not adequately controlled on statin therapy, without new safety findings.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04669041).

Coronary artery calcium score is a prognostic factor for mortality in idiopathic pulmonary fibrosis

BACKGROUND

Cardiovascular diseases are frequent in idiopathic pulmonary fibrosis (IPF) and impact on survival. We investigated the association of coronary artery calcium (CAC) score at IPF diagnosis and during mid-term follow-up, with adverse cardiovascular events and all-cause mortality.

METHODS

Consecutive patients with IPF were retrospectively analyzed. Demographic data, smoking history, comorbidities and pulmonary function tests (PFTs) were recorded. All patients had at least two chest high resolution computed tomography (HRCT) performed 2 years apart. The total CAC score and visual fibrotic score were calculated, and all clinically significant cardiovascular events and deaths were reported.

RESULTS

The population consisted of 79 patients (57 males, mean age: 74.4±7.6 years); 67% of patients had a history of smoking, 48% of hypertension, 37% of dyslipidemia and 22.8% of diabetes. The visual score was 21.28±7.99% at T0 and 26.54±9.34% at T1, respectively (T1-T0 5.26±6.13%, P<0.001). CAC score at T0 and at T1 was 537.93±839.94 and 759.98±1027.6, respectively (T1-T0 224.66±406.87, P<0.001). Mean follow-up time was 2.47±1.1 years. On multivariate analysis, male sex (HR=3.58, 95% CI: 1.14-11.2) and CAC score at T0 (HR=1.04, 95% CI: 1.01-1.07) correlated with mortality and cardiovascular events. CAC score at T0≥405 showed 82% sensitivity and 100% specificity for predicting mortality and adverse cardiovascular events.

CONCLUSIONS

IPF patients with a CAC score at diagnosis ≥405 have a poor prognosis over a mid-term follow-up. A higher CAC score is associated with mortality and cardiovascular events.

Vascular aging and cardiovascular disease: pathophysiology and measurement in the coronary arteries

Age is a key risk factor for cardiovascular disease, including atherosclerosis. However, pathophysiological disease processes in the arteries are not an inevitable feature of aging. Large cohort studies with arterial phenotyping along with clinical and demographic data are essential to better understand factors related to the susceptibility or resilience to age-related vascular pathophysiology in humans. This review explores the mechanisms by which vascular structure and function alters with age, and how these changes relate to cardiovascular pathophysiology and disease. Features of vascular aging in the coronary arteries have historically been difficult to quantify pre-mortem due to their size and location. However, non-invasive imaging modalities including CT Coronary Angiogram are now being used to assess coronary vascular age, and further advances in imaging analysis such as the CT Fat Attenuation Index will help provide further measurement of features associated with coronary vascular aging. Currently, markers of vascular aging are not used as therapeutic targets in routine clinical practice, but non-pharmacological interventions including aerobic exercise and low salt diet, as well as anti-hypertensives have been demonstrated to reduce arterial stiffness. Advances in imaging technology, both in acquisition and advanced analysis, as well as harmonisation of measurements for researchers across the globe will be invaluable in understanding what constitutes healthy vascular aging and in identifying features of vascular aging that are associated with coronary artery disease and its adverse outcomes. Assessing such images in large cohorts can facilitate improved definitions of resilient and susceptible phenotypes to vascular aging in the coronary arteries. This is a critical step in identifying further risk factors and biomarkers within these groups and driving forward the development of novel therapies aimed at slowing or stopping age-related vascular changes in the coronary arteries.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

The clinical application of atorvastatin in patients with small-cell lung cancer with dyslipidemia

BACKGROUND

Various experimental studies demonstrated that atorvastatin exerted additive effects with anticancer drugs to impair tumor growth, delay relapse, and prolong survival time in lung cancer. However, it is indistinct whether there are survival benefits of atorvastatin in the treatment of small-cell lung cancer (SCLC) patients with dyslipidemia. Therefore, this study aimed to evaluate the efficacy and safety of atorvastatin plus first-line standard chemotherapy in SCLC combined dyslipidemia.

METHODS

This was a retrospective analysis of 91 eligible SCLC patients with dyslipidemia registered at the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from October 2018 to October 2022. SCLC patients with confirmed dyslipidemia were assigned to the treatment group to receive atorvastatin plus first-line standard chemotherapy (n = 45) or to the control group to accept chemotherapy (n = 46) until disease progression or unmanageable toxicity occurred. The clinicopathological parameters and survival data were collected and analyzed. Univariate and multivariate analyses were performed to investigate the prognostic significance of SCLC. The median progression-free survival (mPFS) was considered to be the pivotal symbol as the primary endpoint. The second endpoints were recognized as the median overall survival (mOS) and toxicity.

RESULTS

In the total of 91 enrolled patients, the curative effect can be evaluated in all patients. Research results showed that atorvastatin added to first-line standard chemotherapy was associated with a significant improvement in survival (mPFS: 7.4 vs 6.8 months, P = 0.031; mOS: 14.7 vs 13.2 months, P = 0.002).

CONCLUSION

Atorvastatin added to first-line standard chemotherapy achieved prospective efficacy and manageable safety in SCLC combined dyslipidemia.

Single-Cell RNA Sequencing of Coronary Perivascular Adipose Tissue From End-Stage Heart Failure Patients Identifies SPP1+ Macrophage Subpopulation as a Target for Alleviating Fibrosis

BACKGROUND

Perivascular adipose tissue (PVAT) is vital for vascular homeostasis, and PVAT dysfunction is associated with increased atherosclerotic plaque burden. But the mechanisms underlining coronary PVAT dysfunction in coronary atherosclerosis remain elusive.

METHODS

We performed single-cell RNA sequencing of the stromal vascular fraction of coronary PVAT from 3 groups of heart transplant recipients with end-stage heart failure, including 3 patients with nonobstructive coronary atherosclerosis, 3 patients with obstructive coronary artery atherosclerosis, and 4 nonatherosclerosis control subjects. Bioinformatics was used to annotate the cellular populations, depict the cellular developmental trajectories and interactions, and explore the differences among 3 groups of coronary PVAT at the cellular and molecular levels. Pathological staining, quantitative real-time polymerase chain reaction, and in vitro studies were performed to validate the key findings.

RESULTS

Ten cell types were identified among 67 936 cells from human coronary PVAT. Several cellular subpopulations, including SPP1+ (secreted phosphoprotein 1) macrophages and profibrotic fibroadipogenic progenitor cells, were accumulated in PVAT surrounding atherosclerotic coronary arteries compared with nonatherosclerosis coronary arteries. The fibrosis percentage was increased in PVAT surrounding atherosclerotic coronary arteries, and it was positively associated with the grade of coronary artery stenosis. Cellular interaction analysis suggested OPN (osteopontin) secreted by SPP1+ macrophages interacted with CD44 (cluster of differentiation 44)/integrin on fibroadipogenic progenitor cells. Strikingly, correlation analyses uncovered that higher level of SPP1 in PVAT correlates with a more severe fibrosis degree and a higher coronary stenosis grade. In vitro studies showed that conditioned medium from atherosclerotic coronary PVAT promoted the migration and proliferation of fibroadipogenic progenitor cells, while such effect was prevented by blocking CD44 or integrin.

CONCLUSIONS

SPP1+ macrophages accumulated in the PVAT surrounding atherosclerotic coronary arteries, and they promoted the migration and proliferation of fibroadipogenic progenitor cells via OPN-CD44/integrin interaction and thus aggravated the fibrosis of coronary PVAT, which was positively correlated to the coronary stenosis burden. Therefore, SPP1+ macrophages in coronary PVAT may participate in the progression of coronary atherosclerosis.

Coronary Artery Calcium Scoring in Asymptomatic Patients

Coronary artery calcium (CAC) scoring is an important prognostic tool for personalized cardiovascular preventive care and has recently been incorporated into American College of Cardiology/American Heart Association guidelines. CAC provides direct visualization and quantification of CAC burden for risk stratification and primary prevention of cardiovascular events in an asymptomatic population. CAC scoring is recommended for individuals with intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk and selective populations with borderline ASCVD risk. In this review, we outline the interpretation of CAC scores for predicting the risk of cardiovascular events, and we highlight the guidelines for starting statin and potentially starting aspirin therapy. A CAC score of 0 is the strongest negative predictive factor for cardiovascular disease (CVD), and a 0 score can successfully de-risk a patient. On the contrary, higher CAC scores correlate with worse cardiovascular prognostic outcomes. The CAC scan is a widely available and reproducible means for an early look at the atherosclerotic burden, and it can help strategize early interventions. The CAC interpretation and the decision to start treatment need to be personalized based on individual risk factors. We believe the emerging literature supports our contention that the CAC score can be used more broadly to improve the prophylaxis and treatment of a wider range of apparently healthy patients.

[Coronary CT angiography and coronary atherosclerosis : Where do we stand today?]

Cardiac computed tomography (CT) has made substantial progress in recent years. The main field of application is CT coronary angiography for visualization of the coronary arteries and for the detection and exclusion of coronary artery stenosis. This has been included in international guidelines for the management of stable coronary artery disease or chronic coronary syndrome as well as for the diagnostic work-up of patients with acute chest pain; however, it must be taken into account that the diagnostic validity is only sufficiently high when the image quality is good and therefore alternative diagnostic procedures should be included in patients where an unrestricted good image quality is not to be expected. The fact that CT angiography enables the detection not only of coronary stenosis but also of nonobstructive atherosclerotic plaque is interesting for the estimation of the risk of atherosclerotic events. It is practically certain that in the absence of detectable atherosclerotic plaque in CT angiography, statin treatment does not lower the risk of atherosclerotic events. To what extent CT is suitable to provide indications for statin treatment and the threshold for which the presence of nonobstructive plaque should prompt initiation of statin treatment are currently the subject of intensive research.

Reporting and Outcomes of Coronary Calcification on Lung Cancer Screening CT

RATIONALE AND OBJECTIVES

To evaluate the accuracy and downstream testing and statin prescribing of real-world reporting of coronary calcification on lung cancer screening (LCS) CT.

MATERIALS AND METHODS

We retrospectively reviewed LCS CTs from January 2015 to November 2021 for reporting of coronary calcification; reports that denoted coronary calcification as a significant incidental finding ("S" modifier) were also noted. We evaluated calcium scoring accuracy in patients in whom a cardiac or calcium scoring CT was performed within 1 year of the LCS CT. For the first LCS CT in all patients, we evaluated whether a stress test was performed within 6 months and whether a new statin prescription was written within 90 days of the LCS CT. Patients were stratified by atherosclerotic cardiovascular disease (ASCVD) risk group, used in a multivariable regression analysis for new statin prescriptions.

RESULTS

Eight thousand nine hundred eighty-seven patients underwent screening. In 117 patients who had a paired cardiac CT, scores were concordant in 65 (56%), and LCS CTs did not mention or underestimated calcifications in 40 (34%). Reporting of coronary artery calcifications led to new statin prescriptions, with OR of 1.8 for calcifications without S modifier and 4.4 for calcifications with S modifier. Reporting of coronary artery calcification with S modifier led to subsequent stress testing in 141/1582 (9%) of patients.

CONCLUSION

Coronary calcifications are frequently not mentioned or underestimated at LCS CT. Reporting of coronary calcifications leads to new statin prescriptions, and radiologists should consider reporting these to allow for a risk-benefit discussion with the patient's physician.