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Chen LQ, Scheiner J, Nashta NF, Weber J, Zhou Q, Rapelje K, Dey D, Cao JJ. Epicardial fat modifies the relationship between coronary calcium score and all-cause mortality: The St. Francis Heart Study. Am J Prev Cardiol 2024; 19:100689. [PMID: 39005754 PMCID: PMC11245900 DOI: 10.1016/j.ajpc.2024.100689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/20/2024] [Accepted: 06/12/2024] [Indexed: 07/16/2024] Open
Abstract
Objective Epicardial fat is associated with cardiovascular risk factors and adverse outcomes. However, it is not clear if epicardial fat remains to be a mortality risk when coronary calcium score (CAC) is taken into account. Methods We studied the 1005 participants from the St. Francis Heart Study who were apparently healthy with CAC scores at 80th percentile or higher for age and gender, randomly assigned to placebo or statin therapy. At baseline, lipid profiles and non-contrast CT images were obtained where the epicardial fat volume was analyzed. Likelihood ratio testing was used to assess the additional prognostic value of epicardial fat to CAC for the risk of all-cause mortality. Results Increased epicardial fat volume was associated with higher CAC. For each unit increase in lnCAC, the average epicardial fat volume increased by 3.34 mL/m2. After a mean follow-up period of 17 years, 179 (18%) participants died. Increased epicardial fat volume was associated with an adjusted hazard ratio of 1.11 (95% CI: 1.02 to 1.20) predicting all-cause mortality. In the stratified analysis testing strata of epicardial fat and CAC, those with increased epicardial fat and increased CAC had the highest risk of death. Compared with a model containing lnCAC and traditional risk factors, a model additionally containing epicardial fat volume yielded a better model fit (likelihood ratio test p < 0.001). Conclusion Increased epicardial fat volume is associated with increased all-cause mortality risk. In addition, it portends incremental prognostic value to CAC score in mortality prediction.
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Affiliation(s)
- Lu Q. Chen
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
| | - Jonathan Scheiner
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
| | - Niloofar Fouladi Nashta
- Sol Price School of Health Policy, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Weber
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
| | - Qingtao Zhou
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
| | - Kathleen Rapelje
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
| | - Damini Dey
- Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - J. Jane Cao
- St Francis Hospital & Heart Center, The Heart Center 101 Northern Boulevard, Roslyn, NY 11548, United States
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Arslan A, Aytemiz F, Işıklar İ, Özkaya ÖG. Re-Evaluation of Cardiovascular Disease Risk and Primary Prevention Treatments with Coronary Artery Calcium Scoring in Primary Prevention Patients. J Clin Med 2024; 13:4125. [PMID: 39064165 PMCID: PMC11278108 DOI: 10.3390/jcm13144125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
Objective: The coronary artery calcium score (CACS) is used as a screening tool to identify the presence/absence of subclinical atherosclerosis in asymptomatic individuals. We evaluated the risk categories and medical therapy of asymptomatic individuals with subclinical atherosclerosis (CACS > 0) and applied the atherosclerotic cardiovascular disease (ASCVD) score and Framingham risk score (FRS) to assess those at a high risk of subclinical atherosclerosis (CACS ≥ 400). Methods: We retrospectively enrolled 218 asymptomatic individuals (65.6% women, and mean age 67.5 ± 10.3 years) who had their CACS evaluated at the cardiovascular department of our hospital between 2016 and 2020. Results: Among the 218 participants, 24.3% were classified as low-risk according to the FRS, and 19.3% had no subclinical atherosclerosis. However, only 12.8% and 27.5% of the study population were taking statins and aspirin, respectively. Furthermore, although more than half of the individuals without subclinical atherosclerosis were in the intermediate- and high-risk groups according to the risk scores, there were no considerable differences in the rates of taking aspirin and statins between the groups. When patients in the very-high-risk group according to the CACS and low-intermediate-risk patients were compared, there was no considerable difference in the rates of risk subgroups and taking statins, whereas high-risk patients took statistically significantly more aspirin. Conclusions: In primary prevention screening, CACS can be used as a reliable marker of subclinical ASCVD and help physicians optimize and improve adherence to medical therapy, including aspirin and statins, particularly for high-risk individuals.
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Affiliation(s)
- Abdulla Arslan
- Department of Cardiology, Baskent University, Istanbul 34662, Turkey;
| | - Fatih Aytemiz
- Department of Cardiology, City Hospital of Manisa, Istanbul 45030, Turkey;
| | - İclal Işıklar
- Department of Radiology, Baskent University, Istanbul 34662, Turkey;
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Zhu Y. Non-gated chest CT for coronary artery calcium score: is this reliable? Eur Radiol 2024; 34:4457-4458. [PMID: 38940856 DOI: 10.1007/s00330-023-10472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 06/29/2024]
Affiliation(s)
- Yeqing Zhu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.
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4
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Klemenz AC, Beckert L, Manzke M, Lang CI, Weber MA, Meinel FG. Influence of Deep Learning Based Image Reconstruction on Quantitative Results of Coronary Artery Calcium Scoring. Acad Radiol 2024; 31:2259-2267. [PMID: 38582685 DOI: 10.1016/j.acra.2024.03.020] [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] [Received: 01/10/2024] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/08/2024]
Abstract
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.
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Affiliation(s)
- Ann-Christin Klemenz
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Schillingallee 36, 18057 Rostock, Germany
| | - Lynn Beckert
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Schillingallee 36, 18057 Rostock, Germany
| | - Mathias Manzke
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Schillingallee 36, 18057 Rostock, Germany
| | - Cajetan I Lang
- Department of Cardiology, University Medical Center Rostock, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Schillingallee 36, 18057 Rostock, Germany
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Schillingallee 36, 18057 Rostock, Germany.
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5
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Zook S, Tayal B, Kragholm K, Abdelkarim O, Tran D, Cocker M, Ramirez-Giraldo JC, Hallam K, Sexton C, Johnson S, Chang SM. Intraindividual Comparison of Dose Reduction and Coronary Calcium Scoring Accuracy Using Kilovolt-independent and Tin Filtration CT Protocols. Radiol Cardiothorac Imaging 2024; 6:e230246. [PMID: 38934769 PMCID: PMC11211948 DOI: 10.1148/ryct.230246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 04/11/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024]
Abstract
Purpose To investigate the ability of kilovolt-independent (hereafter, kV-independent) and tin filter spectral shaping to accurately quantify the coronary artery calcium score (CACS) and radiation dose reductions compared with the standard 120-kV CT protocol. Materials and Methods This prospective, blinded reader study included 201 participants (mean age, 60 years ± 9.8 [SD]; 119 female, 82 male) who underwent standard 120-kV CT and additional kV-independent and tin filter research CT scans from October 2020 to July 2021. Scans were reconstructed using a Qr36f kernel for standard scans and an Sa36f kernel for research scans simulating artificial 120-kV images. CACS, risk categorization, and radiation doses were compared by analyzing data with analysis of variance, Kruskal-Wallis test, Mann-Whitney test, Bland-Altman analysis, Pearson correlations, and κ analysis for agreement. Results There was no evidence of differences in CACS across standard 120-kV, kV-independent, and tin filter scans, with median CACS values of 1 (IQR, 0-48), 0.6 (IQR, 0-58), and 0 (IQR, 0-51), respectively (P = .85). Compared with standard 120-kV scans, kV-independent and tin filter scans showed excellent correlation in CACS values (r = 0.993 and r = 0.999, respectively), with high agreement in CACS risk categorization (κ = 0.95 and κ = 0.93, respectively). Standard 120-kV scans had a mean radiation dose of 2.09 mSv ± 0.84, while kV-independent and tin filter scans reduced it to 1.21 mSv ± 0.85 and 0.26 mSv ± 0.11, cutting doses by 42% and 87%, respectively (P < .001). Conclusion The kV-independent and tin filter research CT acquisition techniques showed excellent agreement and high accuracy in CACS estimation compared with standard 120-kV scans, with large reductions in radiation dose. Keywords: CT, Cardiac, Coronary Arteries, Radiation Safety, Coronary Artery Calcium Score, Radiation Dose Reduction, Low-Dose CT Scan, Tin Filter, kV-Independent Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Salma Zook
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Bhupendar Tayal
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Kristian Kragholm
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Ola Abdelkarim
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Diana Tran
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Myra Cocker
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Juan Carlos Ramirez-Giraldo
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Kristina Hallam
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Colleen Sexton
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Stephanie Johnson
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
| | - Su Min Chang
- From the Department of Cardiology, Houston Methodist DeBakey Heart
and Vascular Center, Houston Methodist Hospital, 6550 Fannin St, Ste 1801,
Houston, TX 77030 (S.Z., B.T., K.K., O.A., D.T., C.X., S.J., S.M.C.); Department
of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
(O.A.); and CT R&D Collaborations, Siemens Healthineers, Malvern, Pa
(M.C., J.C.R.G., K.H.)
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Mszar R, Katz ME, Grandhi GR, Osei AD, Gallo A, Blaha MJ. Subclinical Atherosclerosis to Guide Treatment in Dyslipidemia and Diabetes Mellitus. Curr Atheroscler Rep 2024; 26:217-230. [PMID: 38662272 DOI: 10.1007/s11883-024-01202-w] [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] [Accepted: 04/03/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Dyslipidemia and type 2 diabetes mellitus are two common conditions that are associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we aimed to provide an in-depth and contemporary review of non-invasive approaches to assess subclinical atherosclerotic burden, predict cardiovascular risk, and guide appropriate treatment strategies. We focused this paper on two main imaging modalities: coronary artery calcium (CAC) score and computed tomography coronary angiography. RECENT FINDINGS Recent longitudinal studies have provided stronger evidence on the relationship between increased CAC, thoracic aorta calcification, and risk of cardiovascular events among those with primary hypercholesterolemia, highlighting the beneficial role of statin therapy. Interestingly, resilient profiles of individuals not exhibiting atherosclerosis despite dyslipidemia have been described. Non-conventional markers of dyslipidemia have also been associated with increased subclinical atherosclerosis presence and burden, highlighting the contribution of apolipoprotein B-100 (apoB)-rich lipoprotein particles, such as remnant cholesterol and lipoprotein(a), to the residual risk of individuals on-target for low-density lipoprotein cholesterol (LDL-C) goals. Regarding type 2 diabetes mellitus, variability in atherosclerotic burden has also been found, and CAC testing has shown significant predictive value in stratifying cardiovascular risk. Non-invasive assessment of subclinical atherosclerosis can help reveal the continuum of ASCVD risk in those with dyslipidemia and diabetes mellitus and can inform personalized strategies for cardiovascular disease prevention in the primary prevention setting.
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Affiliation(s)
- Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Miriam E Katz
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Gowtham R Grandhi
- Virginia Commonwealth University Health Pauley Heart Center, Richmond, VA, USA
| | - Albert D Osei
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Antonio Gallo
- Department of Nutrition, Lipidology and Cardiovascular Prevention Unit, APHP, INSERM UMR1166, Hôpital Pitié-Salpètriêre, Sorbonne Université, Paris, France
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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Doshi A, Gandhi H, Patel KN, Majmundar M, Doshi R. Aspirin for Primary Prevention in Patients With Elevated Coronary Artery Calcium Score: A Systematic Review of Current Evidences. Am J Cardiol 2024; 220:9-15. [PMID: 38548012 DOI: 10.1016/j.amjcard.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/20/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024]
Abstract
The 2019 American College of Cardiology and American Heart Association guidelines regarding low-dose aspirin in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) indicate an increased risk of bleeding without a net benefit. The coronary artery calcium (CAC) score could be used to guide aspirin therapy in high-risk patients without an increased risk of bleeding. With this systematic review, we aimed to analyze studies that have investigated the role of CAC in primary prevention with aspirin. A total of 4 relevant studies were identified and the primary outcomes of interest were bleeding events and major adverse cardiac events. The outcomes of interest were stratified into 3 groups based on CAC scoring: 0, 1 to 99, and ≥100. A study concluded from 2,191 patients that with a low bleeding risk, CAC ≥100, and ASCVD risk ≥5% aspirin confers a net benefit, whereas patients with a high bleeding risk would experience a net harm, irrespective of ASCVD risk or CAC. All other studies demonstrated net benefit in patients with CAC ≥100 with a clear benefit. CAC scores correspond to calcified plaque in coronary vessels and are associated with graded increase in adverse cardiovascular events. Our review has found that in the absence of a significant bleeding risk, increased ASCVD risk and CAC score corelate with increased benefit from aspirin. A study demonstrated a decrease in the odds of myocardial infarction from 3 to 0.56 in patients on aspirin. The major drawback of aspirin for primary prevention is the bleeding complication. At present, there is no widely validated tool to predict the bleeding risk with aspirin, which creates difficulties in accurately delineating risk. Barring some discrepancy between studies, evidence shows a net harm for the use of aspirin in low ASCVD risk (<5%), irrespective of CAC score.
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Affiliation(s)
- Apoorva Doshi
- Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Haresh Gandhi
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, California
| | - Kunal N Patel
- Department of Cardiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Monil Majmundar
- Department of Cardiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Rajkumar Doshi
- Department of Cardiology, St Joseph's University Medical Center, Paterson, New Jersey.
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Lei MH, Hsu YC, Chung SL, Chen CC, Chen WC, Chen WM, Jao AT, Hsiao JF, Hsu JT, Wu SY. Assessing mortality risk in Type 2 Diabetes patients with prolonged ASCVD risk factors: the inclusive Poh-Ai predictive scoring system with CAC Score integration. Diabetol Metab Syndr 2024; 16:104. [PMID: 38764060 PMCID: PMC11103845 DOI: 10.1186/s13098-024-01341-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024] Open
Abstract
PURPOSE To enhance the predictive risk model for all-cause mortality in individuals with Type 2 Diabetes (T2DM) and prolonged Atherosclerotic Cardiovascular Disease (ASCVD) risk factors. Despite the utility of the Coronary Artery Calcium (CAC) score in assessing cardiovascular risk, its capacity to predict all-cause mortality remains limited. METHODS A retrospective cohort study included 1929 asymptomatic T2DM patients with ASCVD risk factors, aged 40-80. Variables encompassed demographic attributes, clinical parameters, CAC scores, comorbidities, and medication usage. Factors predicting all-cause mortality were selected to create a predictive scoring system. By using stepwise selection in a multivariate Cox proportional hazards model, we divided the patients into three risk groups. RESULTS In our analysis of all-cause mortality in T2DM patients with extended ASCVD risk factors over 5 years, we identified significant risk factors, their adjusted hazard ratios (aHR), and scores: e.g., CAC score > 1000 (aHR: 1.57, score: 2), CAC score 401-1000 (aHR: 2.05, score: 2), and more. These factors strongly predict all-cause mortality, with varying risk groups (e.g., very low-risk: 2.0%, very high-risk: 24.0%). Significant differences in 5-year overall survival rates were observed among these groups (log-rank test < 0.001). CONCLUSION The Poh-Ai Predictive Scoring System excels in forecasting mortality and cardiovascular events in individuals with Type 2 Diabetes Mellitus and extended ASCVD risk factors.
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Affiliation(s)
- Meng-Huan Lei
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Yu-Chen Hsu
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Sheng-Liang Chung
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Chao-Chin Chen
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Wei-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Wan-Ming Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan
- Artificial Intelligence Development Center, Fu Jen Catholic University, New Taipei City, Taiwan
| | - An-Tzu Jao
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Ju-Feng Hsiao
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan
| | - Jen-Te Hsu
- Division of Cardiology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan.
| | - Szu-Yuan Wu
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan.
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan.
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
- Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Gami A, Bisht S, Satish P, Blaha MJ, Patel J. The utility of coronary artery calcium scoring to enhance cardiovascular risk assessment for South Asian adults. Prog Cardiovasc Dis 2024; 84:7-13. [PMID: 38723928 DOI: 10.1016/j.pcad.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024]
Abstract
South Asian individuals represent a highly diverse population and are one of the fastest growing ethnic groups in the United States. This population has a high prevalence of traditional and non-traditional cardiovascular disease (CVD) risk factors and a disproportionately high prevalence of coronary heart disease. To reflect this, current national society guidelines have designated South Asian ancestry as a "risk enhancing factor" which may be used to guide initiation or intensification of statin therapy. However, current methods of assessing cardiovascular risk in South Asian adults may not adequately capture the true risk in this diverse population. Coronary artery calcium (CAC) scoring provides a reliable, reproducible, and highly personalized method to provide CVD risk assessment and inform subsequent pharmacotherapy recommendations, if indicated. This review describes the utility of CAC scoring for South Asian individuals.
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Affiliation(s)
- Abhishek Gami
- Johns Hopkins University School of Medicine, Department of Internal Medicine, Baltimore, MD, USA
| | - Sushrit Bisht
- Anne Arundel Medical Center, Department of Internal Medicine, Annapolis, MD, USA
| | - Priyanka Satish
- Houston Methodist DeBakey Heart and Vascular Center, TX, USA
| | - Michael J Blaha
- South Asian Cardiovascular Health Initiative (SACHI), Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Jaideep Patel
- South Asian Cardiovascular Health Initiative (SACHI), Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA.
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10
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Azam S, Tamimi RM, Drotman MB, Babagbemi K, Levy AD, Peña JM. Assessing breast arterial calcification in mammograms and its implications for atherosclerotic cardiovascular disease risk. Clin Imaging 2024; 109:110129. [PMID: 38582071 DOI: 10.1016/j.clinimag.2024.110129] [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] [Received: 12/12/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE Breast arterial calcifications (BAC) are incidentally observed on mammograms, yet their implications remain unclear. We investigated lifestyle, reproductive, and cardiovascular determinants of BAC in women undergoing mammography screening. Further, we investigated the relationship between BAC, coronary arterial calcifications (CAC) and estimated 10-year atherosclerotic cardiovascular (ASCVD) risk. METHODS In this cross-sectional study, we obtained reproductive history and CVD risk factors from 215 women aged 18 or older who underwent mammography and cardiac computed tomographic angiography (CCTA) within a 2-year period between 2007 and 2017 at hospital. BAC was categorized as binary (present/absent) and semi-quantitatively (mild, moderate, severe). CAC was determined using the Agatston method and recorded as binary (present/absent). Adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated, accounting for age as a confounding factor. ASCVD risk over a 10-year period was calculated using the Pooled Cohort Risk Equations. RESULTS Older age, systolic and diastolic blood pressures, higher parity, and younger age at first birth (≤28 years) were significantly associated with greater odds of BAC. Women with both BAC and CAC had the highest estimated 10-year risk of ASCVD (13.30 %). Those with only BAC (8.80 %), only CAC (5.80 %), and no BAC or CAC (4.40 %) had lower estimated 10-year risks of ASCVD. No association was detected between presence of BAC and CAC. CONCLUSIONS These findings support the hypothesis that BAC on a screening mammogram may help to identify women at potentially increased risk of future cardiovascular disease without additional cost and radiation exposure.
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Affiliation(s)
- Shadi Azam
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA.
| | - Rulla M Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA.
| | - Michele B Drotman
- Department of Diagnostic Radiology, Weill Cornell Medicine, New York, USA.
| | - Kemi Babagbemi
- Department of Diagnostic Radiology, Weill Cornell Medicine, New York, USA.
| | - Allison D Levy
- Department of Diagnostic Radiology, Weill Cornell Medicine, New York, USA.
| | - Jessica M Peña
- Departments of Medicine and Radiology, Weill Cornell Medicine, New York, USA.
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11
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Yang E, German CA. Coronary Artery Calcium Scoring in the Assessment of ASCVD Risk. J Cardiopulm Rehabil Prev 2024; 44:E7-E8. [PMID: 38465913 DOI: 10.1097/hcr.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Affiliation(s)
- Edward Yang
- Author Affiliations: University of Chicago Medicine, Chicago, Illinois (Dr Yang); and Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois (Dr German)
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12
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Gennari AG, Rossi A, De Cecco CN, van Assen M, Sartoretti T, Giannopoulos AA, Schwyzer M, Huellner MW, Messerli M. Artificial intelligence in coronary artery calcium score: rationale, different approaches, and outcomes. Int J Cardiovasc Imaging 2024; 40:951-966. [PMID: 38700819 PMCID: PMC11147943 DOI: 10.1007/s10554-024-03080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 03/09/2024] [Indexed: 06/05/2024]
Abstract
Almost 35 years after its introduction, coronary artery calcium score (CACS) not only survived technological advances but became one of the cornerstones of contemporary cardiovascular imaging. Its simplicity and quantitative nature established it as one of the most robust approaches for atherosclerotic cardiovascular disease risk stratification in primary prevention and a powerful tool to guide therapeutic choices. Groundbreaking advances in computational models and computer power translated into a surge of artificial intelligence (AI)-based approaches directly or indirectly linked to CACS analysis. This review aims to provide essential knowledge on the AI-based techniques currently applied to CACS, setting the stage for a holistic analysis of the use of these techniques in coronary artery calcium imaging. While the focus of the review will be detailing the evidence, strengths, and limitations of end-to-end CACS algorithms in electrocardiography-gated and non-gated scans, the current role of deep-learning image reconstructions, segmentation techniques, and combined applications such as simultaneous coronary artery calcium and pulmonary nodule segmentation, will also be discussed.
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Affiliation(s)
- Antonio G Gennari
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Carlo N De Cecco
- Division of Cardiothoracic Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University, Atlanta, GA, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University, Atlanta, GA, USA
| | - Thomas Sartoretti
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Moritz Schwyzer
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland.
- University of Zurich, Zurich, Switzerland.
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13
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Watanabe R, Saito Y, Tokimasa S, Takaoka H, Kitahara H, Yamanouchi M, Kobayashi Y. Diagnostic Ability of Manual Calcification Length Assessment on Non-Electrocardiographically Gated Computed Tomography for Estimating the Presence of Coronary Artery Disease. J Clin Med 2024; 13:2255. [PMID: 38673528 PMCID: PMC11051080 DOI: 10.3390/jcm13082255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Coronary artery calcification score (CACS) on electrocardiography (ECG)-gated computed tomography (CT) is used for risk stratification of atherosclerotic cardiovascular disease, which requires dedicated analytic software. In this study, we evaluated the diagnostic ability of manual calcification length assessment on non-ECG-gated CT for epicardial coronary artery disease (CAD). Methods: A total of 100 patients undergoing both non-ECG-gated plain CT scans with a slice interval of 1.25 mm and invasive coronary angiography were retrospectively included. We manually measured the length of the longest calcified lesions of coronary arteries on each branch. The relationship between the number of coronary arteries with the length of coronary calcium > 5, 10, or 15 mm and the presence of epicardial CAD on invasive angiography was evaluated. Standard CACS was also evaluated using established software. Results: Of 100 patients, 49 (49.0%) had significant epicardial CAD on angiography. The median standard CACS was 346 [7, 1965]. In both manual calcium assessment and standard CACS, the increase in calcium burden was progressively associated with the presence of epicardial CAD on angiography. The receiver operating characteristic curve analysis showed similar diagnostic abilities of the two diagnostic methods. The best cut-off values for CAD were 2, 1, and 1 for the number of vessels with calcium > 5, 10, and 15 mm, respectively. Overall, the diagnostic ability of manual calcium assessment was similar to that of standard CACS > 400. Conclusions: Manual assessment of coronary calcium length on non-ECG-gated plain CT provided similar diagnostic ability for the presence of significant epicardial CAD on invasive angiography, as compared to standard CACS.
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Affiliation(s)
- Ryota Watanabe
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan; (R.W.); (H.T.); (H.K.); (Y.K.)
- Department of Cardiology, Chiba Rosai Hospital, Ichihara 290-0003, Chiba, Japan; (S.T.); (M.Y.)
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan; (R.W.); (H.T.); (H.K.); (Y.K.)
| | - Satoshi Tokimasa
- Department of Cardiology, Chiba Rosai Hospital, Ichihara 290-0003, Chiba, Japan; (S.T.); (M.Y.)
| | - Hiroyuki Takaoka
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan; (R.W.); (H.T.); (H.K.); (Y.K.)
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan; (R.W.); (H.T.); (H.K.); (Y.K.)
| | - Masato Yamanouchi
- Department of Cardiology, Chiba Rosai Hospital, Ichihara 290-0003, Chiba, Japan; (S.T.); (M.Y.)
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan; (R.W.); (H.T.); (H.K.); (Y.K.)
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14
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Homma S, Kato K. Validity of Atherosclerotic Calcified Lesions Observed on Low-Dose Computed Tomography and Cardio-Ankle Vascular Index as Surrogate Markers of Atherosclerosis Progression. Angiology 2024; 75:349-358. [PMID: 36787785 DOI: 10.1177/00033197231155963] [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: 02/16/2023]
Abstract
The significance of atherosclerotic calcified lesions observed on low-dose computed tomography (LDCT) performed during general checkups was investigated. The coronary arteries (CA), ascending aorta and aortic arch (AAAA), descending thoracic aorta (DTA), and abdominal aorta (AA) were examined. Semiquantitative calcified index analysis of the DTA and AA in terms of atherosclerosis risk factors and cardio-ankle vascular index (CAVI) measurements was also performed. We included 1594 participants (mean age: 59.2 years; range: 31-91 years). The prevalence of calcified lesions was 71.0%, 66.6%, 57.2%, and 37.9% in the AA, CA, AAAA, and DTA, respectively. Age-related advances in calcification among participants with no major risk factors, revealed that calcification appeared earliest in the AA, followed by the CA, AAAA, and DTA. Participants with calcified lesions in all arteries had a significantly greater CAVI than those without calcification. The CAVI was negatively correlated with low-density lipoprotein cholesterol levels, particularly in participants without calcified lesions in the DTA. Calcified lesions on LDCT could indicate the end stage of atherosclerotic lesions. The CAVI can be used to assess atherosclerotic changes at all stages of disease progression. A combination of LDCT and CAVI could be used as a routine non-invasive assessment of atherosclerosis.
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Affiliation(s)
- Satoki Homma
- Health Care Center in Saitama Medical Center of the Japan Community Health Care Organization, Saitama, Japan
- Faculty of Nursing and Medical Care, Keio University & Keio Research Institute at SFC (Shonan Fujisawa Campus), Fujisawa, Japan
| | - Kiyoe Kato
- Center of General Health Check-Up, Saiseikai Central Hospital, Tokyo, Japan
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15
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Patel V, Patel J, Gan J, Rahiminejad M, Preston R, Mak SM, Benedetti G. Reporting of coronary artery calcification on chest CT studies in patients with interstitial lung disease. Clin Radiol 2024; 79:e532-e538. [PMID: 38242805 DOI: 10.1016/j.crad.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 11/03/2023] [Accepted: 11/29/2023] [Indexed: 01/21/2024]
Abstract
AIM To evaluate the prevalence of coronary artery calcification (CAC) on non-contrast computed tomography (CT) of the thorax in patients with interstitial lung disease (ILD), assess consistency of CAC reporting and assess incidence of subsequent cardiac events. MATERIALS AND METHODS Patients with known interstitial lung disease who underwent a CT thorax over a 2-year period were retrospectively reviewed. Presence of CAC was assessed using a visual scale for CAC reporting and graded as mild, moderate, or severe by two cardiothoracic radiologists. CT reports were reviewed to determine if presence of CAC had been described. Electronic medical records were reviewed for any subsequent cardiothoracic events from the date of the CT thorax to present. RESULTS 254 patients were included in the analysis (54.7% men; mean age 59.9 yo). 43.7% had CAC on their CT thorax; however, in 87.3% of those, reports did not comment on its presence. 8 patients had cardiac events; 7 of them had CAC on CT although only in 1 case this was reported. Global CAC and LAD CAC Patients with cardiac events had a significantly higher global CAC (p=0.016) and LAD CAC (p=0.048) when compared to patients without. CONCLUSION We demonstrated a high prevalence of CAC in ILD patients and its significant association with adverse cardiac events. Unfortunately, CAC on CT thorax is still largely unreported. As per recent BSCI/BSCCT and BSTI guidelines, reporting of CAC should become part of routine practice, as may prompt prevention and impact on patients outcome.
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Affiliation(s)
- V Patel
- The Royal Marsden, Fulham Road, London, SW3 6JJ, UK
| | - J Patel
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - J Gan
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - M Rahiminejad
- National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - R Preston
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - S M Mak
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - G Benedetti
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
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16
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Abdul-Rahman T, Bliss ZSB, Lizano-Jubert I, Muñoz MJS, Garg N, Pachchipulusu VK, Ashinze P, Miteu GD, Baig R, Omar DA, Badawy MM, Bukhari SMA, Wireko AA, Aborode AT, Atallah O, Mahmoud HA, Aldosoky W, Abohashem S. Beyond symptoms: Unlocking the potential of coronary calcium scoring in the prevention and treatment of coronary artery disease. Curr Probl Cardiol 2024; 49:102378. [PMID: 38185434 DOI: 10.1016/j.cpcardiol.2024.102378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
Coronary Artery Disease (CAD) represents a persistent global health menace, particularly prevalent in Eastern European nations. Often asymptomatic until its advanced stages, CAD can precipitate life-threatening events like myocardial infarction or stroke. While conventional risk factors provide some insight into CAD risk, their predictive accuracy is suboptimal. Amidst this, Coronary Calcium Scoring (CCS), facilitated by non-invasive computed tomography (CT), emerges as a superior diagnostic modality. By quantifying calcium deposits in coronary arteries, CCS serves as a robust indicator of atherosclerotic burden, thus refining risk stratification and guiding therapeutic interventions. Despite certain limitations, CCS stands as an instrumental tool in CAD management and in thwarting adverse cardiovascular incidents. This review delves into the pivotal role of CCS in CAD diagnosis and treatment, elucidates the involvement of calcium in atherosclerotic plaque formation, and outlines the principles and indications of utilizing CCS for predicting major cardiovascular events.
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Affiliation(s)
| | | | | | | | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, United States
| | | | - Patrick Ashinze
- Department of Medical Services, Saint Francis Catholic Hospital, Okpara Inland, Delta, Nigeria
| | - Goshen David Miteu
- Department of Biomedical Science, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rusab Baig
- Shadan Institute of Medical Sciences, Hyderabad, India
| | | | | | | | | | | | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | | | - Wesam Aldosoky
- Massachusetts General Hospital and Harvard Medical School, Boston, United States
| | - Shady Abohashem
- Massachusetts General Hospital and Harvard Medical School, Boston, United States.
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17
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Abdelrahman K, Shiyovich A, Huck DM, Berman AN, Weber B, Gupta S, Cardoso R, Blankstein R. Artificial Intelligence in Coronary Artery Calcium Scoring Detection and Quantification. Diagnostics (Basel) 2024; 14:125. [PMID: 38248002 PMCID: PMC10814920 DOI: 10.3390/diagnostics14020125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Coronary artery calcium (CAC) is a marker of coronary atherosclerosis, and the presence and severity of CAC have been shown to be powerful predictors of future cardiovascular events. Due to its value in risk discrimination and reclassification beyond traditional risk factors, CAC has been supported by recent guidelines, particularly for the purposes of informing shared decision-making regarding the use of preventive therapies. In addition to dedicated ECG-gated CAC scans, the presence and severity of CAC can also be accurately estimated on non-contrast chest computed tomography scans performed for other clinical indications. However, the presence of such "incidental" CAC is rarely reported. Advances in artificial intelligence have now enabled automatic CAC scoring for both cardiac and non-cardiac CT scans. Various AI approaches, from rule-based models to machine learning algorithms and deep learning, have been applied to automate CAC scoring. Convolutional neural networks, a deep learning technique, have had the most successful approach, with high agreement with manual scoring demonstrated in multiple studies. Such automated CAC measurements may enable wider and more accurate detection of CAC from non-gated CT studies, thus improving the efficiency of healthcare systems to identify and treat previously undiagnosed coronary artery disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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18
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Gautam A, Raghav P, Subramaniam V, Kumar S, Kumar S, Jain D, Verma A, Singh P, Singhal M, Gupta V, Rathore S, Iyengar S, Rathore S. Fully Automated Agatston Score Calculation From Electrocardiography-Gated Cardiac Computed Tomography Using Deep Learning and Multi-Organ Segmentation: A Validation Study. Angiology 2024:33197231225286. [PMID: 38166442 DOI: 10.1177/00033197231225286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
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.
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Affiliation(s)
| | | | | | - Sunil Kumar
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Dharmendra Jain
- Department of Cardiology, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiology, Banaras Hindu University, Varanasi, India
| | - Parminder Singh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphoul Singhal
- Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikash Gupta
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Srikanth Iyengar
- Department of Radiology, Frimley Park Hospital NHS Foundation Trust, Camberley, UK
| | - Sudhir Rathore
- Department of Cardiology, Frimley Park Hospital NHS Foundation Trust, Camberley, UK
- University of Surrey, Guildford, UK
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19
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Lima MR, Lopes PM, Ferreira AM. Use of coronary artery calcium score and coronary CT angiography to guide cardiovascular prevention and treatment. Ther Adv Cardiovasc Dis 2024; 18:17539447241249650. [PMID: 38708947 PMCID: PMC11075618 DOI: 10.1177/17539447241249650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/08/2024] [Indexed: 05/07/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Rita Lima
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, Lisbon 2790-134, Portugal
| | - Pedro M. Lopes
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - António M. Ferreira
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
- UNICA – Cardiovascular CT and MR Unit, Hospital da Luz, Lisbon, Portugal
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20
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Hashmi S, Shah PW, Aherrahrou Z, Aikawa E, Aherrahrou R. Beyond the Basics: Unraveling the Complexity of Coronary Artery Calcification. Cells 2023; 12:2822. [PMID: 38132141 PMCID: PMC10742130 DOI: 10.3390/cells12242822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Coronary artery calcification (CAC) is mainly associated with coronary atherosclerosis, which is an indicator of coronary artery disease (CAD). CAC refers to the accumulation of calcium phosphate deposits, classified as micro- or macrocalcifications, that lead to the hardening and narrowing of the coronary arteries. CAC is a strong predictor of future cardiovascular events, such as myocardial infarction and sudden death. Our narrative review focuses on the pathophysiology of CAC, exploring its link to plaque vulnerability, genetic factors, and how race and sex can affect the condition. We also examined the connection between the gut microbiome and CAC, and the impact of genetic variants on the cellular processes involved in vascular calcification and atherogenesis. We aimed to thoroughly analyze the existing literature to improve our understanding of CAC and its potential clinical and therapeutic implications.
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Affiliation(s)
- Satwat Hashmi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi 74800, Pakistan;
| | - Pashmina Wiqar Shah
- Institute for Cardiogenetics, Universität zu Lübeck, 23562 Lübeck, Germany; (P.W.S.); (Z.A.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Heart Centre Lübeck, 23562 Lübeck, Germany
| | - Zouhair Aherrahrou
- Institute for Cardiogenetics, Universität zu Lübeck, 23562 Lübeck, Germany; (P.W.S.); (Z.A.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Heart Centre Lübeck, 23562 Lübeck, Germany
| | - Elena Aikawa
- Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Rédouane Aherrahrou
- Institute for Cardiogenetics, Universität zu Lübeck, 23562 Lübeck, Germany; (P.W.S.); (Z.A.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Heart Centre Lübeck, 23562 Lübeck, Germany
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, FI-70211 Kuopio, Finland
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21
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Cesena FY, Generoso G, Santos IDS, Duncan BB, Ribeiro ALP, Brant LC, Mill JG, Pereira AC, Bittencourt MS, Santos RD, Lotufo PA, Benseñor IM. Percentiles of predicted 10-year cardiovascular disease risk by sex and age in Brazil and their association with estimated risk of long-term atherosclerotic events. Prev Med 2023; 177:107755. [PMID: 37931661 DOI: 10.1016/j.ypmed.2023.107755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/17/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Expressing the cardiovascular disease (CVD) risk in relation to peers may complement the estimation of absolute CVD risk. We aimed to determine 10-year CVD risk percentiles by sex and age in the Brazilian population and evaluate their association with estimated long-term atherosclerotic CVD (ASCVD) risk. METHODS A cross-sectional analysis of baseline data from the ELSA-Brasil study was conducted in individuals aged 40-74 years without prior ASCVD. Ten-year CVD risk and long-term ASCVD risk were estimated by the WHO risk score and the Multinational Cardiovascular Risk Consortium tool, respectively. Ten-year risk percentiles were determined by ranking the calculated risks within each sex and age group. RESULTS Ten-year CVD risk versus percentile plots were constructed for each sex and age group using data from 13,364 participants (55% females; median age, 52 [IQR, 46-59] years). Long-term ASCVD risk was calculated in 12,973 (97.1%) participants. Compared to individuals at the <25th risk percentile, those at the ≥75th percentile had a greater risk of being in the highest quartile of long-term risk (ORs [95% CIs] 6.57 [5.18-8.30] in females and 11.59 [8.42-15.96] in males) in regression models adjusted for age, race, education, and 10-year CVD risk. In both sexes, the association between risk percentile and long-term risk weakened after age 50. A tool for calculating 10-year CVD risk and the corresponding percentile is available at https://bit.ly/3CzPUi6. CONCLUSIONS We established percentiles of predicted 10-year CVD risk by sex and age in the Brazilian population, which independently reflect the estimated long-term ASCVD risk in younger individuals.
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Affiliation(s)
| | - Giuliano Generoso
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Itamar de S Santos
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Bruce B Duncan
- School of Medicine and Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Antonio Luiz P Ribeiro
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Luisa Caldeira Brant
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Jose Geraldo Mill
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology (LIM13), University of São Paulo Medical School Hospital, São Paulo, SP, Brazil; Genetics Department, Harvard Medical School, Boston, MA, USA
| | | | - Raul D Santos
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Paulo A Lotufo
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Isabela M Benseñor
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, SP, Brazil
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22
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Caminati A, Zompatori M, Fuccillo N, Sonaglioni A, Elia D, Cassandro R, Trevisan R, Rispoli A, Pelosi G, Harari S. Coronary artery calcium score is a prognostic factor for mortality in idiopathic pulmonary fibrosis. Minerva Med 2023; 114:815-824. [PMID: 35671002 DOI: 10.23736/s0026-4806.22.08018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Antonella Caminati
- Unit of Pneumology and Semi-Intensive Respiratory Therapy, Section of Respiratory Pathophysiology and Pulmonary Hemodynamics, IRCCS MultiMedica, Milan, Italy -
| | - Maurizio Zompatori
- Department of Diagnostic Imaging, IRCCS MultiMedica, Milan, Italy
- DIMES Department, University of Bologna, Bologna, Italy
| | - Nicoletta Fuccillo
- Unit of Pneumology and Semi-Intensive Respiratory Therapy, Section of Respiratory Pathophysiology and Pulmonary Hemodynamics, IRCCS MultiMedica, Milan, Italy
| | | | - Davide Elia
- Unit of Pneumology and Semi-Intensive Respiratory Therapy, Section of Respiratory Pathophysiology and Pulmonary Hemodynamics, IRCCS MultiMedica, Milan, Italy
| | - Roberto Cassandro
- Unit of Pneumology and Semi-Intensive Respiratory Therapy, Section of Respiratory Pathophysiology and Pulmonary Hemodynamics, IRCCS MultiMedica, Milan, Italy
| | - Roberta Trevisan
- Department of Diagnostic Imaging, IRCCS MultiMedica, Milan, Italy
| | - Anna Rispoli
- Department of Diagnostic Imaging, IRCCS MultiMedica, Milan, Italy
| | - Giuseppe Pelosi
- Intercompany Service of Pathological Anatomy, Scientific and Technological Pole, IRCCS MultiMedica, Milan, Italy
| | - Sergio Harari
- Unit of Pneumology and Semi-Intensive Respiratory Therapy, Section of Respiratory Pathophysiology and Pulmonary Hemodynamics, IRCCS MultiMedica, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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23
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Scalia IG, Farina JM, Padang R, Jokerst CE, Pereyra M, Mahmoud AK, Naqvi TZ, Chao CJ, Oh JK, Arsanjani R, Ayoub C. Aortic Valve Calcium Score by Computed Tomography as an Adjunct to Echocardiographic Assessment-A Review of Clinical Utility and Applications. J Imaging 2023; 9:250. [PMID: 37998097 PMCID: PMC10672559 DOI: 10.3390/jimaging9110250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
Aortic valve stenosis (AS) is increasing in prevalence due to the aging population, and severe AS is associated with significant morbidity and mortality. Echocardiography remains the mainstay for the initial detection and diagnosis of AS, as well as for grading of severity. However, there are important subgroups of patients, for example, patients with low-flow low-gradient or paradoxical low-gradient AS, where quantification of severity of AS is challenging by echocardiography and underestimation of severity may delay appropriate management and impart a worse prognosis. Aortic valve calcium score by computed tomography has emerged as a useful clinical diagnostic test that is complimentary to echocardiography, particularly in cases where there may be conflicting data or clinical uncertainty about the degree of AS. In these situations, aortic valve calcium scoring may help re-stratify grading of severity and, therefore, further direct clinical management. This review presents the evolution of aortic valve calcium score by computed tomography, its diagnostic and prognostic value, as well as its utility in clinical care.
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Affiliation(s)
- Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Tasneem Z. Naqvi
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
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24
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Braun FM, Risch F, Decker JA, Woźnicki P, Bette S, Becker J, Rippel K, Scheurig-Münkler C, Kröncke TJ, Schwarz F. Image Characteristics of Virtual Non-Contrast Series Derived from Photon-Counting Detector Coronary CT Angiography-Prerequisites for and Feasibility of Calcium Quantification. Diagnostics (Basel) 2023; 13:3402. [PMID: 37998539 PMCID: PMC10670685 DOI: 10.3390/diagnostics13223402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
In photon-counting detector CT (PCD-CT), coronary artery calcium scoring (CACS) can be performed using virtual non-contrast (VNC) series derived from coronary CT angiography (CCTA) datasets. Our study analyzed image characteristics of VNC series in terms of the efficacy of virtual iodine "removal" and image noise to determine whether the prerequisites for calcium quantification were satisfied. We analyzed 38 patients who had undergone non-enhanced CT followed by CCTA on a PCD-CT. VNC reconstructions were performed at different settings and algorithms (conventional VNCConv; PureCalcium VNCPC). Virtual iodine "removal" was investigated by comparing histograms of heart volumes. Noise was assessed within the left ventricular cavity. Calcium was quantified on the true non-contrast (TNC) and all VNC series. The histograms were comparable for TNC and all VNC. Image noise between TNC and all VNC differed slightly but significantly. VNCConv CACS showed a significant underestimation regardless of the reconstruction setting, while VNCPC CACS were comparable to TNC. Correlations between TNC and VNC were excellent, with a higher predictive accuracy for VNCPC. In conclusion, the iodine contrast can be effectively subtracted from CCTA datasets. The remaining VNC series satisfy the requirements for CACS, yielding results with excellent correlation compared to TNC-based CACS and high predicting accuracy.
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Affiliation(s)
- Franziska M. Braun
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Franka Risch
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Josua A. Decker
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Piotr Woźnicki
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Stefanie Bette
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Judith Becker
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Katharina Rippel
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Christian Scheurig-Münkler
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Thomas J. Kröncke
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
| | - Florian Schwarz
- Clinic for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (F.M.B.); (J.A.D.); (P.W.); (S.B.); (J.B.); (C.S.-M.); (F.S.)
- DONAUISAR Clinic Deggendorf, Perlasberger Str. 41, 94469 Deggendorf, Germany
- Medical Faculty, Ludwig Maximilian University of Munich, Geschwister-Scholl-Platz 1, 80539 Munich, Germany
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25
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Tiansuwan N, Sasiprapha T, Jongjirasiri S, Unwanatham N, Thakkinstian A, Laothamatas J, Limpijankit T. Utility of coronary artery calcium in refining 10-year ASCVD risk prediction using a Thai CV risk score. Front Cardiovasc Med 2023; 10:1264640. [PMID: 38028497 PMCID: PMC10652894 DOI: 10.3389/fcvm.2023.1264640] [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: 07/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Coronary artery calcium (CAC) scanning is a valuable additional tool for calculating the risk of cardiovascular (CV) events. We aimed to determine if a CAC score could improve performance of a Thai CV risk score in prediction of 10-year atherosclerotic cardiovascular disease (ASCVD) risk for asymptomatic patients with CV risk factors. Methods This was a retrospective cohort study that enrolled asymptomatic patients with CV risk factors who underwent CAC scans between 2005 and 2013. The patients were classified as low-, intermediate-, or high-risk (<10%, 10%-<20%, and ≥20%, respectively) of having ASCVD within 10-years based on a Thai CV risk score. In each patient, CAC score was considered as a categorical variable (0, 1-99, and ≥100) and natural-log variable to assess the risk of developing CV events (CV death, non-fatal MI, or non-fatal stroke). The C statistic and the net reclassification improvement (NRI) index were applied to assess whether CAC improved ASCVD risk prediction. Results A total of 6,964 patients were analyzed (mean age: 59.0 ± 8.4 years; 63.3% women). The majority of patients were classified as low- or intermediate-risk (75.3% and 20.5%, respectively), whereas only 4.2% were classified as high-risk. Nearly half (49.7%) of patients had a CAC score of zero (no calcifications detected), while 32.0% had scores of 1-99, and 18.3% of ≥100. In the low- and intermediate-risk groups, patients with a CAC ≥100 experienced higher rates of CV events, with hazard ratios (95% CI) of 1.95 (1.35, 2.81) and 3.04 (2.26, 4.10), respectively. Incorporation of ln(CAC + 1) into their Thai CV risk scores improved the C statistic from 0.703 (0.68, 0.72) to 0.716 (0.69, 0.74), and resulted in an NRI index of 0.06 (0.02, 0.10). To enhance the performance of the Thai CV risk score, a revision of the CV risk model was performed, incorporating ln(CAC + 1), which further increased the C statistic to 0.771 (0.755, 0.788). Conclusion The addition of CAC to traditional risk factors improved CV risk stratification and ASCVD prediction. Whether this adjustment leads to a reduction in CV events and is cost-effective will require further assessment.
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Affiliation(s)
- Noppanat Tiansuwan
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Thinnakrit Sasiprapha
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Sutipong Jongjirasiri
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Nattawut Unwanatham
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Jiraporn Laothamatas
- Faculty of Heath Science Technology, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Thosaphol Limpijankit
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
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Kadoya Y, Abtahi SS, Sritharan S, Omaygenc MO, Nehmeh A, Yam Y, Small GS, Chow BJW. The estimation of left ventricular function using prospective ECG-triggered coronary CT angiography. J Cardiovasc Comput Tomogr 2023; 17:429-435. [PMID: 37777389 DOI: 10.1016/j.jcct.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/23/2023] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is vital for diagnosing coronary artery disease; however, prospective ECG-triggered acquisition, minimizing radiation exposure, limits left ventricular (LV) ejection fraction (EF) evaluation. We aimed to assess the feasibility and utility of LVEF100msec, a new index for estimating LV function using volumetric changes during 100 msec within systole. METHODS This retrospective study analyzed patients who underwent prospective ECG-triggered CCTA with systolic acquisition between January 2015 and June 2022. The LVEF100msec was calculated using the maximum and minimum LV volumes among the three phases (300, 350, and 400 msec post-QRS) and expressed as a percentage. Patients were classified into normal, mild-moderately reduced, or severely reduced LV function categories based on the reference test. The LVEF100msec was compared among groups, and the optimal cutoff value of LVEF100msec for predicting severe LV dysfunction was investigated. RESULTS The study included 271 patients (median age = 58 years, 52% male). LVEF was normal in 188 (69.4%), mild-moderately reduced in 57 (21.0%), and severely reduced in 26 (9.6%) patients. Median LVEF100msec value was 9.0 (6.7-12.6) for normal LV function, 4.7 (3.1-8.8) for mild-moderately reduced, and 2.9 (1.5-3.8) for severely reduced LV function. LVEF100msec values significantly differed among categories (p < 0.001). The optimal LVEF100msec cutoff for severe LV dysfunction was 4.3%, with an AUC of 0.924, sensitivity of 88%, and specificity of 89%. CONCLUSION The LVEF100msec may serve as a valuable indicator of severe LV dysfunction.
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Affiliation(s)
- Yoshito Kadoya
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Shahin Sean Abtahi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Shankavi Sritharan
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Mehmet Onur Omaygenc
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Amal Nehmeh
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Yeung Yam
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Gary S Small
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Benjamin J W Chow
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada.
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27
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Chang S, Ren L, Tang S, Marsh JF, Hsieh S, McCollough CH, Leng S. Technical note: Exploring the detectability of coronary calcification using ultra-high-resolution photon-counting-detector CT. Med Phys 2023; 50:6836-6843. [PMID: 37650788 PMCID: PMC10841095 DOI: 10.1002/mp.16712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Coronary calcification is a strong indicator of coronary artery disease, and patients with a "zero" coronary calcification score have a much lower risk of future cardiac events than those with even small amounts of calcium. However, false-negative (incorrect zero scores) may occur if small calcifications are missed at CT due to limited spatial resolution. PURPOSE To demonstrate lower limits of detection for coronary calcification using an ultra-high-resolution (UHR) mode on a clinical photon-counting-detector CT (PCD-CT), compared to a conventional energy-integrating-detector CT (EID-CT). METHODS Chicken eggshell fragments (0.4-0.8 mm) mimicking coronary calcifications were scanned on a clinical PCD-CT (NAEOTOM Alpha) in UHR mode and a conventional EID-CT (SOMATOM Force) with matched tube potential and radiation dose levels to the PCD-CT. PCD-CT images were reconstructed with a sharp kernel (Qr68) and a quantum iterative algorithm (QIR-3). Two sets of EID-CT images were reconstructed: routine clinical kernel (Qr36, ADMIRE-3) and a sharper kernel (Qr54) with similar noise to PCD-CT images. With institutional review board approval, in vivo exams performed with the PCD-CT in UHR mode were compared against patients' clinical EID-CT exams. The visibility of calcifications on PCD-CT and EID-CT images was assessed and compared qualitatively. RESULTS PCD-CT images visualized all calcified fragments, while EID-CT failed to detect those below 0.6 mm using a routine protocol. EID-CT with Qr54 improved visibility but distorted boundaries. Calcifications were less visible on EID-CT than PCD-CT as phantom sizes increased. 0.6- and 0.7-mm calcified fragments were barely visible on 35- and 40-cm phantom EID-CT images. Patient cases showed small calcifications missed on EID-CT but detected on PCD-CT. CONCLUSION At matched radiation dose, PCD-CT in UHR mode provided higher spatial resolution and improved the detectability of small calcified fragments for different phantom/patient sizes in comparison to EID-CT.
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Affiliation(s)
- Shaojie Chang
- Department of Radiology, Mayo Clinic, Rochester, MN, US
| | - Liqiang Ren
- Department of Radiology, Mayo Clinic, Rochester, MN, US
| | - Shanshan Tang
- Department of Radiology, Mayo Clinic, Rochester, MN, US
| | | | - Scott Hsieh
- Department of Radiology, Mayo Clinic, Rochester, MN, US
| | | | - Shuai Leng
- Department of Radiology, Mayo Clinic, Rochester, MN, US
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Winchester DE, Maron DJ, Blankstein R, Chang IC, Kirtane AJ, Kwong RY, Pellikka PA, Prutkin JM, Russell R, Sandhu AT. ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease. J Cardiovasc Magn Reson 2023; 25:58. [PMID: 37858155 PMCID: PMC10585920 DOI: 10.1186/s12968-023-00958-5] [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] [Received: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 10/21/2023] Open
Abstract
The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting1-4.This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD4. Key changes beyond the updated ratings based on new evidence include the following: 1. Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document under development. 2. Some clinical scenarios and tables were removed in an effort to simplify the selection of clinical scenarios. Additionally, the flowchart of tables has been reorganized, and all clinical scenario tables can now be reached by answering a limited number of clinical questions about the patient, starting with the patient's symptom status. 3. Several clinical scenarios have been revised to incorporate changes in other documents such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessment, syncope, and others. ASCVD risk factors that are not accounted for in contemporary risk calculators have been added as modifiers to certain clinical scenarios. The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.5 These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD.Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented, midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely appropriate.
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Affiliation(s)
| | | | - Ron Blankstein
- Society of Cardiovascular Computed Tomography, Washington, USA
| | | | - Ajay J Kirtane
- Society for Cardiovascular Angiography and Interventions, Washington, USA
| | - Raymond Y Kwong
- Society for Cardiovascular Magnetic Resonance, Washington, USA
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He Z, Luo J, Lv M, Li Q, Ke W, Niu X, Zhang Z. Characteristics and evaluation of atherosclerotic plaques: an overview of state-of-the-art techniques. Front Neurol 2023; 14:1159288. [PMID: 37900593 PMCID: PMC10603250 DOI: 10.3389/fneur.2023.1159288] [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: 02/05/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Atherosclerosis is an important cause of cerebrovascular and cardiovascular disease (CVD). Lipid infiltration, inflammation, and altered vascular stress are the critical mechanisms that cause atherosclerotic plaque formation. The hallmarks of the progression of atherosclerosis include plaque ulceration, rupture, neovascularization, and intraplaque hemorrhage, all of which are closely associated with the occurrence of CVD. Assessing the severity of atherosclerosis and plaque vulnerability is crucial for the prevention and treatment of CVD. Integrating imaging techniques for evaluating the characteristics of atherosclerotic plaques with computer simulations yields insights into plaque inflammation levels, spatial morphology, and intravascular stress distribution, resulting in a more realistic and accurate estimation of plaque state. Here, we review the characteristics and advancing techniques used to analyze intracranial and extracranial atherosclerotic plaques to provide a comprehensive understanding of atheroma.
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Affiliation(s)
- Zhiwei He
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiaying Luo
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mengna Lv
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qingwen Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wei Ke
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xuan Niu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhaohui Zhang
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
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Choi DY, Hayes D, Maidman SD, Dhaduk N, Jacobs JE, Shmukler A, Berger JS, Cuff G, Rehe D, Lee M, Donnino R, Smilowitz NR. Existing Nongated CT Coronary Calcium Predicts Operative Risk in Patients Undergoing Noncardiac Surgeries (ENCORES). Circulation 2023; 148:1154-1164. [PMID: 37732454 PMCID: PMC10592001 DOI: 10.1161/circulationaha.123.064398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Preoperative cardiovascular risk stratification before noncardiac surgery is a common clinical challenge. Coronary artery calcium scores from ECG-gated chest computed tomography (CT) imaging are associated with perioperative events. At the time of preoperative evaluation, many patients will not have had ECG-gated CT imaging, but will have had nongated chest CT studies performed for a variety of noncardiac indications. We evaluated relationships between coronary calcium severity estimated from previous nongated chest CT imaging and perioperative major clinical events (MCE) after noncardiac surgery. METHODS We retrospectively identified consecutive adults age ≥45 years who underwent in-hospital, major noncardiac surgery from 2016 to 2020 at a large academic health system composed of 4 acute care centers. All patients had nongated (contrast or noncontrast) chest CT imaging performed within 1 year before surgery. Coronary calcium in each vessel was retrospectively graded from absent to severe using a 0 to 3 scale (absent, mild, moderate, severe) by physicians blinded to clinical data. The estimated coronary calcium burden (ECCB) was computed as the sum of scores for each coronary artery (0 to 9 scale). A Revised Cardiac Risk Index was calculated for each patient. Perioperative MCE was defined as all-cause death or myocardial infarction within 30 days of surgery. RESULTS A total of 2554 patients (median age, 68 years; 49.7% women; median Revised Cardiac Risk Index, 1) were included. The median time interval from nongated chest CT imaging to noncardiac surgery was 15 days (interquartile range, 3-106 days). The median ECCB was 1 (interquartile range, 0-3). Perioperative MCE occurred in 136 (5.2%) patients. Higher ECCB values were associated with stepwise increases in perioperative MCE (0: 2.9%, 1-2: 3.7%, 3-5: 8.0%; 6-9: 12.6%, P<0.001). Addition of ECCB to a model with the Revised Cardiac Risk Index improved the C-statistic for MCE (from 0.675 to 0.712, P=0.018), with a net reclassification improvement of 0.428 (95% CI, 0.254-0.601, P<0.0001). An ECCB ≥3 was associated with 2-fold higher adjusted odds of MCE versus an ECCB <3 (adjusted odds ratio, 2.11 [95% CI, 1.42-3.12]). CONCLUSIONS Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before noncardiac surgery.
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Affiliation(s)
- Daniel Y Choi
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Dena Hayes
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Samuel D Maidman
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Nehal Dhaduk
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Jill E Jacobs
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
| | - Anna Shmukler
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Department of Surgery (J.S.B.), New York University Grossman School of Medicine, New York, NY
| | - Germaine Cuff
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - David Rehe
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - Mitchell Lee
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - Robert Donnino
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
- Cardiology Division, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, NY (R.D., N.R.S.)
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Cardiology Division, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, NY (R.D., N.R.S.)
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Budoff MJ, Kinninger A, Gransar H, Achenbach S, Al-Mallah M, Bax JJ, Berman DS, Cademartiri F, Callister TQ, Chang HJ, Chow BJW, Cury RC, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann PA, Leipsic J, Lin FY, Kim YJ, Marques H, Pontone G, Rubinshtein R, Shaw LJ, Villines TC, Min JK. When Does a Calcium Score Equate to Secondary Prevention?: Insights From the Multinational CONFIRM Registry. JACC Cardiovasc Imaging 2023; 16:1181-1189. [PMID: 37227328 DOI: 10.1016/j.jcmg.2023.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/30/2023] [Accepted: 03/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Elevated coronary artery calcium (CAC) scores in subjects without prior atherosclerotic cardiovascular disease (ASCVD) have been shown to be associated with increased cardiovascular risk. OBJECTIVES The authors sought to determine at what level individuals with elevated CAC scores who have not had an ASCVD event should be treated as aggressively for cardiovascular risk factors as patients who have already survived an ASCVD event. METHODS The authors performed a cohort study comparing event rates of patients with established ASVCD to event rates in persons with no history of ASCVD and known calcium scores to ascertain at what level elevated CAC scores equate to risk associated with existing ASCVD. In the multinational CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry, the authors compared ASCVD event rates in persons without a history of myocardial infarction (MI) or revascularization (as categorized on CAC scores) to event rates in those with established ASCVD. They identified 4,511 individuals without known coronary artery disease (CAC) who were compared to 438 individuals with established ASCVD. CAC was categorized as 0, 1 to 100, 101 to 300, and >300. Cumulative major adverse cardiovascular events (MACE), MACE plus late revascularization, MI, and all-cause mortality incidence was assessed using the Kaplan-Meier method for persons with no ASCVD history by CAC level and persons with established ASCVD. Cox proportional hazards regression analysis was used to calculate HRs with 95% CIs, which were adjusted for traditional cardiovascular risk factors. RESULTS The mean age was 57.6 ± 12.4 years (56% male). In total, 442 of 4,949 (9%) patients experienced MACEs over a median follow-up of 4 years (IQR: 1.7-5.7 years). Incident MACEs increased with higher CAC scores, with the highest rates observed with CAC score >300 and in those with prior ASCVD. All-cause mortality, MACEs, MACE + late revascularization, and MI event rates were not statistically significantly different in those with CAC >300 compared with established ASCVD (all P > 0.05). Persons with a CAC score <300 had substantially lower event rates. CONCLUSIONS Patients with CAC scores >300 are at an equivalent risk of MACE and its components as those treated for established ASCVD. This observation, that those with CAC >300 have event rates comparable to those with established ASCVD, supplies important background for further study related to secondary prevention treatment targets in subjects without prior ASCVD with elevated CAC. Understanding the CAC scores that are associated with ASCVD risk equivalent to stable secondary prevention populations may be important for guiding the intensity of preventive approaches more broadly.
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Affiliation(s)
- Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-University of California, Los Angeles, Torrance, California, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
| | - April Kinninger
- Department of Medicine, Lundquist Institute at Harbor-University of California, Los Angeles, Torrance, California, USA
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephan Achenbach
- Department of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Mouaz Al-Mallah
- Department of Medicine, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Jeroen J Bax
- CardioVascular Imaging Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Daniel S Berman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA; Department of Imaging, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Filippo Cademartiri
- CardioVascular Imaging Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Tracy Q Callister
- Tennessee Heart and Vascular Institute, Hendersonville, Tennessee, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea
| | - Benjamin J W Chow
- Department of Radiology, University of Ottawa Heart Institute and University of Ottawa, Ontario, Canada
| | - Ricardo C Cury
- Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | - Gudrun Feuchtner
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Martin Hadamitzky
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Joerg Hausleiter
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fay Y Lin
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Hugo Marques
- Department of Radiology, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Gianluca Pontone
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | | | - Leslee J Shaw
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Todd C Villines
- Department of Medicine, Mount Sinai School of Medicine, New York, New York, USA
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Wang FM, Cainzos-Achirica M, Ballew SH, Coresh J, Folsom AR, Howard CM, Post WS, Wagenknecht L, Budoff MJ, Blaha MJ, Matsushita K. Defining Demographic-specific Coronary Artery Calcium Percentiles in the Population Aged ≥75: The ARIC Study and MESA. Circ Cardiovasc Imaging 2023; 16:e015145. [PMID: 37655462 PMCID: PMC10721116 DOI: 10.1161/circimaging.122.015145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/11/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Current clinical guidelines recommend a coronary artery calcium (CAC) score of 100 Agatston Units or demographic-specific 75th percentile as high-risk thresholds for guiding atherosclerotic cardiovascular disease preventive therapy. Meanwhile, low CAC can help derisk individuals who may safely defer statin therapy. However, limited data from the early 2000s, including just 208 older Black individuals, inform CAC percentiles for adults aged 75 to 85 years, and none have been established in adults aged ≥85 years. This study aims to characterize the distribution of CAC and establish demographic-specific CAC percentiles in the population aged ≥75 years. METHODS We assessed 2886 participants aged ≥75 years without clinical coronary heart disease from the ARIC study (Atherosclerosis Risk in Communities) visit 7 (2018-2019; n=2217) and the MESA (Multi-Ethnic Study of Atherosclerosis) visit 5 (2010-2011; n=669). Prevalence of any CAC >0 and sex- and race-specific CAC percentiles across age were estimated nonparametrically with locally weighted regression models and pooled residual ranking. RESULTS The median age was 80 (interquartile interval, 77-83) years, and 60% were female. The prevalence of zero CAC was lowest in White males (4%), followed by Black males (13%), White females (14%), and highest in Black females (18%). Regardless of sex and race, most participants had CAC>100 (62.5%). CAC scores increased with age, with CAC identified in ≈95% of participants aged ≥90 years across sex-race subgroups. The 75th percentile corresponded to higher CAC scores for Black older adults (n=741), especially females, than currently used thresholds. CONCLUSIONS In community-dwelling adults aged ≥75 years free of clinical coronary heart disease, the prevalence of zero CAC was 11%, and CAC >100 as a threshold for high ASCVD risk would categorize most of this older population as high risk. Demographic-specific CAC percentiles from this study are a valuable tool for interpreting CAC in the population aged ≥75 years.
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Affiliation(s)
- Frances M. Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Miguel Cainzos-Achirica
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Cardiovascular Prevention and Wellness, Houston Methodist, Houston, TX
| | - Shoshana H. Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Aaron R. Folsom
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Candace M. Howard
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Wendy S. Post
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lynne Wagenknecht
- Wake Forest University Population Health Sciences, Winston Salem, NC
| | - Matthew J. Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance CA
| | - Michael J. Blaha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Meloni A, Cademartiri F, Positano V, Celi S, Berti S, Clemente A, La Grutta L, Saba L, Bossone E, Cavaliere C, Punzo B, Maffei E. Cardiovascular Applications of Photon-Counting CT Technology: A Revolutionary New Diagnostic Step. J Cardiovasc Dev Dis 2023; 10:363. [PMID: 37754792 PMCID: PMC10531582 DOI: 10.3390/jcdd10090363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/28/2023] Open
Abstract
Photon-counting computed tomography (PCCT) is an emerging technology that can potentially transform clinical CT imaging. After a brief description of the PCCT technology, this review summarizes its main advantages over conventional CT: improved spatial resolution, improved signal and contrast behavior, reduced electronic noise and artifacts, decreased radiation dose, and multi-energy capability with improved material discrimination. Moreover, by providing an overview of the existing literature, this review highlights how the PCCT benefits have been harnessed to enhance and broaden the diagnostic capabilities of CT for cardiovascular applications, including the detection of coronary artery calcifications, evaluation of coronary plaque extent and composition, evaluation of coronary stents, and assessment of myocardial tissue characteristics and perfusion.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.); (A.C.); (E.M.)
- Unità Operativa Complessa di Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.); (A.C.); (E.M.)
| | - Vicenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.); (A.C.); (E.M.)
- Unità Operativa Complessa di Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Simona Celi
- BioCardioLab, Fondazione G. Monasterio CNR-Regione Toscana, 54100 Massa, Italy;
| | - Sergio Berti
- Diagnostic and Interventional Cardiology Department, Fondazione G. Monasterio CNR-Regione Toscana, 54100 Massa, Italy;
| | - Alberto Clemente
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.); (A.C.); (E.M.)
| | - Ludovico La Grutta
- Department of Radiology, University Hospital “P. Giaccone”, 90127 Palermo, Italy;
| | - Luca Saba
- Department of Radiology, University Hospital of Cagliari, 09042 Monserrato, CA, Italy;
| | - Eduardo Bossone
- Department of Cardiology, Ospedale Cardarelli, 80131 Naples, Italy;
| | - Carlo Cavaliere
- Department of Radiology, Istituto di Ricerca e Cura a Carattere Scientifico SynLab-SDN, 80131 Naples, Italy; (C.C.); (B.P.)
| | - Bruna Punzo
- Department of Radiology, Istituto di Ricerca e Cura a Carattere Scientifico SynLab-SDN, 80131 Naples, Italy; (C.C.); (B.P.)
| | - Erica Maffei
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.); (A.C.); (E.M.)
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Miles B, Theng B, Etumuse BO, Zeinoddini A, Saleem A. The potential impact of computed tomography coronary calcium score screening on patients with dyslipidemia. Proc AMIA Symp 2023; 36:586-589. [PMID: 37614860 PMCID: PMC10444005 DOI: 10.1080/08998280.2023.2239083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/06/2023] [Accepted: 06/15/2023] [Indexed: 08/25/2023] Open
Abstract
Background Coronary artery calcium (CAC) scoring helps determine whether patients with known coronary artery disease (CAD) should initiate medical management by predicting future cardiac event risk. CAC scoring is underutilized because many insurance companies consider it experimental. This study aimed to determine whether CAC screening of patients at risk for CAD is associated with decreased risk of myocardial infarction and improved survival. Methods The TriNetX research network was used for this study. Two cohorts of 86,574 patients aged 40 to 70 years were created. All patients were diagnosed with dyslipidemia and without CAD, and the cohorts were matched for demographics, comorbidities, and statin use. One cohort had been screened with CAC scoring while the other had not. The primary outcomes of this study were myocardial infarction and overall survival at 5 years. Results Screened patients had 44% fewer myocardial infarction events at 5 years with a 76% lower risk of death. Conclusion CAC scoring is associated with reduced risk of myocardial infarction and death in asymptomatic dyslipidemia patients and should be considered as a screening tool in these patients. The presumed mechanism for improved outcomes is that early identification of CAD results in earlier or more intensive treatment, reducing future cardiac event risk.
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Affiliation(s)
- Brittany Miles
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Bunnarin Theng
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Bright O. Etumuse
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Atefeh Zeinoddini
- Department of Radiology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Arsalan Saleem
- Department of Radiology, University of Texas Medical Branch, Galveston, Texas, USA
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35
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Ngamdu KS, Ghosalkar DS, Chung HE, Christensen JL, Lee C, Butler CA, Ho T, Chu A, Heath JR, Baig M, Wu WC, Choudhary G, Morrison AR. Long-term statin therapy is associated with severe coronary artery calcification. PLoS One 2023; 18:e0289111. [PMID: 37498869 PMCID: PMC10374064 DOI: 10.1371/journal.pone.0289111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Atherosclerosis and consequent risk of cardiovascular events or mortality can be accurately assessed by quantifying coronary artery calcium score (CACS) derived from computed tomography. HMG-CoA-reductase inhibitors (statins) are the primary pharmacotherapy used to reduce cardiovascular events, yet there is growing data that support statin use may increase coronary calcification. We set out to determine the likelihood of severe CACS in the context of chronic statin therapy. METHODS We established a retrospective, case-control study of 1,181 U.S. veterans without coronary artery disease (CAD) from a single site, the Providence VA Medical Center. Duration of statin therapy for primary prevention was divided into 5-year categorical increments. The primary outcome was CACS derived from low-dose lung cancer screening computed tomography (LCSCT), stratified by CACs severity (none = 0; mild = 1-99; moderate = 100-399; and severe ≥400 AU). Statin duration of zero served as the referent control. Ordinal logistic regression analysis determined the association between duration of statin use and CACS categories. Proportional odds assumption was tested using likelihood ratio test. Atherosclerotic cardiovascular disease (ASCVD) risk score, body mass index, and CKD (glomerular filtration rate of <60 ml/min/1.73 m2) were included in the adjustment models. RESULTS The mean age of the study population was 64.7±7.2 years, and 706 (60%) patients were prescribed a statin at baseline. Duration of statin therapy was associated with greater odds of having increased CACS (>0-5 years, OR: 1.71 [CI: 1.34-2.18], p<0.001; >5-10 years, OR: 2.80 [CI: 2.01-3.90], p<0.001; >10 years, OR: 5.30 [CI: 3.23-8.70], p<0.001), and the relationship between statin duration and CACS remained significant after multivariate adjustment (>0-5 years, OR: 1.49 [CI: 1.16-1.92], p = 0.002; >5-10 years, OR: 2.38 [CI: 1.7-3.35], p<0.001; >10 years, OR: 4.48 [CI: 2.7-7.43], p<0.001). CONCLUSIONS Long-term use of statins is associated with increased likelihood of severe CACS in patients with significant smoking history. The use of CACS to interpret cardiovascular event risk may require adjustment in the context of chronic statin therapy.
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Affiliation(s)
- Kyari Sumayin Ngamdu
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Dhairyasheel S. Ghosalkar
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Hojune E. Chung
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Jared L. Christensen
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Cadence Lee
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Celia A. Butler
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Tiffany Ho
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Alice Chu
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Jacob R. Heath
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Muhammad Baig
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Wen-Chih Wu
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Gaurav Choudhary
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Alan R. Morrison
- Departments of Research and Medicine, Vascular Research Laboratory, Providence VA Medical Center, Providence, Rhode Island, United States of America
- Department of Research, Ocean State Research Institute, Inc., Providence, Rhode Island, United States of America
- Department of Medicine, Section of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
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Fernandes S, Cruz I, Faria R, Almeida J, Fonseca P, Ferreira N, Primo JJ, Fontes-Carvalho R, Ladeiras-Lopes R. Impact of Coronary Artery Calcium Score Screening on Cardiovascular Risk Stratification of Patients with Atrial Fibrillation Undergoing Ablation. Cardiology 2023; 148:427-433. [PMID: 37487471 DOI: 10.1159/000532018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION There is a well-established association between atrial fibrillation (AF) and coronary artery disease. Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular (CV) risk stratification and inform on the best strategies for primary CV prevention. This study aims to evaluate the impact of opportunistic screening with CACS on risk stratification and decision of preventive therapies, in patients with AF. METHODS Cross-sectional study including patients with AF or atrial flutter undergoing cardiac computed tomography for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. CACS was assessed in patients without coronary artery disease using the Agatston method. RESULTS A total of 474 patients were included (93% with AF, mean age of 58 ± 10 years, 62% male). CACS >0 was present in 254 (54%) patients. According to CACS and the Society of Cardiovascular Computed Tomography recommendations, 25% of the patients would be candidates for statin therapy and 17% would be candidates for changes in the current statin intensity; in 11 patients (8%), acetylsalicylic acid would be recommended. CONCLUSION In our study, more than half of the patients undergoing cardiac computed tomography before AF catheter ablation had CACS above zero. Our findings suggest that an opportunistic evaluation of CACS at the time of ablation can be an important tool to improve CV risk stratification, with important clinical and therapeutic implications.
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Affiliation(s)
- Sara Fernandes
- Department of Cardiology, Leiria Hospital Centre, Leira, Portugal
| | - Inês Cruz
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rita Faria
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - João Almeida
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Paulo Fonseca
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Nuno Ferreira
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - João José Primo
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ricardo Ladeiras-Lopes
- Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Winchester DE, Maron DJ, Blankstein R, Chang IC, Kirtane AJ, Kwong RY, Pellikka PA, Prutkin JM, Russell R, Sandhu AT. ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease. J Am Coll Cardiol 2023; 81:2445-2467. [PMID: 37245131 DOI: 10.1016/j.jacc.2023.03.410] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Jayadeva PS, Stowers S, Tang EW, Vitola J, Cerci R, Yao J, Westcott J, Elison B, Better N. The impact of coronary calcium score as an addition to myocardial perfusion imaging in altering clinical management (ICCAMPA trial). J Nucl Cardiol 2023; 30:1004-1018. [PMID: 36097241 DOI: 10.1007/s12350-022-03086-2] [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] [Received: 01/21/2022] [Accepted: 07/20/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION AIM: Myocardial perfusion imaging (MPI) is a key tool for the identification and risk stratification of patients with coronary artery disease. The use of a coronary calcium score further adds to prognostic data above MPI alone. In this study, our aim was to evaluate the extent to which the use of a coronary artery calcium (CAC) score, when co-reported with MPI, impacts changes in clinical management in patients without a history of coronary artery disease (CAD) undergoing functional imaging. METHODS This is a multicenter international study which incorporated a standardized questionnaire to evaluate changes in clinician management after MPI results were given with and without the additional information of a CAC score. Calcium scoring on a SPECT-CT system was performed via a semiquantitative Shemesh score (0-12) with a 0-3 score from the left main, left anterior descending, left circumflex, and right coronary arteries. CT of the chest was read independently, and non-coronary findings were reported alongside the CAC score. RESULTS A total of 281 patients were enrolled across 3 international centers (Brazil, Australia, New Zealand). Of the 281 patients, 133 (47%) had management altered after the clinician was made aware of the CAC score. The impact of the CAC in changing clinical management was significant, particularly in patients with a negative MPI (P < 0.0001), but also in MPI-positive patients (P = 0.0021). The most common management change was the addition or intensification of statin therapy. CONCLUSION The addition of the CAC component to MPI yielded significant management changes in nearly half of all patients undergoing MPI for suspected CAD. This trend was observed across all centers in the three countries involved and was particularly evident in patient with a negative MPI.
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Affiliation(s)
- Pavithra S Jayadeva
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.
| | - Stephen Stowers
- Department of Cardiology, Palmerston North Hospital, Palmerston North, New Zealand
| | - E W Tang
- Department of Cardiology, Palmerston North Hospital, Palmerston North, New Zealand
| | - Joao Vitola
- Department of Nuclear Medicine, Quanta Diagnostico por Imagem, Curitiba, Brazil
| | - Rodrigo Cerci
- Department of Nuclear Medicine, Quanta Diagnostico por Imagem, Curitiba, Brazil
| | - Jessica Yao
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - James Westcott
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Barry Elison
- Department of Nuclear Medicine, Wollongong Hospital, Wollongong, NSW, Australia
| | - Nathan Better
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Departments of Nuclear Medicine and Cardiology, Royal Melbourne Hospital, Parkville, Australia
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Bianchini E, Lønnebakken MT, Wohlfahrt P, Piskin S, Terentes‐Printzios D, Alastruey J, Guala A. Magnetic Resonance Imaging and Computed Tomography for the Noninvasive Assessment of Arterial Aging: A Review by the VascAgeNet COST Action. J Am Heart Assoc 2023; 12:e027414. [PMID: 37183857 PMCID: PMC10227315 DOI: 10.1161/jaha.122.027414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Magnetic resonance imaging and computed tomography allow the characterization of arterial state and function with high confidence and thus play a key role in the understanding of arterial aging and its translation into the clinic. Decades of research into the development of innovative imaging sequences and image analysis techniques have led to the identification of a large number of potential biomarkers, some bringing improvement in basic science, others in clinical practice. Nonetheless, the complexity of some of these biomarkers and the image analysis techniques required for their computation hamper their widespread use. In this narrative review, current biomarkers related to aging of the aorta, their founding principles, the sequence, and postprocessing required, and their predictive values for cardiovascular events are summarized. For each biomarker a summary of reference values and reproducibility studies and limitations is provided. The present review, developed in the COST Action VascAgeNet, aims to guide clinicians and technical researchers in the critical understanding of the possibilities offered by these advanced imaging modalities for studying the state and function of the aorta, and their possible clinically relevant relationships with aging.
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Affiliation(s)
| | - Mai Tone Lønnebakken
- Department of Clinical ScienceUniversity of BergenBergenNorway
- Department of Heart DiseaseHaukeland University HospitalBergenNorway
| | - Peter Wohlfahrt
- Department of Preventive CardiologyInstitute for Clinical and Experimental MedicinePragueCzech Republic
- Centre for Cardiovascular PreventionCharles University Medical School I and Thomayer HospitalPragueCzech Republic
- Department of Medicine IICharles University in Prague, First Faculty of MedicinePragueCzech Republic
| | - Senol Piskin
- Department of Mechanical Engineering, Faculty of Engineering and Natural SciencesIstinye UniversityIstanbulTurkey
- Modeling, Simulation and Extended Reality LaboratoryIstinye UniversityIstanbulTurkey
| | - Dimitrios Terentes‐Printzios
- First Department of Cardiology, Hippokration Hospital, Athens Medical SchoolNational and Kapodistrian University of AthensGreece
| | - Jordi Alastruey
- School of Biomedical Engineering and Imaging SciencesKing’s College LondonLondonUK
| | - Andrea Guala
- Vall d’Hebron Institut de Recerca (VHIR)BarcelonaSpain
- CIBER‐CV, Instituto de Salud Carlos IIIMadridSpain
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Huang EPY, Lin HS, Chen YC, Li YH, Huang YL, Ju YJ, Yu HC, Kicska GA, Wu MT. Lower attenuation and higher kurtosis of coronary artery calcification associated with vulnerable plaque - an agatston score propensity-matched CT radiomics study. BMC Cardiovasc Disord 2023; 23:158. [PMID: 36973668 PMCID: PMC10045966 DOI: 10.1186/s12872-023-03162-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Coronary artery calcification (CAC) burden assessed by Agatston score (AS) is currently recommended to stratify patients at risk for future acute coronary syndrome (ACS). Besides the CAC burden, the biostructure of CAC may also play a vital role in the vulnerability of CAC, which CT radiomics could reveal. Propensity-score matching of the traditional risk factors and CAC burden between the ACS and asymptomatic groups could radically remove biases and allow the exploration of characteristic features of CAC in ACS. METHODS We retrospectively identified 77 patients with ACS who had a CAC scan before percutaneous coronary intervention between 2016 and 2019. These 77 patients were one-to-two propensity-score matched for traditional risk factors of ACS and AS ranks to select 154 subjects from 2890 asymptomatic subjects. A validation cohort of 30 subjects was also enrolled. Radiomics features of each plaque were extracted and averaged in each person. Conditional logistic regression and area-under-curve analysis were used for statistical analysis. RESULTS A higher number of coronary segments involved, lower mean, median, first quartile, and standard deviation of attenuation, and increased kurtosis of attenuation of CAC were associated with the ACS group compared to the control group (p < 0.05 for all). Multivariable analysis showed that the lower median attenuation (OR = 0.969, p < 0.001) and higher Kurtosis (OR = 18.7, p < 0.001) were associated with the ACS group. The median attenuation and kurtosis significantly increase across AS ranks 1 to 4 (p = 0.001). The AUC of kurtosis (0.727) and median attenuation (0.66) were both significantly higher than that of the standard AS (AUC = 0.502) and the number of TRF (AUC = 0.537). The best cut-off of kurtosis at 2.74 yielded an accuracy of 74%, and the cut-off of median attenuation at 196 yielded an accuracy of 68%. The accuracy of kurtosis was 64%, and the accuracy of median attenuation was 55% in the validation cohort. CONCLUSION After propensity-matching traditional risk factors and CAC burden, CT radiomics highlighted that lower median attenuation and higher kurtosis were the CAC characteristics of vulnerable plaques. These features improve the understanding of the biomechanics of CAC evolution and enhance the value of CAC scan in ACS risk assessment.
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Affiliation(s)
- Eric Po-Yu Huang
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
- Department of Radiology, New Taipei City Hospital, No. 3, Sec. 1, New Taipei Blvd., Sanchong Dist., New Taipei City, 241204, Taiwan
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, 151 Chin-Hsueh Rd., Ta-Liao District, Kaohsiung, 831301, Taiwan
| | - Yi-Chun Chen
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
| | - Yi-He Li
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
| | - Yi-Luan Huang
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
| | - Yu-Jeng Ju
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Department of Psychology, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd, Taipei, 10617, Taiwan
| | - Hsien-Chung Yu
- Health Management Center, Kaohsiung Veterans General Hospital, No. 386, Ta- Chung 1st Road, Kaohsiung, 813414, Taiwan
| | - Gregory A Kicska
- Section Chief of Thoracic Imaging, Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States of America
| | - Ming-Ting Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan.
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
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Javan-Khoshkholgh A, Sassoon JC, Behbodikhah J, Dai W, Alemu S, Quadri S, Singh M, Savinova OV, Farajidavar A. Recording and analysis of slow waves of the small intestine of mice with heart failure. Neurogastroenterol Motil 2023; 35:e14514. [PMID: 36480434 DOI: 10.1111/nmo.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/18/2022] [Accepted: 11/23/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrointestinal (GI) symptoms in heart failure (HF) patients are associated with increased morbidity and mortality. We hypothesized that HF reduces bioelectrical activity underlying peristalsis. In this study, we aimed to establish a method to capture and analyze slow waves (SW) in the small intestine in mice with HF. METHODS We established a model of HF secondary to coronary artery disease in mice overexpressing tissue-nonspecific alkaline phosphatase (TNAP) in endothelial cells. The myoelectric activity was recorded from the small intestine in live animals under anesthesia. The low- and high-frequency components of SW were isolated in MATLAB and compared between the control (n = 12) and eTNAP groups (n = 8). C-kit-positive interstitial cells of Cajal (ICC) and Pgp9.5-positive myenteric neurons were detected by immunofluorescence. Myenteric ganglia were assessed by hematoxylin and eosin (H&E) staining. RESULTS SW activity was successfully captured in vivo, with both high- and low-frequency components. Low-frequency component of SW was not different between endothelial TNAP (eTNAP) and control mice (mean[95% CI]: 0.032[0.025-0.039] vs. 0.040[0.028-0.052]). High-frequency component of SW showed a reduction eTNAP mice relative to controls (0.221[0.140-0.302] vs. 0.394[0.295-0.489], p < 0.01). Dysrhythmia was also apparent upon visual review of signals. The density of ICC and neuronal networks remained the same between the two groups. No significant reduction in the size of myenteric ganglia of eTNAP mice was observed. CONCLUSIONS A method to acquire SW activity from small intestines in vivo and isolate low- and high-frequency components was established. The results indicate that HF might be associated with reduced high-frequency SW activity.
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Affiliation(s)
- Amir Javan-Khoshkholgh
- Department of Materials Science and Biomedical Engineering, University of Wisconsin - Eau Claire, Eau Claire, Wisconsin, USA
| | - Joseph C Sassoon
- College of Engineering and Computing Sciences, Department of Electrical and Computer Engineering, New York Institute of Technology, Old Westbury, New York, USA
| | - Jennifer Behbodikhah
- College of Osteopathic Medicine, Department of Biomedical Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Wenchen Dai
- College of Engineering and Computing Sciences, Department of Electrical and Computer Engineering, New York Institute of Technology, Old Westbury, New York, USA
| | - Senayt Alemu
- College of Osteopathic Medicine, Department of Biomedical Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Saad Quadri
- College of Osteopathic Medicine, Department of Biomedical Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Mohnish Singh
- College of Osteopathic Medicine, Department of Biomedical Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Olga V Savinova
- College of Osteopathic Medicine, Department of Biomedical Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Aydin Farajidavar
- College of Engineering and Computing Sciences, Department of Electrical and Computer Engineering, New York Institute of Technology, Old Westbury, New York, USA
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Agarwala A, Satish P, Al Rifai M, Mehta A, Cainzos-Achirica M, Shah NS, Kanaya AM, Sharma GV, Dixon DL, Blumenthal RS, Natarajan P, Nasir K, Virani SS, Patel J. Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S. JACC. ADVANCES 2023; 2:100258. [PMID: 38089916 PMCID: PMC10715803 DOI: 10.1016/j.jacadv.2023.100258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 12/20/2023]
Abstract
South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.
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Affiliation(s)
- Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, Texas, USA
| | - Priyanka Satish
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Anurag Mehta
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
- Hospital del Mar, Parc Salut Mar, Barcelona, Spain
| | - Nilay S. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alka M. Kanaya
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Garima V. Sharma
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Dave L. Dixon
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Pradeep Natarajan
- Cardiovascular Disease Initiative Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
- Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Salim S. Virani
- Aga Khan University, Karachi, Pakistan
- Texas Heart Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Jaideep Patel
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
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The Impact of Novel Reconstruction Algorithms on Calcium Scoring: Results on a Dedicated Cardiac CT Scanner. Diagnostics (Basel) 2023; 13:diagnostics13040789. [PMID: 36832277 PMCID: PMC9955482 DOI: 10.3390/diagnostics13040789] [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: 12/27/2022] [Revised: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
Contemporary reconstruction algorithms yield the potential of reducing radiation exposure by denoising coronary computed tomography angiography (CCTA) datasets. We aimed to assess the reliability of coronary artery calcium score (CACS) measurements with an advanced adaptive statistical iterative reconstruction (ASIR-CV) and model-based adaptive filter (MBAF2) designed for a dedicated cardiac CT scanner by comparing them to the gold-standard filtered back projection (FBP) calculations. We analyzed non-contrast coronary CT images of 404 consecutive patients undergoing clinically indicated CCTA. CACS and total calcium volume were quantified and compared on three reconstructions (FBP, ASIR-CV, and MBAF2+ASIR-CV). Patients were classified into risk categories based on CACS and the rate of reclassification was assessed. Patients were categorized into the following groups based on FBP reconstructions: 172 zero CACS, 38 minimal (1-10), 87 mild (11-100), 57 moderate (101-400), and 50 severe (400<). Overall, 19/404 (4.7%) patients were reclassified into a lower-risk group with MBAF2+ASIR-CV, while 8 additional patients (27/404, 6.7%) shifted downward when applying stand-alone ASIR-CV. The total calcium volume with FBP was 7.0 (0.0-133.25) mm3, 4.0 (0.0-103.5) mm3 using ASIR-CV, and 5.0 (0.0-118.5) mm3 with MBAF2+ASIR-CV (all comparisons p < 0.001). The concomitant use of ASIR-CV and MBAF2 may allow the reduction of noise levels while maintaining similar CACS values as FBP measurements.
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Andre F, Seitz S, Fortner P, Allmendinger T, Sommer A, Brado M, Sokiranski R, Fink J, Kauczor HU, Heussel CP, Herth F, Frey N, Görich J, Buss SJ. Simultaneous assessment of heart and lungs with gated high-pitch ultra-low dose chest CT using artificial intelligence-based calcium scoring. Eur J Radiol Open 2023; 10:100481. [PMID: 36852255 PMCID: PMC9958356 DOI: 10.1016/j.ejro.2023.100481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/10/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Purpose The combined testing for coronary artery and pulmonary diseases is of clinical interest as risk factors are shared. In this study, a novel ECG-gated tin-filtered ultra-low dose chest CT protocol (GCCT) for integrated heart and lung acquisition and the applicability of artificial intelligence (AI)-based coronary artery calcium scoring were assessed. Methods In a clinical registry of 10481 patients undergoing heart and lung CT, GCCT was applied in 44 patients on a dual-source CT. Coronary calcium scans (CCS) with 120 kVp, 100 kVp, and tin-filtered 100 kVp (Sn100) of controls, matched with regard to age, sex, and body-mass index, were retrieved from the registry (ntotal=176, 66.5 (59.4-74.0) years, 52 men). Automatic tube current modulation was used in all scans. In 20 patients undergoing GCCT and Sn100 CCS, Agatston scores were measured both semi-automatically by experts and by AI, and classified into six groups (0, <10, <100, <400, <1000, ≥1000). Results Effective dose decreased significantly from 120 kVp CCS (0.50 (0.41-0.61) mSv) to 100 kVp CCS (0.34 (0.26-0.37) mSv) to Sn100 CCS (0.14 (0.11-0.17) mSv). GCCT showed higher values (0.28 (0.21-0.32) mSv) than Sn100 CCS but lower than 120 kVp and 100 kVp CCS (all p < 0.05) despite greater scan length. Agatston scores correlated strongly between GCCT and Sn100 CCS in semi-automatic and AI-based measurements (both ρ = 0.98, p < 0.001) resulting in high agreement in Agatston score classification (κ = 0.97, 95% CI 0.92-1.00; κ = 0.89, 95% CI 0.79-0.99). Regarding chest findings, further diagnostic steps were recommended in 28 patients. Conclusions GCCT allows for reliable coronary artery disease and lung cancer screening with ultra-low radiation exposure. GCCT-derived Agatston score shows excellent agreement with standard CCS, resulting in equivalent risk stratification.
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Affiliation(s)
- Florian Andre
- University of Heidelberg, Department of Cardiology, Angiology and Pneumology, Heidelberg, Germany
- MVZ-DRZ Heidelberg, Heidelberg, Germany
- Correspondence to: University of Heidelberg, Department of Cardiology, Angiology and Pneumology, Im Neuenheimer Feld 410, Heidelberg 69120, Germany.
| | | | | | | | | | | | | | | | - Hans-Ulrich Kauczor
- University of Heidelberg, Department of Diagnostic and Interventional Radiology, Heidelberg
| | - Claus P. Heussel
- University of Heidelberg, Thoraxklinik, Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Felix Herth
- University of Heidelberg, Thoraxklinik, Department of Pneumology and Critical Care Medicine, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Norbert Frey
- University of Heidelberg, Department of Cardiology, Angiology and Pneumology, Heidelberg, Germany
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Photon-Counting Computed Tomography (PCCT): Technical Background and Cardio-Vascular Applications. Diagnostics (Basel) 2023; 13:diagnostics13040645. [PMID: 36832139 PMCID: PMC9955798 DOI: 10.3390/diagnostics13040645] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/28/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Photon-counting computed tomography (PCCT) is a new advanced imaging technique that is going to transform the standard clinical use of computed tomography (CT) imaging. Photon-counting detectors resolve the number of photons and the incident X-ray energy spectrum into multiple energy bins. Compared with conventional CT technology, PCCT offers the advantages of improved spatial and contrast resolution, reduction of image noise and artifacts, reduced radiation exposure, and multi-energy/multi-parametric imaging based on the atomic properties of tissues, with the consequent possibility to use different contrast agents and improve quantitative imaging. This narrative review first briefly describes the technical principles and the benefits of photon-counting CT and then provides a synthetic outline of the current literature on its use for vascular imaging.
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Maceira A, Valenzuela PL, Santos-Lozano A, García-González MP, Ortega LH, Díaz-Gonzalez L, Boraita A, Barranco-Gil D, Lucia A. Myocardial Fibrosis and Coronary Calcifications Caused by Endurance Exercise? Insights from Former Professional Cyclists. Med Sci Sports Exerc 2023; 55:151-157. [PMID: 36136597 DOI: 10.1249/mss.0000000000003043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE This study aimed to compare the prevalence of myocardial fibrosis and coronary calcification in individuals who have performed very high levels of strenuous endurance exercise (SEE; former male professional cyclists) and sex/age-matched controls. METHODS We used a retrospective cohort study design, where cases were former finishers of ≥1 Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals free of cardiovascular risk. All participants underwent cardiac magnetic resonance and cardiac computer tomography in the same center during years 2020-2021 to detect myocardial fibrosis (late gadolinium enhancement) and to quantify coronary calcium, respectively. RESULTS Twenty-three cases (age, 46 ± 6 yr) and 59 controls (47 ± 7 yr) were studied. Fibrotic patches were evidenced only in the left ventricle, with a higher prevalence in cases (23% vs 2% in controls, P = 0.006). However, fibrotic tissue was nonischemic and of low extension (0.6% ± 0.4% of left ventricle mass), and no significant differences were found between cases and controls for native T1 or T2 values. No between-group differences were found for coronary calcium indicators, including Agatston or density scores. Subanalyses revealed no differences attending to whether cases were still performing regular SEE ( n = 8) or not ( n = 15) after professional retirement. CONCLUSIONS Although former professional cyclists seemed to show a greater prevalence of myocardial fibrosis, the extension of fibrotic tissue was minimal and no alterations were found in coronary calcification indicators. While keeping in mind the low sample size of the cases' group, our results do not support evidence for major cardiac maladaptations with long-term exposure to SEE, at least in middle-age adults.
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Affiliation(s)
| | - Pedro L Valenzuela
- Research Institute of the Hospital 12 de Octubre ("imas12," PaHerg group), Madrid, SPAIN
| | | | | | | | | | - Araceli Boraita
- Department of Cardiology, Sports Medicine Center, Spanish Agency for Health Protection in Sports, Madrid, SPAIN
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Wetscherek MTA, McNaughton E, Majcher V, Wetscherek A, Sadler TJ, Alsinbili A, Teh WH, Moore SD, Patel N, Smith WPW, Krishnan U. Incidental coronary artery calcification on non-gated CT thorax correlates with risk of cardiovascular events and death. Eur Radiol 2023:10.1007/s00330-023-09428-z. [PMID: 36705681 PMCID: PMC9881510 DOI: 10.1007/s00330-023-09428-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To assess coronary artery calcification (CAC) on non-contrast non-ECG-gated CT thorax (NC-NECG-CTT) and to evaluate its correlation with short-term risk of cardiovascular disease (CVD) events and death. METHODS Single-institution retrospective study including all patients 40-70 years old who underwent NC-NECG-CTT over a period of 6 months. Individuals with known CVD were excluded. The presence of CAC was assessed and quantified by the Agatston score (CACS). CAC severity was defined as mild (< 100), moderate (100-400), or severe (> 400). CVD events (including CVD death, myocardial infarction, revascularisation procedures, ischaemic stroke, acute peripheral atherosclerotic ischaemia), and all-cause mortality over a median of 3.5 years were recorded. Cox proportional-hazards regression modelling was performed including CACS, age, gender and CVD risk factors (smoking, hypertension, diabetes mellitus, dyslipidaemia, and family history of CVD). RESULTS Of the total 717 eligible cases, 325 (45%) had CAC. In patients without CAC, there was only one CVD event, compared to 26 CVD events including 5 deaths in patients with CAC. The presence and severity of CAC correlated with CVD events (p < 0.001). A CACS > 100 was significantly associated with both CVD events, hazard ratio (HR) 5.74, 95% confidence interval: 2.19-15.02; p < 0.001, and all-cause mortality, HR 1.7, 95% CI: 1.08-2.66; p = 0.02. Ever-smokers with CAC had a significantly higher risk for all-cause mortality compared to never-smokers (p = 0.03), but smoking status was not an independent predictor for CVD events in any subgroup category of CAC severity. CONCLUSIONS The presence and severity of CAC assessed on NC-NECG-CTT correlates with short-term cardiovascular events and death. KEY POINTS • Patients aged 40-70 years old without known CVD but with CAC on NC-NECG-CTT have a higher risk of CVD events compared to those without CAC. • CAC (Agatston) score above 100 confers a 5.7-fold increase in the risk of short-term CVD events in these patients. • The presence and severity of CAC on NC-NECG-CTT may have prognostic and therapeutic implications.
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Affiliation(s)
- Maria T A Wetscherek
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - Edwina McNaughton
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Veronika Majcher
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Andreas Wetscherek
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Rd, London, SM2 5NG, UK
| | - Timothy J Sadler
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Ahmed Alsinbili
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Wen Hui Teh
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Samuel D Moore
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - Nirav Patel
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - William P W Smith
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - Unni Krishnan
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
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Major Global Coronary Artery Calcium Guidelines. JACC. CARDIOVASCULAR IMAGING 2023; 16:98-117. [PMID: 36599573 DOI: 10.1016/j.jcmg.2022.06.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/14/2022] [Accepted: 06/22/2022] [Indexed: 01/07/2023]
Abstract
This review summarizes the framework behind global guidelines of coronary artery calcium (CAC) in atherosclerotic cardiovascular disease risk assessment, for applications in both the clinical setting and preventive therapy. By comparing similarities and differences in recommendations, this review identifies most notable common features for the application of CAC presented by different cardiovascular societies across the world. Guidelines included from North America are as follows: 1) the 2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease; and 2) the 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for Prevention of Adult Cardiovascular Disease. The authors also included European guidelines: 1) the 2019 European Society for Cardiology/European Atherosclerosis Society Guidelines for the Management of Dyslipidemias; and 2) the 2016 National Institute for Health and Care Excellence Clinical Guidelines. In this comparison, the authors also discuss: 1) the Cardiac Society of Australia and New Zealand Guidelines on CAC; 2) the Chinese Society of Cardiology Guidelines; and 3) the Japanese Atherosclerosis Society Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases. Last, they include statements made by specialty societies including the National Lipid Association, Society of Cardiovascular Computed Tomography, and U.S. Preventive Services Task Force. Utilizing an in-depth review of clinical evidence, these guidelines emphasize the importance of CAC in the primary and secondary prevention of atherosclerotic cardiovascular disease. International guidelines all empower a dynamic clinician-patient relationship and advocate for individualized discussions regarding disease management and pharmacotherapy treatment. Some differences in precise coronary artery calcium score intervals, risk cut points, treatment thresholds, and stratifiers of specific patient subgroups do exist. However, international guidelines employ more similarities than differences from both a clinical and functional perspective. Understanding the parallels among international coronary artery calcium guidelines is essential for clinicians to correctly adjudicate personalized statin and aspirin therapy and further medical management.
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Lopes Fernandes S, Ladeiras-Lopes R, Silva M, Silva G, Cruz I, Diaz SO, Barros AS, Saraiva F, Faria R, Almeida J, Fonseca P, Gonçalves H, Oliveira M, Ferreira N, Primo J, Fontes-Carvalho R. Higher coronary artery calcium score is associated with increased risk of atrial fibrillation recurrence after catheter ablation. J Cardiovasc Comput Tomogr 2023; 17:22-27. [PMID: 36372722 DOI: 10.1016/j.jcct.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/04/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Coronary artery calcium score (CACS) is associated with an increased risk of atrial fibrillation (AF) development, but scarce data are available regarding the impact on AF recurrence. This study aims to assess the impact of CACS on AF recurrence following catheter ablation. METHODS Retrospective study of patients with AF undergoing cardiac computed tomography (CCT) before ablation (2017-2019). Patients with coronary artery disease (CAD), significant valvular heart disease and previous catheter ablation were excluded. A cut-off of CACS ≥ 100 was used according to literature. RESULTS A total of 311 patients were included (median age 57 [48, 64] years, 65% men and 21% with persistent AF). More than half of the patients had a CACS > 0 (52%) and 18% a CACS ≥ 100. Patients with CACS ≥ 100 were older (64 [59, 69] vs 55 [46, 63] years, p < 0.001), had more frequently hypertension (68% vs 42%, p < 0.001) and diabetes mellitus (21% vs 10%, p = 0.020). During a median follow-up of 34 months (12-57 months), 98 patients (32%) had AF recurrence. CACS ≥ 100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 2.0; 95% confidence interval [CI], 1.3-3.1, p = 0.002). After covariate adjustment, CACS ≥ 100 and persistent AF remained independent predictors of AF recurrence (HR, 1.7; 95% CI, 1.0-2.8, p = 0.039 and HR, 2.0; 95% CI, 1.3-3.2, p = 0.004, respectively). CONCLUSION An opportunistic evaluation of CACS could be an important tool to improve clinical care considering that CACS ≥ 100 was independently associated with a 69% increase in the risk of AF recurrence after first catheter ablation.
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Affiliation(s)
| | - Ricardo Ladeiras-Lopes
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal; Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Mariana Silva
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Gualter Silva
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Inês Cruz
- Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Sílvia O Diaz
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - António S Barros
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Francisca Saraiva
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Rita Faria
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - João Almeida
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Paulo Fonseca
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Helena Gonçalves
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Marco Oliveira
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Nuno Ferreira
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - João Primo
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Gaia Hospital Centre, 4434-502 Vila Nova de Gaia, Portugal; Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
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Razavi AC, Mortensen MB, Blaha MJ, Dzaye O. Coronary artery calcium testing in young adults. Curr Opin Cardiol 2023; 38:32-38. [PMID: 36598447 PMCID: PMC9830553 DOI: 10.1097/hco.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW To provide a summary of recent literature on coronary artery calcium testing (CAC) for risk stratification in young adults <45 years old. RECENT FINDINGS One of every ten young adults in the general population, and one out of every three young adults with traditional atherosclerotic cardiovascular disease (ASCVD) risk factors, have CAC. While the definition of premature CAC has yet to be formally defined in guidelines, it has become increasingly clear that any prevalent CAC among adults <45 years old should be considered premature. Traditional risk factors are strong predictors of CAC in young adults; however, this association has been found to wane over the life course which suggests that the onset and severity of risk factors for calcific atherosclerosis varies as individuals age. Though CAC is a robust predictor of both ASCVD and cancer-related mortality in old age, CAC in young adults confers a stepwise higher risk uniquely for incident ASCVD mortality, and not for non-ASCVD causes. New tools are available to assist in interpretation of CAC in the young, and for estimating the ideal age to initiate CAC scoring. SUMMARY The identification of premature CAC is important because it suggests that calcific plaque can be detected with modern imaging earlier in the natural history than previously thought. Taken together, these findings underline a utility of selective use of CAC scoring on non-contrast computed tomography among at-risk young adults to facilitate timely lifestyle modification and pharmacotherapies for the prevention of later life ASCVD.
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Affiliation(s)
- Alexander C. Razavi
- Center for Heart Disease Prevention, Emory University Hospital, Atlanta, Georgia, United States of America
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | | | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Omar Dzaye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
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