Relationship of exercise to coronary artery disease extent, severity and plaque type: A coronary computed tomography angiography study

Screening Sportsmen and Sportswomen Over Age 35: The Relevance of an Exercise Electrocardiogram. Data From the SEEPRED Study

INTRODUCTION

The importance of exercise electrocardiogram (ECG) is still controversial in the prevention of cardiovascular events among sportsmen and sportswomen. The aim of this study was to assess the relevance of exercise ECG as a screening tool to prevent cardiovascular events when any cardiovascular disease (CVD) risk factors are present.

METHODS

The study included leisure time asymptomatic sportsmen and sportswomen over age 35 evaluated from 2011 to 2016 at the University Hospital of Saint-Etienne (France). Major adverse cardiovascular events (MACE) and atrial fibrillation were collected at 3 years.

RESULTS

Of the cohort of 2457 sportsmen and sportswomen (mean age 50.2 ± 9.4 years), 50 (2%) had a high-risk SCORE2. A total of 256 exercise ECGs (10%) were defined as positive, most of them due to silent myocardial ischemia (SMI) (n = 196; 8%). These 196 SMI cases led to 33 coronary angiograms (1%), which revealed 23 significant coronary stenoses requiring revascularization. In multivariate logistic regression analysis, having at least two CVD risk factors was independently associated with (1) positive exercise ECG (OR = 1.80 [95% CI: 1.29-2.52], p = 0.0006), with (2) suspected SMI (OR = 2.57 [95% CI: 1.10-6.02], p = 0.0304), with (3) confirmed SMI (OR = 8.20 [95% CI: 3.46-19.46], p < 0.0001) and with (4) cardiovascular events (MACE or atrial fibrillation) (OR = 6.95 [95% CI: 3.49-13.81], p < 0.0001) at 3 years (median).

CONCLUSIONS

The study supports the European recommendations for the use of exercise ECG in evaluation of asymptomatic leisure time sportsmen over age 35. Having at least two CVD risk factors was the best predictor for presence of coronary artery stenosis that may increase the risk for adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06024863.

Self-reported exercise activity influences the relationship between coronary computed tomography angiographic finding and mortality

AIM

Recent studies suggest that the application of exercise activity questionnaires, including the use of a single-item exercise question, can be additive to the prognostic efficacy of imaging findings. This study aims to evaluate the prognostic efficacy of exercise activity in patients undergoing coronary computed tomography angiography (CCTA).

METHODS AND RESULTS

We assessed 9772 patients who underwent CCTA at a single center between 2007 and 2020. Patients were divided into 4 groups of physical activity as no exercise (n ​= ​1643, 17%), mild exercise (n ​= ​3156, 32%), moderate exercise (n ​= ​3542, 36%), and high exercise (n ​= ​1431,15%), based on a single-item self-reported questionnaire. Coronary stenosis was categorized as no (0%), non-obstructive (1-49%), borderline (50-69%), and obstructive (≥70%). During a median follow-up of 4.64 (IQR 1.53-7.89) years, 490 (7.6%) died. There was a stepwise inverse relationship between exercise activity and mortality (p ​< ​0.001). Compared with the high activity group, the no activity group had a 3-fold higher mortality risk (HR: 3.3, 95%CI (1.94-5.63), p ​< ​0.001) after adjustment for age, clinical risk factors, symptoms, and statin use. For any level of CCTA stenosis, mortality rates were inversely associated with the degree of patients' exercise activity. The risk of all-cause mortality was similar among the patients with obstructive stenosis with high exercise versus those with no coronary stenosis but no exercise activity (p ​= ​0.912).

CONCLUSION

Physical activity as assessed by a single-item self-reported questionnaire is a strong stepwise inverse predictor of mortality risk among patients undergoing CCTA.

Coronary atherosclerotic burden in veteran athletes: The relationship between cardiovascular risk and volume of exercise

INTRODUCTION AND OBJECTIVES

The association between exercise and coronary atherosclerosis still remains unclarified. We aimed to analyze the prevalence of high coronary atherosclerotic burden in veteran athletes, considering cardiovascular (CV) risk and volume of exercise.

METHODS

A total of 105 asymptomatic male veteran athletes (48±5.6 years old) were studied. A high coronary atherosclerotic burden was defined as one of the following characteristics in coronary computed tomography angiography: calcium score >100, >75th percentile, obstructive plaques, involving left main, three-vessels or two-vessels including proximal anterior descending artery, segment involvement score >5 or CT-adapted Leaman score ≥5. CV risk was stratified by SCORE2 and volume of exercise by metabolic equivalent task score.

RESULTS

Most athletes (n=88) were engaged in endurance sports for 17.1±9.8 years, with a median exercise volume of 66 [IQR 44-103] metabolic equivalent of tasks/hour/week. The mean Systematic Coronary Risk Evaluation 2 was 2.8±1.5%; 76.9% of athletes had a low-moderate risk and none a very high risk. High coronary atherosclerotic burden was present in 25.7% athletes. Athletes with high cardiovascular risk and high exercise volume (above the median) showed significantly high coronary atherosclerotic burden compared to those with low-moderate risk and high volume (50.0% vs. 15.6%; p=0.017). Among athletes with low to moderate risk, a high volume of exercise tended to be protective, while in those with low volume, there was similar rate of high coronary atherosclerotic burden, regardless of CV risk.

CONCLUSIONS

A combination of higher volume of exercise and high cardiovascular risk revealed the worst association with coronary atherosclerosis in veteran athletes. The relationship between these variables is controversial, but integrating exercise characteristics and risk assessment into preparticipation evaluation is essential.

The heart of the ageing endurance athlete: the role of chronic coronary stress

Moderate physical exercise is associated with an irrefutable reduction in cardiac morbidity and mortality. The current guidelines recommend at least 150 min of moderate exercise or 75 min of vigorous exercise per week. Endurance athletes perform exercise at a level that is 10- to 20-fold greater than these recommendations. These athletes reveal several structural and functional cardiac adaptations including increased cardiac size, enhanced ventricular filling, and augmentation of stroke volume even at the highest heart rates. The long-term effects of endurance exercise on the heart are unknown. Endurance exercise is associated with a transient increase in serum concentrations of biomarkers of cardiac damage and ventricular dysfunction which improves within 72 h. Over the past decade, there have been emerging studies reporting attenuated mortality benefit amongst individuals who perform the highest volume of exercise. Studies in lifelong male athletes aged above 40 years old show a higher prevalence of high coronary artery calcium scores (>300 Agatston units), a higher coronary plaque burden, and myocardial fibrosis compatible with subclinical myocardial infarction compared with relatively sedentary healthy controls, raising speculation that lifelong intense exercise imposes chronic coronary stress on the heart. This review article will provide a critical analysis of the existing data.

Prevalence and Characterization of Subclinical Coronary Atherosclerotic Plaque with CT among Individuals with HIV: Results from the Canadian HIV and Aging Cohort Study

Background People living with HIV (PLWH) have a higher risk of myocardial infarction. Coronary atherosclerotic plaque CT characterization helps to predict cardiovascular risk. Purpose To measure CT characteristics of coronary plaque in PLWH without known cardiovascular disease and healthy volunteers without HIV. Materials and Methods In this prospective study, noncontrast CT (all participants, n = 265) was used for coronary artery calcium (CAC) scoring in asymptomatic PLWH and healthy volunteers without HIV, without known cardiovascular disease, from 2012 to 2019. At coronary CT angiography (n = 233), prevalence, frequency, and volume of calcified, mixed, and noncalcified plaque were measured. Poisson regressions were used with adjustment for cardiovascular risk factors. Results There were 181 PLWH (mean age, 56 years ± 7; 167 men) and 84 healthy volunteers (mean age, 57 years ± 8; 65 men) evaluated by using noncontrast CT. CT angiography was performed in 155 PLWH and 78 healthy volunteers. Median 10-year Framingham risk score was not different between PLWH and healthy volunteers (10% vs 9%, respectively; P = .45), as were CAC score (odds ratio [OR], 1.06; 95% CI: 0.58, 1.94; P = .85) and overall plaque prevalence (prevalence ratio, 1.07; 95% CI: 0.86, 1.32; P = .55) after adjustment for cardiovascular risk. Noncalcified plaque prevalence (prevalence ratio, 2.5; 95% CI: 1.07, 5.67; P = .03) and volume (OR, 2.8; 95% CI: 1.05, 7.40; P = .04) were higher in PLWH. Calcified plaque frequency was reduced in PLWH (OR, 0.6; 95% CI: 0.40, 0.91; P = .02). Treatment with protease inhibitors was associated with higher volume of overall (OR, 1.8; 95% CI: 1.09, 2.85; P = .02) and mixed plaque (OR, 1.6; 95% CI: 1.04, 2.45; P = .03). Conclusion Noncalcified coronary plaque burden at coronary CT angiography was two- to threefold higher in asymptomatic people living with HIV without known cardiovascular disease compared with healthy volunteers without HIV. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lai in this issue.

Metabolite Profiling of Osteoporosis and Atherosclerosis in Postmenopausal Women: A Cross-Sectional Study

Purpose

Atherosclerosis (AS) and osteoporosis (OP) are common causes of morbidity and mortality in postmenopausal women and are connected via an unknown mechanistic link. Metabolite profiling of blood samples may allow the identification of new biomarkers and pathways for this enigmatic association.

Patients and Methods

We studied the difference in 148 metabolite levels from serum samples in postmenopausal women with AS and OP compared with those in healthy participants in this cross-sectional study. Quantitative AS was assessed by carotid artery intima-media thickness (cIMT) and carotid artery calcifications (CACs) by ultrasound, as well as OP by femoral neck (FN) bone mineral density (BMD) and 148 metabolic measures with high-throughput proton (¹H) nuclear magnetic resonance (NMR) in serum samples from 280 postmenopausal (PM) women. Subjects were a randomly selected subsample from the population-based Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study. The final study population included the following groups: OP with CAC (n=16, group I), non-OP with no CAC (n=59, group II), high cIMT tertile with OP (n=11, group III) and low cIMT tertile without OP (n=48, group IV).

Results

There were differences in several metabolite levels between groups I and II. The acetate level was lower in group I compared to that in group II (group I mean ± SD: 0.033 ± 0.0070; group II: 0.041 ± 0.014, CI95%: 0.018‒0.15, p=0.014). The result was similar with diacylglycerol (p=0.002), leucine (p=0.031), valine (p=0.022) and several very low-density lipoprotein (VLDL) metabolite levels, which were lower in group I compared to those in group II. However, no associations were found in adjusted analyses with total body (TB) fat mass (FM), age and statin use (p>0.05).

Conclusion

Our novel study found differences in the metabolite profiling of altered amino acid and lipoprotein metabolism in participants with OP and AS compared with those in healthy women. The causative mechanisms remain unknown and further studies are needed.

Ambient air pollution, traffic proximity and coronary atherosclerotic phenotype in China

BACKGROUND

Exposure to ambient air pollution is associated with cardiovascular risk, potentially via atherosclerosis promotion. The disease mechanisms underlying these associations remain uncertain.

OBJECTIVES

We aim to investigate the relationship of air pollution and traffic proximity with subclinical atherosclerosis, using coronary plaque phenotypes to gain insight into potential mechanisms.

METHODS

Coronary plaque total and component volumes, high-risk plaque (HRP) appearance, and luminal stenosis were characterized by coronary computed tomography angiography in 2279 patients with atherosclerosis at baseline between 2014 and 2017. Annual average exposure to air pollutants including fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃) was estimated by air pollution models for individual participants. Multiple linear regression models were used to assess the association of each exposure with plaque phenotypes and coronary stenosis, controlling for potential confounders. Multiple logistic regression models were used to estimate associations with plaque vulnerability.

RESULTS

The studied population was 60.2±9.2 years old. PM_2.5 and NO₂ concentrations were significantly associated with a 5.0% (95%CI: 0.3, 9.9%, per 15 μg/m³ increase for PM_2.5), 12.0% (95%CI: 2.5, 22.5% per 20 μg/m³ for NO₂) larger volume of non-calcified plaque, respectively. Increase in O₃ concentration was associated with a 12.2% (95%CI: 2.2, 23.2%, per 5 μg/m³ O₃) larger volume of calcified plaque and a 12.8% (95%CI: 0.9, 26.2%) greater lumen narrowing. Increased PM_2.5 and NO₂, was also associated with increase in HRP, determined by the napkin ring sign (odds ratio: 1.41 [95%CI: 1.10, 1.80] for PM_2.5 and 1.78 [95%CI: 1.20, 2.63] for NO₂) and positive remodeling index (OR: 1.11 [95%CI: 1.01, 1.21] for PM_2.5 and 1.20 [95%CI: 1.02, 1.42] for NO₂), respectively, indicating increased plaque vulnerability.

CONCLUSION

Long-term exposures to air pollution were associated with greater plaque volume and luminal stenosis, and increased plaque vulnerability with attendant risk of plaque rupture and erosion.

Endurance exercise training volume is not associated with progression of coronary artery calcification

BACKGROUND

Recent cross-sectional studies have suggested a dose-dependent relationship between lifelong exposure to physical activity and the burden of calcified coronary artery disease (CAD). No longitudinal studies have addressed this concern.

HYPOTHESIS

Exercise volume is associated with progression of coronary artery calcium (CAC), defined as ≥10 units increase in CAC score.

METHODS

Sixty-one recreational athletes who were assessed by coronary computed tomography angiography (CCTA) as part of the NEEDED 2013/14 study were re-assessed 4-5 years later, in 2018.

RESULTS

Subjects were 45.9 ± 9.6 years old at inclusion, and 46 (74%) were male. Between 2013 and 2018, the participants reported median 5 (range: 0-20, 25th-75th percentile: 4-6) hours of high-intensity exercise per week. None of the included subjects smoked during follow-up. At inclusion, 21 (33%) participants had coronary artery calcifications. On follow-up CCTA in 2018, 15 (25%) subjects had progressive coronary calcification (≥10 Agatston units increase in CAC). These subjects were older (53 ± 9 vs 44 ± 9 years old, P = .002) and had higher levels of low-density lipoprotein at baseline (3.5 (2.9-4.3) vs 2.9 (2.3-3.5) mmol/L, P = .031) as compared to subjects with stable condition. No relationship was found between hours of endurance training per week and progression of coronary artery calcification. In multiple regression analysis, age and baseline CAC were the only significant predictors of progressive CAC.

CONCLUSION

No relationship between exercise training volume and the progression of coronary artery calcification was found in this longitudinal study of middle-aged recreational athletes.