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Yong Y, Giovannucci J, Pang SN, Hong W, Han D, Berman DS, Dey D, Nicholls SJ, Nerlekar N, Lin A. Coronary Artery Calcium Density and Risk of Cardiovascular Events: A Systematic Review and Meta-Analysis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00314-0. [PMID: 39243235 DOI: 10.1016/j.jcmg.2024.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND There is increasing evidence that coronary artery calcium (CAC) density is inversely associated with plaque vulnerability and atherosclerotic cardiovascular disease risk. OBJECTIVES A systematic review and meta-analysis were performed to examine the predictive value of CAC density for future cardiovascular events in asymptomatic individuals undergoing noncontrast CAC scoring computed tomography. METHODS Electronic databases were searched for studies reporting CAC density and subsequent cardiovascular disease (CVD) or coronary heart disease (CHD) events. Two independent reviewers performed data extraction. Random-effects models were used to estimate pooled HRs and 95% CIs. Subgroup analyses were performed with studies stratified by CVD vs CHD events and by statin use. RESULTS Of 5,029 citations, 5 studies with 6 cohorts met inclusion criteria. In total, 1,309 (6.1%) cardiovascular events occurred in 21,346 participants with median follow-up ranging from 5.2 to 16.7 years. Higher CAC density was inversely associated with risk of cardiovascular events following adjustment for clinical risk factors and CAC volume (HR: 0.80 per SD of density [95% CI: 0.72-0.89]; P < 0.01; I2 = 0%). There was no significant difference in the pooled HRs for CVD vs CHD events (HR: 0.80 per SD [95% CI: 0.71-0.90] vs 0.74 per SD [95% CI: 0.59-0.94] respectively; P = 0.59). The protective association between CAC density and event risk persisted among statin-naive patients (HR: 0.79 per SD [95% CI: 0.70-0.89]; P < 0.01) but not statin-treated patients (HR: 0.97 per SD [95% CI: 0.77-1.22]; P = 0.78); the test for interaction indicated no significant between-group differences (P = 0.12). CONCLUSIONS Higher CAC density is associated with a lower risk of cardiovascular events when adjusted for risk factors and CAC volume. Future work may expand the contribution of CAC density in CAC scoring, and enhance its role in CVD risk assessment, treatment, and prevention.
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Affiliation(s)
| | | | | | - Wei Hong
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Donghee Han
- Department of Imaging and Medicine and the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel S Berman
- Department of Imaging and Medicine and the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen J Nicholls
- Monash Victorian Heart Institute and Monash Health Heart, Victorian Heart Hospital, Monash University, Clayton, Victoria, Australia
| | - Nitesh Nerlekar
- Monash Victorian Heart Institute and Monash Health Heart, Victorian Heart Hospital, Monash University, Clayton, Victoria, Australia
| | - Andrew Lin
- Monash Victorian Heart Institute and Monash Health Heart, Victorian Heart Hospital, Monash University, Clayton, Victoria, Australia.
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Fink N, Emrich T, Schoepf UJ, Zsarnoczay E, O’Doherty J, Halfmann MC, Griffith JP, Pinos D, Suranyi P, Baruah D, Kabakus IM, Ricke J, Varga-Szemes A. Improved Detection of Small and Low-Density Plaques in Virtual Noncontrast Imaging-based Calcium Scoring at Photon-Counting Detector CT. Radiol Cardiothorac Imaging 2024; 6:e230328. [PMID: 39023373 PMCID: PMC11369658 DOI: 10.1148/ryct.230328] [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: 06/09/2023] [Revised: 03/26/2024] [Accepted: 05/30/2024] [Indexed: 07/20/2024]
Abstract
Purpose To investigate the impact of plaque size and density on virtual noncontrast (VNC)-based coronary artery calcium scoring (CACS) using photon-counting detector CT and to provide safety net reconstructions for improved detection of subtle plaques in patients whose VNC-based CACS would otherwise be erroneously zero when compared with true noncontrast (TNC)-based CACS. Materials and Methods In this prospective study, CACS was evaluated in a phantom containing calcifications with different diameters (5, 3, and 1 mm) and densities (800, 400, and 200 mg/cm3) and in participants who underwent TNC and contrast-enhanced cardiac photon-counting detector CT (July 2021-March 2022). VNC images were reconstructed at different virtual monoenergetic imaging (55-80 keV) and quantum iterative reconstruction (QIR) levels (QIR,1-4). TNC scans at 70 keV with QIR off served as the reference standard. In vitro CACS was analyzed using standard settings (3.0-mm sections, kernel Qr36, 130-HU threshold). Calcification detectability and CACS of small and low-density plaques were also evaluated using 1.0-mm sections, kernel Qr44, and 120- or 110-HU thresholds. Safety net reconstructions were defined based on background Agatston scores and evaluated in vivo in TNC plaques initially nondetectable using standard VNC reconstructions. Results The in vivo cohort included 63 participants (57.8 years ± 15.5 [SD]; 37 [59%] male, 26 [41%] female). Correlation and agreement between standard CACSVNC and CACSTNC were higher in large- and medium-sized and high- and medium-density than in low-density plaques (in vitro: intraclass correlation coefficient [ICC] ≥ 0.90; r > 0.9 vs ICC = 0.20-0.48; r = 0.5-0.6). Small plaques were not detectable using standard VNC reconstructions. Calcification detectability was highest using 1.0-mm sections, kernel Qr44, 120- and 110-HU thresholds, and QIR level of 2 or less VNC reconstructions. Compared with standard VNC, using safety net reconstructions (55 keV, QIR 2, 110-HU threshold) for in vivo subtle plaque detection led to higher detection (increased by 89% [50 of 56]) and improved correlation and agreement of CACSVNC with CACSTNC (in vivo: ICC = 0.51-0.61; r = 0.6). Conclusion Compared with TNC-based calcium scoring, VNC-based calcium scoring was limited for small and low-density plaques but improved using safety net reconstructions, which may be particularly useful in patients with low calcium scores who would otherwise be treated based on potentially false-negative results. Keywords: Coronary Artery Calcium CT, Photon-Counting Detector CT, Virtual Noncontrast, Plaque Size, Plaque Density Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Nicola Fink
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Tilman Emrich
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - U. Joseph Schoepf
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Emese Zsarnoczay
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Jim O’Doherty
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Moritz C. Halfmann
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Joseph P. Griffith
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Daniel Pinos
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Pal Suranyi
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Dhiraj Baruah
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Ismail M. Kabakus
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Jens Ricke
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
| | - Akos Varga-Szemes
- From the Department of Radiology and Radiological Science, Division
of Cardiovascular Imaging, Medical University of South Carolina, Ashley River
Tower, 25 Courtenay Dr, MUSC 226, Charleston, SC 29425-2260 (N.F., T.E., U.J.S.,
E.Z., J.O., J.P.G., D.P., P.S., D.B., I.M.K., A.V.S.); Department of Radiology,
University Hospital, LMU Munich, Munich, Germany (N.F., J.R.); Department of
Diagnostic and Interventional Radiology, University Medical Center of Johannes
Gutenberg-University, Mainz, Germany (T.E., M.C.H.); German Centre for
Cardiovascular Research, Mainz, Germany (T.E.); Medical Imaging Center,
Semmelweis University, Budapest, Hungary (E.Z.); and Siemens Medical Solutions,
Malvern, Pa (J.O.)
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3
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Razavi AC, Shaw LJ, Berman DS, Budoff MJ, Wong ND, Vaccarino V, van Assen M, De Cecco CN, Quyyumi AA, Mehta A, Muntner P, Miedema MD, Rozanski A, Rumberger JA, Nasir K, Blumenthal RS, Sperling LS, Mortensen MB, Whelton SP, Blaha MJ, Dzaye O. Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000. JACC Cardiovasc Imaging 2024; 17:766-776. [PMID: 38385932 DOI: 10.1016/j.jcmg.2023.12.006] [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: 09/28/2023] [Revised: 12/04/2023] [Accepted: 12/15/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined. OBJECTIVES Among persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates. METHODS The authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years). RESULTS The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]). CONCLUSIONS Among asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.
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Affiliation(s)
- Alexander C Razavi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, Blavatnik Family Women's Health Research Institute, New York, New York, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anurag Mehta
- VCU Health Pauley Heart Center and Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael D Miedema
- Nolan Family Center for Cardiovascular Health, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | | | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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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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5
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Tajima A, Bouisset F, Ohashi H, Sakai K, Mizukami T, Rizzini ML, Gallo D, Chiastra C, Morbiducci U, Ali ZA, Spratt JC, Ando H, Amano T, Kitslaar P, Wilgenhof A, Sonck J, De Bruyne B, Collet C. Advanced CT Imaging for the Assessment of Calcific Coronary Artery Disease and PCI Planning. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101299. [PMID: 39131223 PMCID: PMC11307873 DOI: 10.1016/j.jscai.2024.101299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 08/13/2024]
Abstract
Vascular calcification is a hallmark of atherosclerosis and adds considerable challenges for percutaneous coronary intervention (PCI). This review underscores the critical role of coronary computed tomography (CT) angiography in assessing and quantifying vascular calcification for optimal PCI planning. Severe calcification significantly impacts procedural outcomes, necessitating accurate preprocedural evaluation. We describe the potential of coronary CT for calcium assessment and how CT may enhance precision in device selection and procedural strategy. These advancements, along with the ongoing Precise Procedural and PCI Plan study, represent a transformative shift toward personalized PCI interventions, ultimately improving patient outcomes in the challenging landscape of calcified coronary lesions.
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Affiliation(s)
- Atomu Tajima
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | | | - Hirofumi Ohashi
- Department of Cardiology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Koshiro Sakai
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | | | - Maurizio Lodi Rizzini
- PolitoMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Diego Gallo
- PolitoMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Claudio Chiastra
- PolitoMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Umberto Morbiducci
- PolitoMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | | | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Aichi, Japan
| | | | - Adriaan Wilgenhof
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Jeroen Sonck
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
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6
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Selvam PV, Grandhi GR, Leucker TM, Arbab-Zadeh A, Gulati M, Blumenthal RS, Whelton SP. Recent advances in cardiovascular risk assessment: The added value of non-invasive anatomic imaging. J Cardiovasc Comput Tomogr 2024; 18:113-119. [PMID: 38326189 DOI: 10.1016/j.jcct.2024.01.012] [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: 07/12/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
Abstract
In 2022, multiple original research studies were conducted highlighting the utility of coronary artery calcium (CAC) imaging in young individuals and provided further evidence for the role of CAC to improve atherosclerotic cardiovascular disease (ASCVD) risk assessment. Mean calcium density was shown to be a more reliable predictor than peak density in risk assessment. Additionally, in light of the ACC/AHA/Multispecialty Chest Pain Guideline's recent elevation of coronary computed tomography angiography (CCTA) to a Class I (level of evidence A) recommendation as an index diagnostic test for acute or stable chest pain, several studies support the utility of CCTA and guided future directions. This review summarizes recent studies that highlight the role of non-invasive imaging in enhancing ASCVD risk assessment across different populations.
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Affiliation(s)
- Pooja V Selvam
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Gowtham R Grandhi
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thorsten M Leucker
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Armin Arbab-Zadeh
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seamus P Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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7
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Lacaita PG, Barbieri F, Plank F, Beyer C, Friedrich G, Widmann G, Feuchtner G. Prediction of high coronary artery calcium (CAC) scores from aortic arch calcification: An efficient tool for selection of non-optimal candidates for coronary CTA? Eur J Radiol 2024; 170:111216. [PMID: 38029704 DOI: 10.1016/j.ejrad.2023.111216] [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: 09/18/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Overutilization of healthcare resources is causing a high socioeconomic burden. Patients with high coronary artery calcium (CAC) scores > 1000AU are not optimal candidates for coronary CTA and better suited for other diagnostic strategies. Therefore, our objective was to evaluate whether a 4-scale aortic arch calcification severity (AoArCa) score from CT and X-Ray predicts high-CAC scores. METHODS Patients referred to coronary/aortic CT-Angiography were enrolled. The severity of aortic arch calcification (AoArCa) was scored as grade: 0 = absent, 1 = minimal (<25 % of circumference), 2 = mild (25-50 %), 3 = moderate (50-75 %) and 4 = severe (75-100 %) on both thoracic CT and X-ray. RESULTS In 130 patients, the absence of AoArCa by CT was highly accurate to rule out CAC > 1000AU (sens. 100 %). No or minimal AoArCa had a high NPV of 95.6 % to rule out CAC > 1000 and grade 0,1 + 2 a NPV of 86.96 %. The AUC of AoArCa by CT for predicting high CAC > 1000 was c = 0.84 (p < 0.001; 95 %CI: 0.771--0.91). For moderate-to-severe AoArCa, accuracy was c = 0.792 (p < 0.001). The intermodality agreement between CT and X-Ray based AoArCa Scores was good (r = 0.824, p < 0.001); ICC = 0.902. For X-ray, AUC was c = 0.715 to predict CAC > 1000 (p < 0.001). In regression models, only moderate-or-severe AoArCa, but not the other CVRF predicted CAC > 1000 (p < 0.001), and there was an association of the number of CVRF. CONCLUSIONS Patients with moderate-to-severe aortic arch calcification have a high probability of CAC > 1000AU, but not those with no, minimal and mild. The absence of AoArCa rules out CAC > 1000AU. AoArCa severity may serve as valuable tool for selecting the diagnostic strategy.
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Affiliation(s)
| | - Fabian Barbieri
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Fabian Plank
- Department of Internal Medicine, Tyrol Clinicum Hall, Austria
| | - Christoph Beyer
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - Guy Friedrich
- Department of Internal Medicine, Cardiology, Medical University Innsbruck, Austria
| | - Gerlig Widmann
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - Gudrun Feuchtner
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria.
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8
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Razavi AC, Kim C, van Assen M, De Cecco CN, Berman DS, Budoff MJ, Quyyumi AA, Vaccarino V, Miedema MD, Nasir K, Rozanski A, Fernandez C, Rumberger JA, Shaw LJ, Mortensen MB, Wong ND, Blumenthal RS, Sperling LS, Whelton SP, Blaha MJ, Dzaye O. Thoracic Aortic Calcium Density and Area in Long-Term Atherosclerotic Cardiovascular Disease Risk Among Men Versus Women. Circ Cardiovasc Imaging 2023; 16:e015690. [PMID: 38054290 PMCID: PMC10841590 DOI: 10.1161/circimaging.123.015690] [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: 05/17/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND The development of thoracic aortic calcium (TAC) temporally precedes coronary artery calcium more often in women versus men. Whether TAC density and area confer sex-specific differences in atherosclerotic cardiovascular disease (ASCVD) risk is unknown. METHODS We studied 5317 primary prevention patients who underwent coronary artery calcium scoring on noncontrast cardiac gated computed tomography with TAC >0. The Agatston TAC score (Agatston units), density (Hounsfield units), and area (mm2) were compared between men and women. Cox proportional hazards regression calculated adjusted hazard ratios for TAC density-area groups with ASCVD mortality, adjusting for traditional risk factors, coronary artery calcium, and TAC. Multinomial logistic regression calculated adjusted odds ratios for the association between traditional risk factors and TAC density-area groups. RESULTS The mean age was 60.7 years, 38% were women, and 163 ASCVD deaths occurred over a median of 11.7-year follow-up. Women had higher median TAC scores (97 versus 84 Agatston units; P=0.004), density (223 versus 210 Hounsfield units; P<0.001), and area (37 versus 32 mm2; P=0.006) compared with men. There was a stepwise higher incidence of ASCVD deaths across increasing TAC density-area groups in men though women with low TAC density relative to TAC area (3.6 per 1000 person-years) had survival probability commensurate with the high-density-high-area group (4.8 per 1000 person-years). Compared with low TAC density-area, low TAC density/high TAC area conferred a 3.75-fold higher risk of ASCVD mortality in women (adjusted hazard ratio, 3.75 [95% CI, 1.13-12.44]) but not in men (adjusted hazard ratio, 1.16 [95% CI, 0.48-2.84]). Risk factors most strongly associated with low TAC density/high TAC area differed in women (diabetes: adjusted odds ratio, 2.61 [95% CI, 1.34-5.07]) versus men (hypertension: adjusted odds ratio, 1.45 [95% CI, 1.11-1.90]). CONCLUSIONS TAC density-area phenotypes do not consistently associate with ASCVD mortality though low TAC density relative to area may be a marker of increased ASCVD risk in women.
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Affiliation(s)
- Alexander C. Razavi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Cherry Kim
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
- Department of Radiology, Korea University College of Medicine, Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, South Korea
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Carlo N. De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Daniel S. Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Matthew J. Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael D. Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, United States
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, United States
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke’s Hospital, New York, NY, United States
| | - Camilo Fernandez
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | | | - Leslee J. Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | | | - Nathan D. Wong
- Heart Disease Prevention Program, University of California Irvine, Irvine, CA, United States
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Laurence S. Sperling
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Seamus P. Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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9
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Fyyaz S, Papadakis M. Fit to a fault? The paradox of coronary artery disease in veteran athletes. Eur Heart J 2023:7175012. [PMID: 37210080 DOI: 10.1093/eurheartj/ehad271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Affiliation(s)
- Saad Fyyaz
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, Cranmer Terrace, London SW17 0RE, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, Cranmer Terrace, London SW17 0RE, UK
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10
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Fink N, Zsarnoczay E, Schoepf UJ, O'Doherty J, Griffith JP, Pinos D, Tesche C, Ricke J, Willemink MJ, Varga-Szemes A, Emrich T. Radiation Dose Reduction for Coronary Artery Calcium Scoring Using a Virtual Noniodine Algorithm on Photon-Counting Detector Computed-Tomography Phantom Data. Diagnostics (Basel) 2023; 13:diagnostics13091540. [PMID: 37174932 PMCID: PMC10177425 DOI: 10.3390/diagnostics13091540] [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: 03/14/2023] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Background: On the basis of the hypothesis that virtual noniodine (VNI)-based coronary artery calcium scoring (CACS) is feasible at reduced radiation doses, this study assesses the impact of radiation dose reduction on the accuracy of this VNI algorithm on a photon-counting detector (PCD)-CT. Methods: In a systematic in vitro setting, a phantom for CACS simulating three chest sizes was scanned on a clinical PCD-CT. The standard radiation dose was chosen at volumetric CT dose indices (CTDIVol) of 1.5, 3.3, 7.0 mGy for small, medium-sized, and large phantoms, and was gradually reduced by adjusting the tube current resulting in 100, 75, 50, and 25%, respectively. VNI images were reconstructed at 55 keV, quantum iterative reconstruction (QIR)1, and at 60 keV/QIR4, and evaluated regarding image quality (image noise (IN), contrast-to-noise ratio (CNR)), and CACS. All VNI results were compared to true noncontrast (TNC)-based CACS at 70 keV and standard radiation dose (reference). Results: INTNC was significantly higher than INVNI, and INVNI at 55 keV/QIR1 higher than at 60 keV/QIR4 (100% dose: 16.7 ± 1.9 vs. 12.8 ± 1.7 vs. 7.7 ± 0.9; p < 0.001 for every radiation dose). CNRTNC was higher than CNRVNI, but it was better to use 60 keV/QIR4 (p < 0.001). CACSVNI showed strong correlation and agreement at every radiation dose (p < 0.001, r > 0.9, intraclass correlation coefficient > 0.9). The coefficients of the variation in root-mean squared error were less than 10% and thus clinically nonrelevant for the CACSVNI of every radiation dose. Conclusion: This phantom study suggests that CACSVNI is feasible on PCD-CT, even at reduced radiation dose while maintaining image quality and CACS accuracy.
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Affiliation(s)
- Nicola Fink
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Emese Zsarnoczay
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
- Medical Imaging Center, Semmelweis University, Korányi Sándor utca 2, 1083 Budapest, Hungary
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Jim O'Doherty
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
- Siemens Medical Solutions, 40 Liberty Boulevard, Malvern, PA 19355, USA
| | - Joseph P Griffith
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Daniel Pinos
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Tilman Emrich
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
- Department of Diagnostic and Interventional Radiology, University Medical Center of Johannes-Gutenberg-University, Langenbeckstr. 1, 55131 Mainz, Germany
- German Centre for Cardiovascular Research, Partner Site Rhine-Main, 55131 Mainz, Germany
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11
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Nasir K, Razavi AC, Dzaye O. Coronary Artery Calcium Density in Clinical Risk Prediction: Ready for Primetime? Circ Cardiovasc Imaging 2023; 16:e015150. [PMID: 36802446 DOI: 10.1161/circimaging.123.015150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX (K.N.)
| | - Alexander C Razavi
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA (A.C.R.).,Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (A.C.R., O.D.)
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (A.C.R., O.D.)
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12
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Villines TC, Javaid A. CAC Density and Cardiovascular Risk: Is Less Really More? JACC. CARDIOVASCULAR IMAGING 2022; 15:1941-1943. [PMID: 36357135 DOI: 10.1016/j.jcmg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Todd C Villines
- Division of Cardiology, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA.
| | - Aamir Javaid
- Division of Cardiology, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
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