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Bosco G, Mszar R, Piro S, Sabouret P, Gallo A. Cardiovascular Risk Estimation and Stratification Among Individuals with Hypercholesterolemia. Curr Atheroscler Rep 2024; 26:537-548. [PMID: 38965183 DOI: 10.1007/s11883-024-01225-3] [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: 06/17/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE OF THE REVIEW This review aims to assess the variability in considering hypercholesterolemia for cardiovascular risk stratification in the general population. Recent literature on the integration of hypercholesterolemia into clinical risk scores and its interaction with other risk factors will be explored. RECENT FINDINGS The impact of hypercholesterolemia on risk estimation varies among different cardiovascular risk calculators. Elevated lipid levels during early life stages contribute to atherosclerotic plaque development, influencing disease severity despite later treatment initiation. The interplay between low-density lipoprotein cholesterol (LDLc), inflammatory markers and non-LDL lipid parameters enhances cardiovascular risk stratification. Studies have also examined the role of coronary artery calcium (CAC) score as a negative risk marker in populations with severe hypercholesterolemia. Furthermore, polygenic risk scores (PRS) may aid in diagnosing non-monogenic hypercholesterolemia, refining cardiovascular risk stratification and guiding lipid-lowering therapy strategies. Understanding the heterogeneity in risk estimation and the role of emerging biomarkers and imaging techniques is crucial for optimizing cardiovascular risk prediction and guiding personalized treatment strategies in individuals with hypercholesterolemia.
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Affiliation(s)
- Giosiana Bosco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Sorbonne Université, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpètriêre, 47/83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pierre Sabouret
- Heart Institute, Cardiology Department, Sorbonne University, 47-83 Boulevard de L'Hôpital, 75013, Paris, FR, France
- National College of French Cardiologists, 13 Rue Niepce, 75014, Paris, FR, France
| | - Antonio Gallo
- Sorbonne Université, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpètriêre, 47/83 Boulevard de L'Hôpital, 75013, Paris, France.
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2
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Ferreira AM. Replacing SCORE with SCORE2 in Portuguese primary care: News from the frontline of cardiovascular prevention. Rev Port Cardiol 2024; 43:457-458. [PMID: 38701968 DOI: 10.1016/j.repc.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/06/2024] Open
Affiliation(s)
- António Miguel Ferreira
- Cardiology Department, Hospital Santa Cruz - Unidade Local de Saúde de Lisboa Ocidental, Carnaxide, Portugal; Advanced Cardiovascular Imaging Unit, Hospital da Luz, Lisboa, Portugal.
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3
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Kampaktsis PN, Hennecken C, Shetty M, McLaughlin L, Rampidis G, Samaras A, Avgerinos D, Spilias N, Kuno T, Briasoulis A, Einstein AJ. Current and Emerging Approaches for Primary Prevention of Coronary Artery Disease Using Cardiac Computed Tomography. Curr Cardiol Rep 2024:10.1007/s11886-024-02104-8. [PMID: 39066990 DOI: 10.1007/s11886-024-02104-8] [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] [Accepted: 07/12/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE OF REVIEW To summarize the current use of cardiac computed tomography (CT) technologies as well as their pertinent evidence in regards to prevention of coronary artery disease (CAD). RECENT FINDINGS Cardiac CTA has now become a main non-invasive method for the evaluation of symptomatic CAD. In addition to coronary calcium score, other CT technologies such as atherosclerotic plaque analysis, fractional flow reserve estimation by CT, pericoronary fat attenuation, and endothelial wall shear stress have emerged. Whether the use of CT modalities can enhance risk prediction and prevention in CAD has not been fully answered. We discuss the evidence for coronary artery calcium scoring and coronary CT angiography in primary prevention and the current barriers to their use. We attempt to delineate what can be done to expand use and what studies are needed to broaden adoption in the future. We also examine the potential roles of emerging CT technologies. Finally, we describe potential clinical approaches to prevention that would incorporate cardiac CT technologies.
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Affiliation(s)
- Polydoros N Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 177 Fort Washington Ave, MHB2, New York, NY, 10032, USA.
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA.
- Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece.
| | - Carolyn Hennecken
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 177 Fort Washington Ave, MHB2, New York, NY, 10032, USA
| | - Mrinali Shetty
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 177 Fort Washington Ave, MHB2, New York, NY, 10032, USA
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Laura McLaughlin
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 177 Fort Washington Ave, MHB2, New York, NY, 10032, USA
| | - Georgios Rampidis
- Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece
| | - Athanasios Samaras
- Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece
| | | | - Nikolaos Spilias
- Cardiovascular Division, University of Miami Health System, Miami, FL, USA
| | | | | | - Andrew J Einstein
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 177 Fort Washington Ave, MHB2, New York, NY, 10032, USA
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA
- Department of Radiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA
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4
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Ledda RE, Funk GC, Sverzellati N. The pros and cons of lung cancer screening. Eur Radiol 2024:10.1007/s00330-024-10939-6. [PMID: 39014085 DOI: 10.1007/s00330-024-10939-6] [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: 04/08/2024] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024]
Abstract
Several trials have shown that low-dose computed tomography-based lung cancer screening (LCS) allows a substantial reduction in lung cancer-related mortality, carrying the potential for other clinical benefits. There are, however, some uncertainties to be clarified and several aspects to be implemented to optimize advantages and minimize the potential harms of LCS. This review summarizes current evidence on LCS, discussing some of the well-established and potential benefits, including lung cancer (LC)-related mortality reduction and opportunity for smoking cessation interventions, as well as the disadvantages of LCS, such as overdiagnosis and overtreatment. CLINICAL RELEVANCE STATEMENT: Different perspectives are provided on LCS based on the updated literature. KEY POINTS: Lung cancer is a leading cancer-related cause of death and screening should reduce associated mortality. This review summarizes current evidence related to LCS. Several aspects need to be implemented to optimize benefits and minimize potential drawbacks of LCS.
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Affiliation(s)
| | - Georg-Christian Funk
- Department of Medicine II with Pneumology, Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Nicola Sverzellati
- Department of Medicine and Surgery (DiMeC), University of Parma, Parma, Italy
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5
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Thiele M, Kamath PS, Graupera I, Castells A, de Koning HJ, Serra-Burriel M, Lammert F, Ginès P. Screening for liver fibrosis: lessons from colorectal and lung cancer screening. Nat Rev Gastroenterol Hepatol 2024; 21:517-527. [PMID: 38480849 DOI: 10.1038/s41575-024-00907-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/18/2024]
Abstract
Many countries have incorporated population screening programmes for cancer, such as colorectal and lung cancer, into their health-care systems. Cirrhosis is more prevalent than colorectal cancer and has a comparable age-standardized mortality rate to lung cancer. Despite this fact, there are no screening programmes in place for early detection of liver fibrosis, the precursor of cirrhosis. In this Perspective, we use insights from colorectal and lung cancer screening to explore the benefits, challenges, implementation strategies and pathways for future liver fibrosis screening initiatives. Several non-invasive methods and referral pathways for early identification of liver fibrosis exist, but in addition to accurate detection, screening programmes must also be cost-effective and demonstrate benefit through a reduction in liver-related mortality. Randomized controlled trials are needed to confirm this. Future randomized screening trials should evaluate not only the screening tests, but also interventions used to halt disease progression in individuals identified through screening.
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Affiliation(s)
- Maja Thiele
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Isabel Graupera
- Liver Unit Hospital Clínic, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Catalonia, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Antoni Castells
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Catalonia, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
- Department of Gastroenterology, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Miquel Serra-Burriel
- Epidemiology, Statistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
- Hannover Medical School (MHH), Hannover, Germany
| | - Pere Ginès
- Liver Unit Hospital Clínic, Barcelona, Catalonia, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Catalonia, Spain.
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.
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McDermott M, Meah MN, Khaing P, Wang KL, Ramsay J, Scott G, Rickman H, Burt T, McGowan I, Fairbairn T, Bucukoglu M, Bull R, Timmis A, van Beek EJR, Roditi G, Adamson PD, Lewis S, Norrie J, McKinstry B, Guthrie B, Ritchie L, Mills NL, Dweck MR, Williams MC, Newby DE. Rationale and Design of SCOT-HEART 2 Trial: CT Angiography for the Prevention of Myocardial Infarction. JACC Cardiovasc Imaging 2024:S1936-878X(24)00228-6. [PMID: 39001735 DOI: 10.1016/j.jcmg.2024.05.016] [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: 02/06/2024] [Revised: 05/01/2024] [Accepted: 05/17/2024] [Indexed: 07/15/2024]
Abstract
Coronary artery disease continues to be the leading cause of death globally. Identifying patients who are at risk of coronary artery disease remains a public health priority. At present, the focus of cardiovascular disease prevention relies heavily on probabilistic risk scoring despite no randomized controlled trials demonstrating their efficacy. The concept of using imaging to guide preventative therapy is not new, but has previously focused on indirect measures such as carotid intima-media thickening or coronary artery calcification. In recent trials, patients found to have coronary artery disease on computed tomography (CT) coronary angiography were more likely to be started on preventative therapy and had lower rates of cardiac events. This led to the design of the SCOT-HEART 2 (Scottish Computed Tomography of the Heart 2) trial, which aims to determine whether screening with the use of CT coronary angiography is more clinically effective than cardiovascular risk scoring to guide the use of primary preventative therapies and reduce the risk of myocardial infarction.
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Affiliation(s)
- Michael McDermott
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Mohammed N Meah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Phyo Khaing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kang-Ling Wang
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Gillian Scott
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Hannah Rickman
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | | | - Timothy Fairbairn
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Marise Bucukoglu
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Russell Bull
- University Hospital Dorset, Dorset, United Kingdom
| | - Adam Timmis
- The William Harvey Research Institute, Queen Mary University, London, United Kingdom
| | - Edwin J R van Beek
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Giles Roditi
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom; School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Steff Lewis
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Brian McKinstry
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Bruce Guthrie
- Advanced Care Research Centre, University of Edinburgh, Edinburgh, United Kingdom
| | - Lewis Ritchie
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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7
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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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8
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Bischoff LM, Luetkens JA. [Screening, risk stratification and CT imaging for assessment of coronary artery disease]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:488-494. [PMID: 38514506 DOI: 10.1007/s00117-024-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Early treatment of cardiovascular risk factors and characterization of coronary plaques is essential to collect prognostic information about coronary artery disease (CAD) and prevent cardiovascular events. OBJECTIVES Discussion of the most important risk factors of CAD, basic diagnostic of CAD, prevention, and prognostic factors of CAD with focus on cardiac computed tomography (CT). MATERIALS AND METHODS Prevalence and prognostic impact of CAD risk factors; description of specific assessment of risk profiles; estimation of pretest probability; conventional prevention of CAD; prognostic assessment of CAD using the Calcium Scoring and coronary CT angiography. RESULTS Assessment of risk profiles and estimation of pretest probability for obstructive coronary stenosis necessitates a thorough evaluation of medical history and laboratory values. The composition and extent of calcified and noncalcified plaques in CT exams based on the criteria of the Coronary Artery Disease-Reporting and Data System give important prognostic information about the risk of cardiovascular events, which increases with high plaque burden and vice versa. Initial imaging with CT for evaluation of CAD leads to a reduction of invasive coronary angiographies and catheter-associated complications. CONCLUSIONS Besides early detection of cardiovascular risk factors, the additional assessment of plaque burden and significant stenosis in CT gives further prognostic information to facilitate effective therapies to prevent cardiovascular events and in the case of low plaque burden avoid invasive coronary angiography. However, systmatic screening using Calcium Scoring is not established yet due to insufficient data, although it could potentially be used for an early risk stratification in patients with multiple risk factors.
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Affiliation(s)
- Leon M Bischoff
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
- Quantitative Imaging Lab Bonn (QILaB), Universitätsklinikum Bonn, Bonn, Deutschland.
| | - Julian A Luetkens
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
- Quantitative Imaging Lab Bonn (QILaB), Universitätsklinikum Bonn, Bonn, Deutschland
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9
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Nielsen RV, Fuster V, Bundgaard H, Fuster JJ, Johri AM, Kofoed KF, Douglas PS, Diederichsen A, Shapiro MD, Nicholls SJ, Nordestgaard BG, Lindholt JS, MacRae C, Yuan C, Newby DE, Urbina EM, Bergström G, Ridderstråle M, Budoff MJ, Bøttcher M, Raitakari OT, Hansen TH, Näslund U, Sillesen H, Eldrup N, Ibanez B. Personalized Intervention Based on Early Detection of Atherosclerosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:2112-2127. [PMID: 38777513 DOI: 10.1016/j.jacc.2024.02.053] [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: 01/04/2024] [Revised: 02/12/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide and challenges the capacity of health care systems globally. Atherosclerosis is the underlying pathophysiological entity in two-thirds of patients with CVD. When considering that atherosclerosis develops over decades, there is potentially great opportunity for prevention of associated events such as myocardial infarction and stroke. Subclinical atherosclerosis has been identified in its early stages in young individuals; however, there is no consensus on how to prevent progression to symptomatic disease. Given the growing burden of CVD, a paradigm shift is required-moving from late management of atherosclerotic CVD to earlier detection during the subclinical phase with the goal of potential cure or prevention of events. Studies must focus on how precision medicine using imaging and circulating biomarkers may identify atherosclerosis earlier and determine whether such a paradigm shift would lead to overall cost savings for global health.
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Affiliation(s)
- Rikke V Nielsen
- Department of Medical Science, Novo Nordisk Foundation, Hellerup, Denmark; Department of Cardiothoracic Anesthesiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark.
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Mount Sinai Fuster Heart Hospital, New York, New York, USA
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jose J Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Amer M Johri
- Department of Medicine Queen's University, Kingston, Ontario, Canada
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Pamela S Douglas
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Michael D Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Børge G Nordestgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry and The Copenhagen General Population Study, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark. https://twitter.com/BNordestgaard
| | - Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Elite Research Centre of Individualised Treatment of Arterial Disease (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Calum MacRae
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
| | - Chun Yuan
- Department of Radiology and Imaging Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, Ohio, USA
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, California, USA
| | - Morten Bøttcher
- University Clinic for Cardiovascular Research, Department of Cardiology, Aarhus University/Gødstrup Hospital, Aarhus, Denmark
| | - Olli T Raitakari
- Centre for Population Health Research, Research Centre of Applied and Preventive Cardiovascular Medicine, InFLAMES Research Flagship, University of Turku, Turku, Finland; Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Thomas H Hansen
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Ulf Näslund
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Henrik Sillesen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
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10
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Nurmohamed NS, van Rosendael AR, Danad I, Ngo-Metzger Q, Taub PR, Ray KK, Figtree G, Bonaca MP, Hsia J, Rodriguez F, Sandhu AT, Nieman K, Earls JP, Hoffmann U, Bax JJ, Min JK, Maron DJ, Bhatt DL. Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography. Eur Heart J 2024; 45:1783-1800. [PMID: 38606889 PMCID: PMC11129796 DOI: 10.1093/eurheartj/ehae190] [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: 10/07/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.
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Affiliation(s)
- Nick S Nurmohamed
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit
Amsterdam, Amsterdam, The
Netherlands
- Department of Vascular Medicine, Amsterdam UMC, University of
Amsterdam, Amsterdam, The
Netherlands
- Division of Cardiology, The George Washington University School of
Medicine, Washington, DC, United States
| | | | - Ibrahim Danad
- Department of Cardiology, University Medical Center Utrecht,
Utrecht, The Netherlands
- Department of Cardiology, Radboud University Medical Center,
Nijmegen, The Netherlands
| | - Quyen Ngo-Metzger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson
School of Medicine, Pasadena, CA, United States
| | - Pam R Taub
- Section of Cardiology, Department of Medicine, University of
California, San Diego, CA, United States
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College
London, London, United
Kingdom
| | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney,
Australia, St Leonards, Australia
| | - Marc P Bonaca
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, United States
| | - Judith Hsia
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, United States
| | - Fatima Rodriguez
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Koen Nieman
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - James P Earls
- Cleerly, Inc., Denver, CO, United States
- Department of Radiology, The George Washington University School of
Medicine, Washington, DC, United States
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center,
Leiden, The Netherlands
| | | | - David J Maron
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount
Sinai, 1 Gustave Levy Place, Box 1030, New York, NY
10029, United States
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11
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Lee E, Amadi C, Williams MC, Agarwal PP. Coronary Artery Disease: Role of Computed Tomography and Recent Advances. Radiol Clin North Am 2024; 62:385-398. [PMID: 38553176 DOI: 10.1016/j.rcl.2023.12.017] [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: 04/02/2024]
Abstract
In this review, the authors summarize the role of coronary computed tomography angiography and coronary artery calcium scoring in different clinical presentations of chest pain and preventative care and discuss future directions and new technologies such as pericoronary fat inflammation and the growing footprint of artificial intelligence in cardiovascular medicine.
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Affiliation(s)
- Elizabeth Lee
- Department of Radiology, Michigan Medicine, 1500 East Medical Center Drive, TC B1-148, Ann Arbor, MI 48109-5030, USA.
| | - Chiemezie Amadi
- Department of Radiology, Michigan Medicine, 1500 Medical Center Drive, Room 5481, Ann Arbor, MI 48109-5868, USA
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, The Queen's Medical Research Institute, Edinburg BioQuarter, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Prachi P Agarwal
- Department of Radiology, Division of Cardiothoracic Radiology, Michigan Medicine, 1500 East Medical Center Drive SPC 5868, Ann Arbor, MI 48109, USA
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12
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Groen RA, Jukema JW, van Dijkman PRM, Bax JJ, Lamb HJ, Antoni ML, de Graaf MA. The Clear Value of Coronary Artery Calcification Evaluation on Non-Gated Chest Computed Tomography for Cardiac Risk Stratification. Cardiol Ther 2024; 13:69-87. [PMID: 38349434 PMCID: PMC10899125 DOI: 10.1007/s40119-024-00354-9] [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: 11/21/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024] Open
Abstract
To enhance risk stratification in patients suspected of coronary artery disease, the assessment of coronary artery calcium (CAC) could be incorporated, especially when CAC can be readily assessed on previously performed non-gated chest computed tomography (CT). Guidelines recommend reporting on patients' extent of CAC on these non-cardiac directed exams and various studies have shown the diagnostic and prognostic value. However, this method is still little applied, and no current consensus exists in clinical practice. This review aims to point out the clinical utility of different kinds of CAC assessment on non-gated CTs. It demonstrates that these scans indeed represent a merely untapped and underestimated resource for risk stratification in patients with stable chest pain or an increased risk of cardiovascular events. To our knowledge, this is the first review to describe the clinical utility of different kinds of visual CAC evaluation on non-gated unenhanced chest CT. Various methods of CAC assessment on non-gated CT are discussed and compared in terms of diagnostic and prognostic value. Furthermore, the application of these non-gated CT scans in the general practice of cardiology is discussed. The clinical utility of coronary calcium assessed on non-gated chest CT, according to the current literature, is evident. This resource of information for cardiac risk stratification needs no specific requirements for scan protocol, and is radiation-free and cost-free. However, some gaps in research remain. In conclusion, the integration of CAC on non-gated chest CT in general cardiology should be promoted and research on this method should be encouraged.
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Affiliation(s)
- Roos A Groen
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.
- Netherlands Heart Institute, Utrecht, The Netherlands.
| | - Paul R M van Dijkman
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - M Louisa Antoni
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Michiel A de Graaf
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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13
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Lakshmanan S, Gimelli A. Cardiovascular Imaging in Clinical Trial Design: A Vision for Sustainability. JACC Case Rep 2023; 24:102048. [PMID: 37869224 PMCID: PMC10589438 DOI: 10.1016/j.jaccas.2023.102048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
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14
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Balbi M, Sabia F, Ledda RE, Milanese G, Ruggirello M, Silva M, Marchianò AV, Sverzellati N, Pastorino U. Automated Coronary Artery Calcium and Quantitative Emphysema in Lung Cancer Screening: Association With Mortality, Lung Cancer Incidence, and Airflow Obstruction. J Thorac Imaging 2023; 38:W52-W63. [PMID: 36656144 PMCID: PMC10287055 DOI: 10.1097/rti.0000000000000698] [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] [Indexed: 01/20/2023]
Abstract
PURPOSE To assess automated coronary artery calcium (CAC) and quantitative emphysema (percentage of low attenuation areas [%LAA]) for predicting mortality and lung cancer (LC) incidence in LC screening. To explore correlations between %LAA, CAC, and forced expiratory value in 1 second (FEV 1 ) and the discriminative ability of %LAA for airflow obstruction. MATERIALS AND METHODS Baseline low-dose computed tomography scans of the BioMILD trial were analyzed using an artificial intelligence software. Univariate and multivariate analyses were performed to estimate the predictive value of %LAA and CAC. Harrell C -statistic and time-dependent area under the curve (AUC) were reported for 3 nested models (Model survey : age, sex, pack-years; Model survey-LDCT : Model survey plus %LAA plus CAC; Model final : Model survey-LDCT plus selected confounders). The correlations between %LAA, CAC, and FEV 1 and the discriminative ability of %LAA for airflow obstruction were tested using the Pearson correlation coefficient and AUC-receiver operating characteristic curve, respectively. RESULTS A total of 4098 volunteers were enrolled. %LAA and CAC independently predicted 6-year all-cause (Model final hazard ratio [HR], 1.14 per %LAA interquartile range [IQR] increase [95% CI, 1.05-1.23], 2.13 for CAC ≥400 [95% CI, 1.36-3.28]), noncancer (Model final HR, 1.25 per %LAA IQR increase [95% CI, 1.11-1.37], 3.22 for CAC ≥400 [95%CI, 1.62-6.39]), and cardiovascular (Model final HR, 1.25 per %LAA IQR increase [95% CI, 1.00-1.46], 4.66 for CAC ≥400, [95% CI, 1.80-12.58]) mortality, with an increase in concordance probability in Model survey-LDCT compared with Model survey ( P <0.05). No significant association with LC incidence was found after adjustments. Both biomarkers negatively correlated with FEV 1 ( P <0.01). %LAA identified airflow obstruction with a moderate discriminative ability (AUC, 0.738). CONCLUSIONS Automated CAC and %LAA added prognostic information to age, sex, and pack-years for predicting mortality but not LC incidence in an LC screening setting. Both biomarkers negatively correlated with FEV 1 , with %LAA enabling the identification of airflow obstruction with moderate discriminative ability.
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Affiliation(s)
- Maurizio Balbi
- Departments of Thoracic Surgery
- Department of Medicine and Surgery, Section of Radiology, University of Parma, Parma, Italy
| | | | - Roberta E. Ledda
- Departments of Thoracic Surgery
- Department of Medicine and Surgery, Section of Radiology, University of Parma, Parma, Italy
| | - Gianluca Milanese
- Department of Medicine and Surgery, Section of Radiology, University of Parma, Parma, Italy
| | | | - Mario Silva
- Department of Medicine and Surgery, Section of Radiology, University of Parma, Parma, Italy
| | | | - Nicola Sverzellati
- Department of Medicine and Surgery, Section of Radiology, University of Parma, Parma, Italy
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15
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Dobrolinska MM, van der Werf NR, van der Bie J, de Groen J, Dijkshoorn M, Booij R, Budde RPJ, Greuter MJW, van Straten M. Radiation dose optimization for photon-counting CT coronary artery calcium scoring for different patient sizes: a dynamic phantom study. Eur Radiol 2023; 33:4668-4675. [PMID: 36729174 PMCID: PMC10290002 DOI: 10.1007/s00330-023-09434-1] [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: 10/19/2022] [Revised: 10/19/2022] [Accepted: 01/07/2023] [Indexed: 02/03/2023]
Abstract
PURPOSE To systematically assess the radiation dose reduction potential of coronary artery calcium (CAC) assessments with photon-counting computed tomography (PCCT) by changing the tube potential for different patient sizes with a dynamic phantom. METHODS A hollow artery, containing three calcifications of different densities, was translated at velocities corresponding to 0, < 60, 60-75, and > 75 beats per minute within an anthropomorphic phantom. Extension rings were used to simulate average- and large -sized patients. PCCT scans were made with the reference clinical protocol (tube potential of 120 kilovolt (kV)), and with 70, 90, Sn100, Sn140, and 140 kV at identical image quality levels. All acquisitions were reconstructed at a virtual monoenergetic energy level of 70 keV. For each calcification, Agatston scores and contrast-to-noise ratios (CNR) were determined, and compared to the reference with Wilcoxon signed-rank tests, with p < 0.05 indicating significant differences. RESULTS A decrease in radiation dose (22%) was achieved at Sn100 kV for the average-sized phantom. For the large phantom, Sn100 and Sn140 kV resulted in a decrease in radiation doses of 19% and 3%, respectively. Irrespective of CAC density, Sn100 and 140 kVp did not result in significantly different CNR. Only at Sn100 kV were there no significant differences in Agatston scores for all CAC densities, heart rates, and phantom sizes. CONCLUSION PCCT at tube voltage of 100 kV with added tin filtration and reconstructed at 70 keV enables a ≥ 19% dose reduction compared to 120 kV, independent of phantom size, CAC density, and heart rate. KEY POINTS • Photon-counting CT allows for reduced radiation dose acquisitions (up to 19%) for coronary calcium assessment by reducing tube voltage while reconstructing at a normal monoE level of 70 keV. • Tube voltage reduction is possible for medium and large patient sizes, without affecting the Agatston score outcome.
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Affiliation(s)
- Magdalena M Dobrolinska
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesiain , Katowice, Katowice, Poland
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Niels R van der Werf
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Judith van der Bie
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joël de Groen
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marcel Dijkshoorn
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ronald Booij
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marcel J W Greuter
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | - Marcel van Straten
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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16
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Soares C, Kwok M, Boucher KA, Haji M, Echouffo-Tcheugui JB, Longenecker CT, Bloomfield GS, Ross D, Jutkowtiz E, Sullivan JL, Rudolph JL, Wu WC, Erqou S. Performance of Cardiovascular Risk Prediction Models Among People Living With HIV: A Systematic Review and Meta-analysis. JAMA Cardiol 2023; 8:139-149. [PMID: 36576812 PMCID: PMC9857084 DOI: 10.1001/jamacardio.2022.4873] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/20/2022] [Indexed: 12/29/2022]
Abstract
Importance Extant data on the performance of cardiovascular disease (CVD) risk score models in people living with HIV have not been synthesized. Objective To synthesize available data on the performance of the various CVD risk scores in people living with HIV. Data Sources PubMed and Embase were searched from inception through January 31, 2021. Study Selection Selected studies (1) were chosen based on cohort design, (2) included adults with a diagnosis of HIV, (3) assessed CVD outcomes, and (4) had available data on a minimum of 1 CVD risk score. Data Extraction and Synthesis Relevant data related to study characteristics, CVD outcome, and risk prediction models were extracted in duplicate. Measures of calibration and discrimination are presented in tables and qualitatively summarized. Additionally, where possible, estimates of discrimination and calibration measures were combined and stratified by type of risk model. Main Outcomes and Measures Measures of calibration and discrimination. Results Nine unique observational studies involving 75 304 people (weighted average age, 42 years; 59 490 male individuals [79%]) living with HIV were included. In the studies reporting these data, 86% were receiving antiretroviral therapy and had a weighted average CD4+ count of 449 cells/μL. Included in the study were current smokers (50%), patients with diabetes (5%), and patients with hypertension (25%). Ten risk prediction scores (6 in the general population and 4 in the HIV-specific population) were analyzed. Most risk scores had a moderate performance in discrimination (C statistic: 0.7-0.8), without a significant difference in performance between the risk scores of the general and HIV-specific populations. One of the HIV-specific risk models (Data Collection on Adverse Effects of Anti-HIV Drugs Cohort 2016) and 2 of the general population risk models (Framingham Risk Score [FRS] and Pooled Cohort Equation [PCE] 10 year) had the highest performance in discrimination. In general, models tended to underpredict CVD risk, except for FRS and PCE 10-year scores, which were better calibrated. There was substantial heterogeneity across the studies, with only a few studies contributing data for each risk score. Conclusions and Relevance Results of this systematic review and meta-analysis suggest that general population and HIV-specific CVD risk models had comparable, moderate discrimination ability in people living with HIV, with a general tendency to underpredict risk. These results reinforce the current recommendations provided by the American College of Cardiology/American Heart Association guidelines to consider HIV as a risk-enhancing factor when estimating CVD risk.
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Affiliation(s)
- Cullen Soares
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Michael Kwok
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Kent-Andrew Boucher
- 27th Special Operations Medical Group, US Air Force, US Department of Defense, Cannon Air Force Base, Clovis, New Mexico
| | - Mohammed Haji
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Justin B. Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Gerald S. Bloomfield
- Department of Medicine, Duke Clinical Research Institute, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - David Ross
- Office of Specialty Care Service, US Department of Veterans Affairs, Washington, DC
- Infectious Disease Section, Washington DC Department of Veterans Affairs Medical Center, Washington, DC
| | - Eric Jutkowtiz
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
- Brown University School of Public Health, Brown University, Providence, Rhode Island
| | - Jennifer L. Sullivan
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island
- Brown University School of Public Health, Brown University, Providence, Rhode Island
| | - James L. Rudolph
- Department of Medicine, Brown University, Providence, Rhode Island
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
- Brown University School of Public Health, Brown University, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
| | - Wen-Chih Wu
- Department of Medicine, Brown University, Providence, Rhode Island
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island
- Brown University School of Public Health, Brown University, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
| | - Sebhat Erqou
- Department of Medicine, Brown University, Providence, Rhode Island
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
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17
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Erbel R, Lehmann N, Schramm S, Schmidt B, Hüsing A, Kowall B, Hermann DM, Gronewold J, Schmermund A, Möhlenkamp S, Moebus S, Grönemeyer D, Seibel R, Stang A, Jöckel KH. Diagnostic Cardiac CT for the Improvement of Cardiovascular Event Prediction. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:25-32. [PMID: 36518091 PMCID: PMC10043455 DOI: 10.3238/arztebl.m2022.0360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/20/2022] [Accepted: 10/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The aim of the long-term Heinz Nixdorf Recall Study (observation period 20 years) was to establish the extent to which computed tomography (CT) improves the predictability of cardiovascular events relative to determination of risk factors alone. METHODS In the period 2000-2003, study staff examined 4355 probands (53% of them female) aged 45-75 years with no signs of cardiovascular disease. The Atherosclerotic Cardiovascular Disease (ASCVD) score was calculated on the basis of demographic data and cardiovascular risk factors. Cardiac CT was carried out over the same period and coronary artery calcification (CAC) was graded according to the Agatston score. RESULTS The median duration of follow-up was 18.2 years for men and 17.8 years for women. Myocardial infarction or stroke occurred in 458 (11%) of the 4154 participants with complete data. Overall, estimation of risk using a combination of ASCVD score and CAC grade was superior to the ASCVD score alone-even after 10 and 20 years. Classification into established risk categories improved by 12.2% (95% confidence interval: [5.3%; 18.1%]). In the highest ASCVD risk category, we observed occurrence of a cardiovascular event over 20 years for 14% [5.0%; 23.1%] of probands with a CAC score = 0 but for 34.2% [27.5%; 41.4%] of those with a CAC score ≥ 400. In the lowest ASCVD risk category, an event occurred in 2.4% [1.4%; 3.7%] of probands with a CAC score = 0 and in 23.5% [2.3%; 35.8%] of those with a CAC score ≥ 400. CONCLUSION Even after 20 years, individual risk prediction is improved by addition of CT-based determination of coronary artery calcification to the ASCVD score. Therefore, assessment of ASCVD risk factors should be complemented more widely by cardiac CT in the primary prevention of cardiovascular disease.
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Affiliation(s)
- Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology, Essen University Hospital, University of Duisburg-Essen; Department of Neurology, Essen University Hospital, University Duisburg-Essen; Institute for Urban Public Health, Essen University Hospital, University Duisburg-Essen; School of Public Health, Department of Epidemiology, Boston University; Cardioangological Center Bethanien, Frankfurt; Department of Cardiology, Bethanien Hospital Moers, Moers; Grönemeyer Institute, Bochum; Diagnostikum, Mülheim an der Ruhr
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18
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Moore JS, Nesbit MA, Moore T. Appraisal of Cardiovascular Risk Factors, Biomarkers, and Ocular Imaging in Cardiovascular Risk Prediction. Curr Cardiol Rev 2023; 19:72-81. [PMID: 37497700 PMCID: PMC10636798 DOI: 10.2174/1573403x19666230727101926] [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: 09/30/2022] [Revised: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 07/28/2023] Open
Abstract
Cardiovascular disease remains a leading cause of death worldwide despite the use of available cardiovascular disease risk prediction tools. Identification of high-risk individuals via risk stratification and screening at sub-clinical stages, which may be offered by ocular screening, is important to prevent major adverse cardiac events. Retinal microvasculature has been widely researched for potential application in both diabetes and cardiovascular disease risk prediction. However, the conjunctival microvasculature as a tool for cardiovascular disease risk prediction remains largely unexplored. The purpose of this review is to evaluate the current cardiovascular risk assessment methods, identifying gaps in the literature that imaging of the ocular microcirculation may have the potential to fill. This review also explores the themes of machine learning, risk scores, biomarkers, medical imaging, and clinical risk factors. Cardiovascular risk classification varies based on the population assessed, the risk factors included, and the assessment methods. A more tailored, standardised and feasible approach to cardiovascular risk prediction that utilises technological and medical imaging advances, which may be offered by ocular imaging, is required to support cardiovascular disease prevention strategies and clinical guidelines.
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Affiliation(s)
- Julie S. Moore
- School of Biomedical Sciences, Ulster University, York St, Belfast BT15 1ED, United Kingdom
- Integrated Diagnostics Laboratory, Ulster University, 3-5a Frederick St, Belfast, Northern Ireland, United Kingdom
| | - M. Andrew Nesbit
- School of Biomedical Sciences, Ulster University, York St, Belfast BT15 1ED, United Kingdom
- Integrated Diagnostics Laboratory, Ulster University, 3-5a Frederick St, Belfast, Northern Ireland, United Kingdom
| | - Tara Moore
- School of Biomedical Sciences, Ulster University, York St, Belfast BT15 1ED, United Kingdom
- Integrated Diagnostics Laboratory, Ulster University, 3-5a Frederick St, Belfast, Northern Ireland, United Kingdom
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19
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Sumin AN, Shcheglova AV, Kokov AN, Kachurina EN, Barbarash OL. Relationship Between Cardio-Ankle Vascular Index And Coronary Artery Calcification In A Population Sample Of Southwestern Siberia. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective — To examine associations between cardio-ankle vascular index (CAVI) and coronary artery calcium (CAC) score a population sample of southwestern Siberia. Methods — From the sample of 1,620 people the final analysis included 1,316 participants 25 to 64 years of age who were enrolled in an observational cross-sectional study, Epidemiology of Cardiovascular Diseases and Their Risk Factors in the Russian Federation (ESSE-RF). Study participants were split among two groups: Group 1 with CAVI≥9.0 (n=128) and Group 2 with CAVI<9.0 (n=1,188). Prevalence of coronary artery calcification in both groups was analyzed via the Agatston method. We compared main demographic and clinical data between the groups, as well as CAC scores. Results — Elevated CAVI (≥9.0) was present in 9.7% of people included in a population sample from southwestern Siberia, and coronary artery calcification was found in 33.5% of the sample. While similar rates of minimum, mild, moderate and severe CAC score were observed in the participants with elevated and normal CAVI values, CAVI as a continuous variable was statistically significantly associated with moderate and severe CAC scores (OR 1.20, 95% CI 1.06-1.37, p=0.004). CAC score values were higher in individuals at the age of ≥50 years with pathological CAVI values (116±489 vs. 75±425 in normal CAVI, p=0.035), but not in patients under the age of 50 years (64±227 and 85±475, p=0.343). Conclusion — CAVI could possibly be used as a feasible marker before assessing the CAC score in some asymptomatic Caucasian subjects, but identifying the most appropriate methods and participants, whom it could be clearly applicable to, requires further studying.
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Affiliation(s)
- Aleksei N. Sumin
- Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
| | - Anna V. Shcheglova
- Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
| | - Aleksandr N. Kokov
- Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
| | - Elena N. Kachurina
- Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
| | - Olga L. Barbarash
- Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
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20
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Piña P, Lorenzatti D, Paula R, Daich J, Schenone AL, Gongora C, Garcia MJ, Blaha MJ, Budoff MJ, Berman DS, Virani SS, Slipczuk L. Imaging subclinical coronary atherosclerosis to guide lipid management, are we there yet? Am J Prev Cardiol 2022; 13:100451. [PMID: 36619296 PMCID: PMC9813535 DOI: 10.1016/j.ajpc.2022.100451] [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: 10/08/2022] [Revised: 12/07/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Atherosclerotic cardiovascular disease risk (ASCVD) is an ongoing epidemic, and lipid abnormalities are its primordial cause. Most individuals suffering a first ASCVD event are previously asymptomatic and often do not receive preventative therapies. The cornerstone of primary prevention has been the identification of individuals at risk through risk calculators based on clinical and laboratory traditional risk factors plus risk enhancers. However, it is well accepted that a clinical risk calculator misclassifies a significant proportion of individuals leading to the prescription of a lipid-lowering medication with very little yield or a missed opportunity for lipid-lowering agents with a potentially preventable event. The development of coronary artery calcium scoring (CAC) and CT coronary angiography (CCTA) provide complementary tools to directly visualize coronary plaque and other risk-modifying imaging components that can potentially provide individualized lipid management. Understanding patient selection for CAC or potentially CCTA and the risk implications of the different parameters provided, such as CAC score, coronary stenosis, plaque characteristics and burden, epicardial adipose tissue, and pericoronary adipose tissue, have grown more complex as technologies evolve. These parameters directly affect the shared decision with patients to start or withhold lipid-lowering therapies, to adjust statin intensity or LDL cholesterol goals. Emerging lipid lowering studies with non-invasive imaging as a guide to patient selection and treatment efficacy, plus the evolution of lipid lowering therapies from statins to a diverse armament of newer high-cost agents have pushed these two fields forward with a complex interaction. This review will discuss existing risk estimators, and non-invasive imaging techniques for subclinical coronary atherosclerosis, traditionally studied using CAC and more recently CCTA with qualitative and quantitative measurements. We will also explore the current data, gaps of knowledge and future directions on the use of these techniques in the risk-stratification and guidance of lipid management.
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Affiliation(s)
- Pamela Piña
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Daniel Lorenzatti
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Rita Paula
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Jonathan Daich
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Aldo L Schenone
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Carlos Gongora
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Mario J Garcia
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. Baltimore, MD, USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine. Baylor College of Medicine, and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- The Aga Khan University, Karachi, Pakistan
| | - Leandro Slipczuk
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
- Corresponding author.
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21
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van der Bijl P, Kuneman J, Bax JJ. Coronary artery calcium scoring in the general population. Eur Heart J Cardiovasc Imaging 2022; 24:36-37. [PMID: 36208189 DOI: 10.1093/ehjci/jeac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Pieter van der Bijl
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Jurrien Kuneman
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands.,Heart Centre, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
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22
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Who should be referred for a CT coronary calcium score? Introducing a simple patient risk questionnaire combining traditional and novel risk factors. Coron Artery Dis 2022; 33:618-625. [DOI: 10.1097/mca.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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Osborne-Grinter M, Kwiecinski J, Doris M, McElhinney P, Cadet S, Adamson PD, Moss AJ, Alam S, Hunter A, Shah ASV, Mills NL, Pawade T, Wang C, Weir-McCall JR, Roditi G, van Beek EJR, Shaw LJ, Nicol ED, Berman D, Slomka PJ, Newby DE, Dweck MR, Dey D, Williams MC. Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial. Eur Heart J Cardiovasc Imaging 2022; 23:1210-1221. [PMID: 34529050 PMCID: PMC9612790 DOI: 10.1093/ehjci/jeab135] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/22/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown. METHODS AND RESULTS In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1-9 AU), low (10-99 AU), moderate (100-399 AU), high (400-999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P < 0.001), but there was no statistically significant difference between those with medium, high, and very high CACS. Myocardial infarction occurred in 41 patients, 10% of whom had zero CACS. CACS >1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score. CONCLUSION In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque.
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Affiliation(s)
- Maia Osborne-Grinter
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | - Jacek Kwiecinski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Mhairi Doris
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | - Priscilla McElhinney
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Sebastien Cadet
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Alastair J Moss
- NIHR Leicester Biomedical Research Centre and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Shirjel Alam
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | - Amanda Hunter
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | - Anoop S V Shah
- Department of non-communicable disease epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tania Pawade
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | - Chengjia Wang
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
| | | | - Giles Roditi
- Institute of Cardiovascular & Medical Sciences, Glasgow University, Glasgow, UK
| | - Edwin J R van Beek
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | | | - Edward D Nicol
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel Berman
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Piotr J Slomka
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building,49 Little France Crescent, Edinburgh, EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
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24
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Ties D, van der Ende YM, Pundziute G, van der Schouw YT, Bots ML, Xia C, van Ooijen PMA, Pelgrim GJ, Vliegenthart R, van der Harst P. Pre-screening to guide coronary artery calcium scoring for early identification of high-risk individuals in the general population. Eur Heart J Cardiovasc Imaging 2022; 24:27-35. [PMID: 35851802 PMCID: PMC9762935 DOI: 10.1093/ehjci/jeac137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/24/2022] [Accepted: 07/02/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS To evaluate the ability of Systematic COronary Risk Estimation 2 (SCORE2) and other pre-screening methods to identify individuals with high coronary artery calcium score (CACS) in the general population. METHODS AND RESULTS Computed tomography-based CACS quantification was performed in 6530 individuals aged 45 years or older from the general population. Various pre-screening methods to guide referral for CACS were evaluated. Miss rates for high CACS (CACS ≥300 and ≥100) were evaluated for various pre-screening methods: moderate (≥5%) and high (≥10%) SCORE2 risk, any traditional coronary artery disease (CAD) risk factor, any Risk Or Benefit IN Screening for CArdiovascular Disease (ROBINSCA) risk factor, and moderately (>3 mg/24 h) increased urine albumin excretion (UAE). Out of 6530 participants, 643 (9.8%) had CACS ≥300 and 1236 (18.9%) had CACS ≥100. For CACS ≥300 and CACS ≥100, miss rate was 32 and 41% for pre-screening by moderate (≥5%) SCORE2 risk and 81 and 87% for high (≥10%) SCORE2 risk, respectively. For CACS ≥300 and CACS ≥100, miss rate was 8 and 11% for pre-screening by at least one CAD risk factor, 24 and 25% for at least one ROBINSCA risk factor, and 67 and 67% for moderately increased UAE, respectively. CONCLUSION Many individuals with high CACS in the general population are left unidentified when only performing CACS in case of at least moderate (≥5%) SCORE2, which closely resembles current clinical practice. Less stringent pre-screening by presence of at least one CAD risk factor to guide CACS identifies more individuals with high CACS and could improve CAD prevention.
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Affiliation(s)
- Daan Ties
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yldau M van der Ende
- Department of Cardiology, Division of Heart and Lungs, Utrecht University, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Gabija Pundziute
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, Utrecht University, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, Utrecht University, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Congying Xia
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter M A van Ooijen
- Department of Radiation Oncology and Data Science Center in Health, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert Jan Pelgrim
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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25
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Koopman MY, Reijnders JJW, Willemsen RTA, van Bruggen R, Doggen CJM, Kietselaer B, Oude Wolcherink MJ, van Ooijen PMA, Gratama JWC, Braam R, Oudkerk M, van der Harst P, Dinant GJ, Vliegenthart R. Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial. BMJ Open 2022; 12:e055123. [PMID: 35440450 PMCID: PMC9020291 DOI: 10.1136/bmjopen-2021-055123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/16/2022] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs. METHODS AND ANALYSIS CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier. ETHICS AND DISSEMINATION CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen. TRIAL REGISTRATION NUMBER NTR 7475; Pre-results.
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Affiliation(s)
- Moniek Y Koopman
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorn J W Reijnders
- Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Rykel van Bruggen
- Multicenter General Practitioners Organisation 'HuisartsenOrganisatie Oost-Gelderland', Apeldoorn, The Netherlands
| | - Carine J M Doggen
- Department of Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Bas Kietselaer
- Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Martijn J Oude Wolcherink
- Department of Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Peter M A van Ooijen
- Department of Data Science Center in Health, University of Groniningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Richard Braam
- Department of Cardiology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Matthijs Oudkerk
- Department of Medical Science, University of Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, Division of Heart and Lungs, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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26
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Williams MC, Weir-McCall J, Moss AJ, Schmitt M, Stirrup J, Holloway B, Gopalan D, Deshpande A, Hughes GM, Agrawal B, Nicol E, Roditi G, Shambrook J, Bull R. Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT. BJR Open 2022; 4:20210057. [PMID: 36105421 PMCID: PMC9459857 DOI: 10.1259/bjro.20210057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/07/2022] [Accepted: 02/12/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood. Methods UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification. Results The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations. Conclusion Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality. Advances in knowledge On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.
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Affiliation(s)
- Michelle C Williams
- BHF Centre for Cardiovascular Science and Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
| | | | - Alastair J Moss
- British Heart Foundation Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Matthias Schmitt
- North West Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Ben Holloway
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Aparna Deshpande
- Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | | | | | - Edward Nicol
- Royal Brompton and Harefield NHS Foundation Trust Departments of Cardiology and Radiology, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, London, UK
| | - Giles Roditi
- Dept. of Radiology, Glasgow Royal Infirmary, NHS Greater Glasgow & Clyde, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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27
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. Eur Heart J Cardiovasc Imaging 2022; 23:299-314. [PMID: 35076061 PMCID: PMC8863074 DOI: 10.1093/ehjci/jeab293] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Indexed: 01/26/2023] Open
Abstract
Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.
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Affiliation(s)
- Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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28
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Vonder M, Zheng S, Dorrius MD, van der Aalst CM, de Koning HJ, Yi J, Yu D, Gratama JWC, Kuijpers D, Oudkerk M. Deep Learning for Automatic Calcium Scoring in Population-Based Cardiovascular Screening. JACC Cardiovasc Imaging 2022; 15:366-367. [PMID: 34419401 DOI: 10.1016/j.jcmg.2021.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/15/2021] [Accepted: 07/09/2021] [Indexed: 11/24/2022]
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29
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Onnis C, Muscogiuri G, Paolo Bassareo P, Cau R, Mannelli L, Cadeddu C, Suri JS, Cerrone G, Gerosa C, Sironi S, Faa G, Carriero A, Pontone G, Saba L. Non-invasive coronary imaging in patients with COVID-19: a narrative review. Eur J Radiol 2022; 149:110188. [PMID: 35180580 PMCID: PMC8805958 DOI: 10.1016/j.ejrad.2022.110188] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/20/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
SARS-CoV-2 infection, responsible for COVID-19 outbreak, can cause cardiac complications, worsening outcome and prognosis. In particular, it can exacerbate any underlying cardiovascular condition, leading to atherosclerosis and increased plaque vulnerability, which may cause acute coronary syndrome. We review current knowledge on the mechanisms by which SARS-CoV-2 can trigger endothelial/myocardial damage and cause plaque formation, instability and deterioration. The aim of this review is to evaluate current non-invasive diagnostic techniques for coronary arteries evaluation in COVID-19 patients, such as coronary CT angiography and atherosclerotic plaque imaging, and their clinical implications. We also discuss the role of artificial intelligence, deep learning and radiomics in the context of coronary imaging in COVID-19 patients.
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30
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Fogante M, Cavagna E, Rinaldi G. REMOVED: Correlation between COVID-19 and cardiac calcification. J Med Imaging Radiat Sci 2022:S1939-8654(22)00003-0. [PMID: 35131217 PMCID: PMC8761559 DOI: 10.1016/j.jmir.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/03/2021] [Accepted: 01/11/2022] [Indexed: 11/05/2022]
Abstract
The Publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Marco Fogante
- Azienda Ospedaliero Universitaria "Ospedali Riuniti" Ancona.
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31
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Possari RY, Andrade-Gomes HJ, Mello VC, Galdeano EA, Aguiar-Filho LF, Bittencourt MS, Ponte EV, Bertoche LR, Caio LRS, Rodrigues JD, Alcantara FB, Freitas MAC, Sarinho JCGC, Cervigne NK, Rodrigues WM, Aprahamian I. Association of coronary calcification with prognosis of Covid-19 patients without known heart disease. Braz J Med Biol Res 2021; 54:e11681. [PMID: 34878066 PMCID: PMC8647900 DOI: 10.1590/1414-431x2021e11681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022] Open
Abstract
Risk factors that determine the severity of Covid-19 have not been fully elucidated. The aim of this study was to evaluate the role of coronary artery calcification (CAC) as a risk factor for death or mechanical ventilation (MV) of patients without known heart disease infected with Covid-19. We analyzed 283 consecutive in-patients with acute respiratory symptoms with chest computed tomography (chest-CT), without previous heart disease, and criteria for Covid-19 (RT-PCR positive and/or typical clinical and chest-CT findings). CAC was classified by the number of coronary segments affected as absent (0), mild (1-3), and severe calcification (more than 3). The association between CAC, CAC severity, and death or MV due to severe respiratory failure was assessed by logistic regression. The mean age was 58.7±15.7 years and 54.1% were men. Patients with CAC were older, more likely to have hypertension, and less likely to be obese. CAC was present in 75 patients (26.5%), of which 42 had a mild calcification and 33 had severe calcification, and was associated with death (OR=2.35, 95%CI: 1.01-5.48) or MV (OR=2.72, 95%CI: 1.20-6.20) adjusted for multiple confounders, with significant and increased odds ratio for the severe form of CAC (death: OR=3.70, 95%CI: 1.20-11.42; MV: OR=3.30, 95%CI: 1.09-9.95). We concluded that CAC was an independent risk factor for death or MV in Covid-19 patients without previous heart disease, particularly for those with severe calcification. CAC can be easily visualized on common chest-CT, widely used in evaluation of moderate to severe Covid-19.
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Affiliation(s)
- R Y Possari
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - H J Andrade-Gomes
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Imagem Cardíaca, Prevent Senior, São Paulo, SP, Brasil.,Imagem Cardíaca, United Health Group, São Paulo, SP, Brasil
| | - V C Mello
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - E A Galdeano
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - L F Aguiar-Filho
- Imagem Cardíaca, Prevent Senior, São Paulo, SP, Brasil.,Imagem Cardíaca, United Health Group, São Paulo, SP, Brasil.,Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - M S Bittencourt
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Laboratório DASA, São Paulo, SP, Brasil.,University of Pittsburgh Medical Center and University of Pittsburgh, Pittsburgh, PA, USA
| | - E V Ponte
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - L R Bertoche
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - L R S Caio
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - J D Rodrigues
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - F B Alcantara
- Departamento de Regulação da Saúde, Prefeitura de Jundiaí, Jundiaí, SP, Brasil
| | - M A C Freitas
- Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - J C G C Sarinho
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - N K Cervigne
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - W M Rodrigues
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - I Aprahamian
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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32
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Williams MC, Ferencik M, Branch KR, Nieman K, Ghoshhajra BB, Choi AD, Nicol ED, Williamson E. Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography. J Cardiovasc Comput Tomogr 2021; 15:506-512. [PMID: 34688579 DOI: 10.1016/j.jcct.2021.10.002] [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: 08/17/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/15/2022]
Abstract
The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32 hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.
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Affiliation(s)
- Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | | | - Koen Nieman
- Stanford University School of Medicine, Departments of Medicine and Radiology, Cardiovascular Institute, Stanford, CA, USA
| | - Brian B Ghoshhajra
- Division of Cardiovascular Imaging and Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew D Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Edward D Nicol
- Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Biomedical Engineering and Imaging Sciences, Kings College London, UK
| | - Eric Williamson
- Division of Cardiovascular Radiology, Mayo Clinic Rochester, MN, USA
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33
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Edvardsen T, Donal E, Marsan NA, Maurovich-Horvat P, Dweck MR, Maurer G, Petersen SE, Cosyns B. The year 2020 in the European Heart Journal - Cardiovascular Imaging: part I. Eur Heart J Cardiovasc Imaging 2021; 22:1219-1227. [PMID: 34463734 DOI: 10.1093/ehjci/jeab148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/24/2021] [Indexed: 12/22/2022] Open
Abstract
The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these 9 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as number 20 among all cardiovascular journals. Our journal is well established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal in 2020 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.
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Affiliation(s)
- Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Postbox 4950 Nydalen, Sognsvannsveien 20, NO-0424 Oslo, Norway.,Institute for clinical medicine, University of Oslo, Sognsvannsveien 20, NO-0424 Oslo, Norway
| | - Erwan Donal
- Department of Cardiology and CIC-IT1414, CHU Rennes, Inserm, LTSI-UMR 1099, University Rennes-1, Rennes F-35000, France
| | - Nina A Marsan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, 2 Korányi u., 1083 Budapest, Hungary
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Gerald Maurer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Wahringer Gurtel 18-20, 1090 Vienna, Austria
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University of London, CharterhouseSquare, London EC1M 6BQ, UK
| | - Bernard Cosyns
- Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, 109 Laarbeeklaan, Brussels 1090, Belgium
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34
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Tini G, Ameri P, Buzzatti G, Sarocchi M, Murialdo R, Guglielmi G, Arboscello E, Ballestrero A, Del Mastro L, Spallarossa P, Porto I. Diversity of Cardiologic Issues in a Contemporary Cohort of Women With Breast Cancer. Front Cardiovasc Med 2021; 8:654728. [PMID: 34660706 PMCID: PMC8517118 DOI: 10.3389/fcvm.2021.654728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 09/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Women with breast cancer (BC) represent a special population particularly exposed to cardiovascular disease (CVD) risk. However, cardiologic assessment in BC is mostly limited to detection of left ventricular dysfunction cardiotoxicity (LVD-CTX) due to anticancer treatments. Our aim was to comprehensively investigate CV profile and events in a contemporary BC cohort. Methods and Results: Records of BC patients referred for a Cardio-Oncologic evaluation before starting anticancer treatments, between 2016 and 2019, were retrospectively reviewed (n = 508). Information regarding prevalence and control of CV risk factors, and novel CVD diagnoses were extracted. Occurrence of LVD-CTX, CV events other than LVD-CTX and mortality was assessed. Mean age of study population was 64 ± 13 years; 287 patients were scheduled to receive anthracycline and 165 anti-HER2 therapy. Overall, 53% of BC women had ≥2 CV risk factors, and 67% had at least one of arterial hypertension, dyslipidaemia or diabetes mellitus not adequately controlled. Eighteen (4%) patients were diagnosed a previously unknown CVD. Over a mean follow-up of 2.5 ± 1 years, 3% of BC patients developed LVD-CTX, 2% suffered from other CV events and 11% died. CV risk factors were not associated with LVD-CTX, except for family history of CAD. On the contrary, patients with other CV events exhibited a worse CV profile. Those who died more commonly experienced CV events other than LVD-CTX (p = 0.02). Conclusions: BC women show a suboptimal CV risk profile and are at risk of CV events not limited to LVD-CTX. A baseline Cardio-Oncologic evaluation was instrumental to implement CV prevention and to optimize CV therapies.
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Affiliation(s)
- Giacomo Tini
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Giulia Buzzatti
- Breast Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Matteo Sarocchi
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Roberto Murialdo
- Internal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Giulia Guglielmi
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Eleonora Arboscello
- Department of Emergency, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Ballestrero
- Department of Internal Medicine, University of Genova, Genova, Italy
- Internal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine, University of Genova, Genova, Italy
- Breast Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
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35
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Lenselink C, Ties D, Pleijhuis R, van der Harst P. Validation and comparison of 28 risk prediction models for coronary artery disease. Eur J Prev Cardiol 2021; 29:666-674. [PMID: 34329420 DOI: 10.1093/eurjpc/zwab095] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/29/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022]
Abstract
AIMS Risk prediction models (RPMs) for coronary artery disease (CAD), using variables to calculate CAD risk, are potentially valuable tools in prevention strategies. However, their use in the clinical practice is limited by a lack of poor model description, external validation, and head-to-head comparisons. METHODS AND RESULTS CAD RPMs were identified through Tufts PACE CPM Registry and a systematic PubMed search. Every RPM was externally validated in the three cohorts (the UK Biobank, LifeLines, and PREVEND studies) for the primary endpoint myocardial infarction (MI) and secondary endpoint CAD, consisting of MI, percutaneous coronary intervention, and coronary artery bypass grafting. Model discrimination (C-index), calibration (intercept and regression slope), and accuracy (Brier score) were assessed and compared head-to-head between RPMs. Linear regression analysis was performed to evaluate predictive factors to estimate calibration ability of an RPM. Eleven articles containing 28 CAD RPMs were included. No single best-performing RPM could be identified across all cohorts and outcomes. Most RPMs yielded fair discrimination ability: mean C-index of RPMs was 0.706 ± 0.049, 0.778 ± 0.097, and 0.729 ± 0.074 (P < 0.01) for prediction of MI in UK Biobank, LifeLines, and PREVEND, respectively. Endpoint incidence in the original development cohorts was identified as a significant predictor for external validation performance. CONCLUSION Performance of CAD RPMs was comparable upon validation in three large cohorts, based on which no specific RPM can be recommended for predicting CAD risk.
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Affiliation(s)
- Chris Lenselink
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Daan Ties
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Rick Pleijhuis
- Department of Internal Medicine, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
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36
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Zamorano JL, Pinto FJ, Solano-López J, Bucciarelli-Ducci C. The year in cardiovascular medicine 2020: imaging. Eur Heart J 2021; 42:740-749. [PMID: 33388781 DOI: 10.1093/eurheartj/ehaa1035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/13/2020] [Accepted: 12/07/2020] [Indexed: 01/06/2023] Open
Affiliation(s)
- José Luis Zamorano
- Department of Cardiology, University Hospital Ramon y Cajal, Carretera de Colmenar Km 9.100, 28034 Madrid; Spain
| | - Fausto J Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte (CHULN), CCUL, Universidade de Lisboa, Av. Prof. Egas Moniz MB 1649-028 Lisboa, Portugal
| | - Jorge Solano-López
- Department of Cardiology, University Hospital Ramon y Cajal, Carretera de Colmenar Km 9.100, 28034 Madrid; Spain
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust and University of Bristol, UK
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37
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Nasir K, Cainzos-Achirica M. Role of coronary artery calcium score in the primary prevention of cardiovascular disease. BMJ 2021; 373:n776. [PMID: 33947652 DOI: 10.1136/bmj.n776] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
First developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called "power of zero"), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to de-risk individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.
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Affiliation(s)
- Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA
| | - Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA
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38
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Ten Haaf K, van der Aalst CM, de Koning HJ, Kaaks R, Tammemägi MC. Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges. Int J Cancer 2021; 149:250-263. [PMID: 33783822 PMCID: PMC8251929 DOI: 10.1002/ijc.33578] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/17/2022]
Abstract
Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.
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Affiliation(s)
- Kevin Ten Haaf
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carlijn M van der Aalst
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Martin C Tammemägi
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
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39
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Moorman AJ, Dean LS, Yang E, Drezner JA. Cardiovascular Risk Assessment in the Older Athlete. Sports Health 2021; 13:622-629. [PMID: 33733939 DOI: 10.1177/19417381211004877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
CONTEXT Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes. EVIDENCE ACQUISITION Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020). STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 3. RESULTS Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended. CONCLUSION We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.
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Affiliation(s)
- Alec J Moorman
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Larry S Dean
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Eugene Yang
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Jonathan A Drezner
- Department of Family Medicine, Sports Medicine Section and UW Medicine Center for Sports Cardiology, University of Washington, Seattle, Washington
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40
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Williams MC, Newby DE. Machine learning to predict cardiac events in asymptomatic individuals. Atherosclerosis 2021; 318:38-39. [PMID: 33353728 DOI: 10.1016/j.atherosclerosis.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK.
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
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41
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van der Aalst CM, Ten Haaf K, de Koning HJ. Implementation of lung cancer screening: what are the main issues? Transl Lung Cancer Res 2021; 10:1050-1063. [PMID: 33718044 PMCID: PMC7947387 DOI: 10.21037/tlcr-20-985] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Two large-scale RCTs have shown computed tomography (CT) lung cancer screening to be efficacious in reducing lung cancer mortality (8–24% in men, 26–59% in women). However, lung cancer screening implicitly means personalised and risk-based approaches. Health care systems’ implementation of personalised screening and prevention is still sparse, and likely to be of variable quality, because of important remaining uncertainties, which have been incompletely addressed or not at all so far. Further optimisation of lung cancer screening programs is expected to reduce harms and maintain or enhance benefit for eligible European citizens, whilst significantly reducing health care costs. Some main uncertainties (e.g., Risk-based eligibility, Risk-based screening intervals, Volume CT screening, Smoking Cessation, Gender and Sex differences, Cost-Effectiveness) are discussed in this review. 4-IN-THE-LUNG-RUN (acronym for: Towards INdividually tailored INvitations, screening INtervals and INtegrated co-morbidity reducing strategies in lung cancer screening) is the first multi-centred implementation trial on volume CT lung cancer screening amongst 24,000 males and females, at high risk for developing lung cancer, across five European countries, started in January 2020. Through providing answers to the remaining questions with this trial, many EU citizens will swiftly benefit from this high-quality screening technology, others will face less harms than previously anticipated, and health care costs will be substantially reduced. Implementing a new cancer screening programme is a major task, with many stakeholders and many possible facilitators but also barriers and obstacle.
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Affiliation(s)
- Carlijn M van der Aalst
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kevin Ten Haaf
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
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42
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Vonder M, van der Aalst CM, de Koning HJ. Coronary artery calcium scoring in individuals at risk for coronary artery disease: current status and future perspectives. Br J Radiol 2020; 93:20190880. [PMID: 31999209 PMCID: PMC7465842 DOI: 10.1259/bjr.20190880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/27/2020] [Indexed: 11/05/2022] Open
Abstract
The aim of this review is to provide clinicians with an overview of the role of coronary artery calcium (CAC) scoring across the spectrum ranging from asymptomatic individuals to chronic chest pain patients. We will briefly introduce the technical background of CAC scoring, summarize the major guidelines per type of patient at risk and discuss latest research with respect to CAC. Finally, the reader should be able to determine when CAC scoring is indicated or may be of added value.
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Affiliation(s)
- Marleen Vonder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlijn M van der Aalst
- Department of Public Health, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
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