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Tian L, Jaeger BC, Scialla JJ, Budoff MJ, Mehta RC, Jaar BG, Saab G, Dobre MA, Reilly MP, Rader DJ, Townsend RR, Lash JP, Greenland P, Isakova T, Bundy JD. Progression of Coronary Artery Calcification and Risk of Clinical Events in CKD: The Chronic Renal Insufficiency Cohort Study. Am J Kidney Dis 2024:S0272-6386(24)00920-X. [PMID: 39154888 DOI: 10.1053/j.ajkd.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/15/2024] [Accepted: 06/10/2024] [Indexed: 08/20/2024]
Abstract
RATIONALE & OBJECTIVE Coronary artery calcification (CAC) progresses rapidly in people with chronic kidney disease (CKD) compared with the general population. We studied the association between CAC progression and higher risks of atherosclerotic cardiovascular disease (CVD), congestive heart failure, and all-cause mortality among adults with CKD. STUDY DESIGN Prospective cohort study. SETTING & Participants: 1,310 participants in the Chronic Renal Insufficiency Cohort (CRIC) Study who had at least one CAC scan with no prior history of CVD and with observed or imputed data on changes in CAC over time. EXPOSURE Observed or imputed CAC progression, categorized as incident CAC among participants with zero CAC on the baseline scan, or progressive CAC when the baseline scan demonstrated CAC and there was an increase in CAC ≥50 Agatston units per year. OUTCOMES Atherosclerotic CVD (myocardial infarction or stroke), congestive heart failure, and all-cause mortality. ANALYTICAL APPROACH Cause-specific Cox proportional hazards regression, stratified by presence of CAC at baseline. RESULTS A total of 545 participants without and 765 with prevalent CAC at baseline were included. During a mean 3.3 years between CAC assessments, 177 (32.5%) participants without baseline CAC developed incident CAC while 270 participants (35.3%) with baseline CAC developed a ≥50 Agatston units per year increase in CAC. After multivariable adjustment, incident CAC was associated with 2.42-fold higher rate of atherosclerotic CVD (95% confidence interval [CI]: 1.23-4.79) and 1.82-fold higher rate of all-cause mortality (95% CI: 1.03-3.22). Progressive CAC (≥50 units per year) was not associated with atherosclerotic CVD (hazard ratio [HR]: 1.42; 95% CI: 0.85-2.35) but was associated with a 1.73-fold higher rate of all-cause mortality (95% CI: 1.31-2.28). Progressive CAC was not associated with incident heart failure. LIMITATIONS Residual confounding and limited statistical power for some outcomes. CONCLUSIONS Among adults with CKD stages 2-4, CAC progression over a mean 3.3 years was associated with higher risk of atherosclerotic CVD and all-cause mortality. The associations were strongest among participants without CAC at baseline.
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Affiliation(s)
- Ling Tian
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA; Tulane University Translational Science Institute, New Orleans, LA
| | - Byron C Jaeger
- Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine
| | - Julia J Scialla
- Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA
| | | | - Rupal C Mehta
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mirela A Dobre
- Department of Medicine, Division of Nephrology and Hypertension, University Hospitals Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Muredach P Reilly
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Daniel J Rader
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James P Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Philip Greenland
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tamara Isakova
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua D Bundy
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA; Tulane University Translational Science Institute, New Orleans, LA.
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Jaminon AMG, Akbulut AC, Rapp N, Kramann R, Biessen EAL, Temmerman L, Mees B, Brandenburg V, Dzhanaev R, Jahnen-Dechent W, Floege J, Uitto J, Reutelingsperger CP, Schurgers LJ. Development of the BioHybrid Assay: Combining Primary Human Vascular Smooth Muscle Cells and Blood to Measure Vascular Calcification Propensity. Cells 2021; 10:2097. [PMID: 34440866 PMCID: PMC8391733 DOI: 10.3390/cells10082097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Vascular calcification is an active process that increases cardiovascular disease (CVD) risk. There is still no consensus on an appropriate biomarker for vascular calcification. We reasoned that the biomarker for vascular calcification is the collection of all blood components that can be sensed and integrated into a calcification response by human vascular smooth muscle cells (hVSMCs). METHODS We developed a new cell-based high-content assay, the BioHybrid assay, to measure in vitro calcification. The BioHybrid assay was compared with the o-Cresolphthalein assay and the T50 assay. Serum and plasma were derived from different cohort studies including chronic kidney disease (CKD) stages III, IV, V and VD (on dialysis), pseudoxanthoma elasticum (PXE) and other cardiovascular diseases including serum from participants with mild and extensive coronary artery calcification (CAC). hVSMCs were exposed to serum and plasma samples, and in vitro calcification was measured using AlexaFluor®-546 tagged fetuin-A as calcification sensor. RESULTS The BioHybrid assay measured the kinetics of calcification in contrast to the endpoint o-Cresolphthalein assay. The BioHybrid assay was more sensitive to pick up differences in calcification propensity than the T50 assay as determined by measuring control as well as pre- and post-dialysis serum samples of CKD patients. The BioHybrid response increased with CKD severity. Further, the BioHybrid assay discriminated between calcification propensity of individuals with a high CAC index and individuals with a low CAC index. Patients with PXE had an increased calcification response in the BioHybrid assay as compared to both spouse and control plasma samples. Finally, vitamin K1 supplementation showed lower in vitro calcification, reflecting changes in delta Agatston scores. Lower progression within the BioHybrid and on Agatston scores was accompanied by lower dephosphorylated-uncarboxylated matrix Gla protein levels. CONCLUSION The BioHybrid assay is a novel approach to determine the vascular calcification propensity of an individual and thus may add to personalised risk assessment for CVD.
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Affiliation(s)
- Armand M. G. Jaminon
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; (A.M.G.J.); (A.C.A.); (N.R.); (C.P.R.)
| | - Asim C. Akbulut
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; (A.M.G.J.); (A.C.A.); (N.R.); (C.P.R.)
| | - Niko Rapp
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; (A.M.G.J.); (A.C.A.); (N.R.); (C.P.R.)
| | - Rafael Kramann
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, 52074 Aachen, Germany;
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Erik A. L. Biessen
- Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 HX Maastricht, The Netherlands; (E.A.L.B.); (L.T.)
- Institute for Molecular Cardiovascular Research (IMCAR), Universitätsklinikum Aachen, 52074 Aachen, Germany
| | - Lieve Temmerman
- Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 HX Maastricht, The Netherlands; (E.A.L.B.); (L.T.)
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands;
| | - Vincent Brandenburg
- Department of Cardiology, Rhein-Maas-Klinikum Würselen, 52146 Würselen, Germany;
| | - Robert Dzhanaev
- Helmholtz Institute for Biomedical Engineering, Biointerface Group, RWTH Aachen University, 52074 Aachen, Germany; (R.D.); (W.J.-D.)
| | - Willi Jahnen-Dechent
- Helmholtz Institute for Biomedical Engineering, Biointerface Group, RWTH Aachen University, 52074 Aachen, Germany; (R.D.); (W.J.-D.)
| | - Juergen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Jouni Uitto
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Chris P. Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; (A.M.G.J.); (A.C.A.); (N.R.); (C.P.R.)
| | - Leon J. Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; (A.M.G.J.); (A.C.A.); (N.R.); (C.P.R.)
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, 52074 Aachen, Germany;
- Institute for Molecular Cardiovascular Research (IMCAR), Universitätsklinikum Aachen, 52074 Aachen, Germany
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Wu PY, Lee SY, Chang KV, Chao CT, Huang JW. Gender-Related Differences in Chronic Kidney Disease-Associated Vascular Calcification Risk and Potential Risk Mediators: A Scoping Review. Healthcare (Basel) 2021; 9:healthcare9080979. [PMID: 34442116 PMCID: PMC8394860 DOI: 10.3390/healthcare9080979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
Vascular calcification (VC) involves the deposition of calcium apatite in vascular intima or media. Individuals of advanced age, having diabetes mellitus or chronic kidney disease (CKD) are particularly at risk. The pathogenesis of CKD-associated VC evolves considerably. The core driver is the phenotypic change involving vascular wall constituent cells toward manifestations similar to that undergone by osteoblasts. Gender-related differences are observed regarding the expressions of osteogenesis-regulating effectors, and presumably the prevalence/risk of CKD-associated VC exhibits gender-related differences as well. Despite the wealth of data focusing on gender-related differences in the risk of atherosclerosis, few report whether gender modifies the risk of VC, especially CKD-associated cases. We systematically identified studies of CKD-associated VC or its regulators/modifiers reporting data about gender distributions, and extracted results from 167 articles. A significantly higher risk of CKD-associated VC was observed in males among the majority of original investigations. However, substantial heterogeneity exists, since multiple large-scale studies yielded neutral findings. Differences in gender-related VC risk may result from variations in VC assessment methods, the anatomical segments of interest, study sample size, and even the ethnic origins of participants. From a biological perspective, plausible mediators of gender-related VC differences include body composition discrepancies, alterations involving lipid profiles, inflammatory severity, diversities in matrix Gla protein (MGP), soluble Klotho, vitamin D, sclerostin, parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), and osteoprotegerin levels. Based on our findings, it may be inappropriate to monotonously assume that male patients with CKD are at risk of VC compared to females, and we should consider more background in context before result interpretation.
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Affiliation(s)
- Patrick Yihong Wu
- School of Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan;
| | - Szu-Ying Lee
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County 640, Taiwan; (S.-Y.L.); (J.-W.H.)
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital BeiHu Branch, Taipei 10845, Taiwan;
| | - Chia-Ter Chao
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital BeiHu Branch, Taipei 10845, Taiwan
- Correspondence: ; Tel.: +886-2-23717101 (ext. 6531); Fax: +886-2-23717101
| | - Jenq-Wen Huang
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County 640, Taiwan; (S.-Y.L.); (J.-W.H.)
- Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
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Wang XR, Zhang JJ, Xu XX, Wu YG. Prevalence of coronary artery calcification and its association with mortality, cardiovascular events in patients with chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2019; 41:244-256. [PMID: 31014155 PMCID: PMC6493287 DOI: 10.1080/0886022x.2019.1595646] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To date, the prevalence and prognostic role of coronary artery calcification (CAC) in patients with chronic kidney disease (CKD) have been investigated in several studies, but have yielded conflicting results. The aim of this meta-analysis is to derive a more precise estimation of CAC prevalence in CKD patients and its association with cardiovascular events and mortality. METHODS The relevant literature was identified and evaluated from inception until July 2018 through multiple search strategies on PubMed, Embase, and Web of Science. Cross-sectional or cohort (baseline data) studies reporting CAC prevalence were included. Data extracted from eligible studies were used to calculate effect estimates (ESs) and 95% confidence intervals (95%CI). We searched databases for observational studies that explored baseline CAC and subsequent cardiovascular or all-cause mortality risk in CKD patients. RESULTS The meta-analysis included 47 studies; 38 of these were included in the final analysis of CAC prevalence. The pooled prevalence of CAC in random effect model was 60% (95%CI 53-68%). CAC was positively associated with an increased risk of all-cause mortality (hazard ratio [HR] 3.44; 95%CI 2.40-4.94), cardiovascular mortality (HR 3.87; 95%CI 2.06-7.26), and cardiovascular events (HR 2.09; 95%CI 1.19-3.67), when comparing individuals in the top CAC score group to those in the bottom CAC score group. CONCLUSIONS The pooled prevalence of CAC is highly prevalent. CAC is independently associated with all-cause and cardiovascular mortality risk as well as cardiovascular events among CKD patients. In view of the high heterogeneity, larger clinical trials are still needed.
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Affiliation(s)
- Xue-Rong Wang
- a Department of Nephrology , The First Affiliated Hospital of Anhui Medical University , Hefei , China.,b Department of Nephrology , The Second Hospital of Anhui Medical University , Hefei , China
| | - Jing-Jing Zhang
- a Department of Nephrology , The First Affiliated Hospital of Anhui Medical University , Hefei , China.,b Department of Nephrology , The Second Hospital of Anhui Medical University , Hefei , China
| | - Xing-Xin Xu
- a Department of Nephrology , The First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Yong-Gui Wu
- a Department of Nephrology , The First Affiliated Hospital of Anhui Medical University , Hefei , China
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Xiong Y, Li J, Sun S, Han M, Liao R, Li Y, Wang L, Lin L, Liu Q, Su B. Association of mineral content outside of bone with coronary artery calcium and 1-year cardiovascular prognosis in maintenance hemodialysis patients. Artif Organs 2019; 43:988-1001. [PMID: 30932185 PMCID: PMC6850757 DOI: 10.1111/aor.13461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 02/05/2023]
Abstract
Coronary artery calcifications (CACs) are common among maintenance hemodialysis (MHD) patients and associated with increased morbidity and mortality due to cardiovascular events. The insight into chronic kidney disease‐mineral and bone disorder (CKD‐MBD) established a correlation between dysregulated mineral metabolism and CACs. This study aimed to identify the association of mineral content outside of bone (MCOB) with CACs and cardiovascular events in MHD patients. In the pilot prospective study with no intervention, patients underwent body composition assessment by body composition monitor after hemodialysis and computed tomography examination using the Agatston scoring method simultaneously within a week. The primary end point included cardiovascular events and cardiovascular death. Correlations and receiver operating characteristic analysis elucidated the associations of MCOB with CACs; multivariate analysis assessed the cardiovascular risk for groups with different MCOB. One hundred three eligible patients with an average age of 48 (35‐63) years old were enrolled and followed up to 12 (11‐12.5) months, among which 52.4% had detectable CACs at baseline. MCOB showed an inverse correlation with Agatston score and significantly discriminated the patients with Agatston score > 0 (AUC = 0.737; P < 0.001) and 400 (AUC = 0.733; P < 0.001). MCOB ≤ 9.2657 mg/kg was an independent risk factor for CACs (OR = 4.853; P = 0.044) and strong predictor for cardiovascular morbidity and mortality (HR = 10.108; P = 0.042), as well as rehospitalization (HR = 2.689; P = 0.004). MCOB inversely correlated with the presence and extent of CACs, and could discriminate Agatston score > 0 and 400, which also presented as an independent indicator for CKD‐MBD and 1‐year cardiovascular prognosis in adult MHD patients. Additional studies are required for identifying this issue.
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Affiliation(s)
- Yuqin Xiong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiameng Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Si Sun
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Mei Han
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruoxi Liao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Liya Wang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Liping Lin
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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Cano-Megías M, Bouarich H, Guisado-Vasco P, Pérez Fernández M, de Arriba-de la Fuente G, Álvarez-Sanz C, Rodríguez-Puyol D. Coronary artery calcification in patients with diabetes mellitus and advanced chronic kidney disease. ACTA ACUST UNITED AC 2018; 66:297-304. [PMID: 30509882 DOI: 10.1016/j.endinu.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) and diabetes mellitus (DM) have high cardiovascular risk. Both conditions are related to systemic atherosclerosis and vascular calcification. The prevalence and severity of coronary artery calcification (CaC) is higher in patients with DM, regardless of their renal function. Data about the long-term prognostic role of CaC in diabetic patients with CKD are scarce. MATERIAL AND METHODS We carried out a prospective longitudinal study enrolling 137 patients with advanced CKD. A non-enhanced multislice coronary computed tomography (CT) was performed at baseline. CaC was assessed using Agatston method. Patients were stratified according to their CaC score: severe calcification group (CaCs≥400HU) and mild-moderate calcification group (CaCs<400HU). RESULTS The median follow-up time was 87.5 months. DM was found in 28% of subjects. The patients with DM showed more severe CaC, lower albumin and higher C-reactive protein serum levels. Serum albumin was correlated with severe CaC (r=-0.45, P=.009). Overall mortality rate reached 58%. Patients with DM also tended to have higher mortality compared to non-diabetic subjects (X2 3.51, P=.061) especially those with severe CaC showed higher mortality than those with severe CaC without DM (93% vs.73%, P=.04). CONCLUSIONS Patients with advanced CKD and DM have more severe CaC, increased inflammation-malnutrition data and higher mortality compared to those without DM.
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Affiliation(s)
- Marta Cano-Megías
- Unidad de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Hanane Bouarich
- Unidad de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Pablo Guisado-Vasco
- Medicina Interna, Universidad Europea, Hospital Ruber Juan Bravo, Madrid, España
| | - María Pérez Fernández
- Unidad de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | | | | | - Diego Rodríguez-Puyol
- Unidad de Nefrología, Fundación para la investigación del Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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Ichii T, Morimoto R, Okumura T, Ishii H, Tatami Y, Yamamoto D, Aoki S, Hiraiwa H, Furusawa K, Kondo T, Watanabe N, Kano N, Fukaya K, Sawamura A, Suzuki S, Yasuda Y, Murohara T. Impact of Renal Functional/Morphological Dynamics on the Calcification of Coronary and Abdominal Arteries in Patients with Chronic Kidney Disease. J Atheroscler Thromb 2017; 24:1092-1104. [PMID: 28392544 PMCID: PMC5684475 DOI: 10.5551/jat.39271] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: Fast-progressing vascular calcification (VC) is accompanied by renal atrophy and functional deterioration along with atherosclerosis in patients with chronic kidney disease (CKD). However, the relationship between VC progression and renal functional and/or morphological changes remains unclear. Methods: We included 70 asymptomatic patients with CKD without hemodialysis in our study. To identify temporal variations, the coronary artery calcification score (CACS), abdominal aortic calcification index (ACI), and renal parenchymal volume index (RPVI) were determined via spiral computed tomography scans taken during the study. We investigated significant factors related to annualized variations of CACS (ΔCACS/y) and ACI (ΔACI/y). Results: During the follow-up period (4.6 years), median values of CACS [in Agatston units (AU)] and ACI increased from 40.2 to 113.3 AU (p = 0.053) and from 13.2 to 21.7% (p = 0.036), respectively. Multivariate analysis revealed that CACS at baseline (p < 0.001) and diabetes mellitus (DM) status (p = 0.037) for ΔCACS/y and ACI at baseline (p = 0.017) and hypertension (HT) status (p = 0.046) for ΔACI/y were significant independent predictors. Furthermore, annualized RPVI variation was significantly related to both ΔCACS/y and ΔACI/y (R = −0.565, p < 0.001, and R = −0.289, p = 0.015, respectively). On the other hand, independent contributions of the estimated glomerular filtration rate (eGFR) and annualized eGFR variation to VC progression were not confirmed. Conclusion: The degree of VC at baseline, DM, HT, and changes in renal volume, but not eGFR, had a strong impact on VC progression in patients with CKD.
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Affiliation(s)
- Takeo Ichii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine.,Department of CKD Initiatives Internal Medicine, Nagoya University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yosuke Tatami
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Dai Yamamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Soichiro Aoki
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kenji Furusawa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Naoki Watanabe
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Naoaki Kano
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kenji Fukaya
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Akinori Sawamura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Susumu Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yoshinari Yasuda
- Department of CKD Initiatives Internal Medicine, Nagoya University Graduate School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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Wasser WG, Gil A, Skorecki KL. The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease. Rambam Maimonides Med J 2015; 6:RMMJ.10214. [PMID: 26241225 PMCID: PMC4524402 DOI: 10.5041/rmmj.10214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.
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Affiliation(s)
- Walter G. Wasser
- Division of Nephrology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Amnon Gil
- Division of Nephrology, Carmel Medical Center, Haifa, Israel
| | - Karl L. Skorecki
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Director of Medical and Research Development, Rambam Health Care Campus, Haifa, Israel
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Malluche HH, Blomquist G, Monier-Faugere MC, Cantor TL, Davenport DL. High Parathyroid Hormone Level and Osteoporosis Predict Progression of Coronary Artery Calcification in Patients on Dialysis. J Am Soc Nephrol 2015; 26:2534-44. [PMID: 25838468 DOI: 10.1681/asn.2014070686] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/25/2014] [Indexed: 12/17/2022] Open
Abstract
Coronary artery calcifications (CACs) are observed in most patients with CKD on dialysis (CKD-5D). CACs frequently progress and are associated with increased risk for cardiovascular events, the major cause of death in these patients. A link between bone and vascular calcification has been shown. This prospective study was designed to identify noninvasive tests for predicting CAC progression, including measurements of bone mineral density (BMD) and novel bone markers in adult patients with CKD-5D. At baseline and after 1 year, patients underwent routine blood tests and measurement of CAC, BMD, and novel serum bone markers. A total of 213 patients received baseline measurements, of whom about 80% had measurable CAC and almost 50% had CAC Agatston scores>400, conferring high risk for cardiovascular events. Independent positive predictors of baseline CAC included coronary artery disease, diabetes, dialysis vintage, fibroblast growth factor-23 concentration, and age, whereas BMD of the spine measured by quantitative computed tomography was an inverse predictor. Hypertension, HDL level, and smoking were not baseline predictors in these patients. Three quarters of 122 patients completing the study had CAC increases at 1 year. Independent risk factors for CAC progression were age, baseline total or whole parathyroid hormone level greater than nine times the normal value, and osteoporosis by t scores. Our results confirm a role for bone in CKD-associated CAC prevalence and progression.
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Colbert G, Jain N, de Lemos JA, Hedayati SS. Utility of traditional circulating and imaging-based cardiac biomarkers in patients with predialysis CKD. Clin J Am Soc Nephrol 2015; 10:515-29. [PMID: 25403922 PMCID: PMC4348678 DOI: 10.2215/cjn.03600414] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiac biomarkers, such as cardiac troponin T (cTnT), brain natriuretic peptide (BNP), and N-terminal-pro-BNP (NT-pro-BNP), are commonly used to diagnose acute coronary syndrome and congestive heart failure exacerbation in symptomatic patients. Levels of these biomarkers are frequently chronically elevated in asymptomatic patients with ESRD who are receiving maintenance dialysis. Other imaging biomarkers commonly encountered in nephrologists' clinical practice, such as coronary artery calcium measured by computed tomography, left ventricular hypertrophy, and carotid intima-media thickness, are also frequently abnormal in asymptomatic patients with ESRD. This article critically reviews the limited observational data on associations between cTnT, BNP, NT-pro-BNP, coronary artery calcium, left ventricular hypertrophy, and carotid intima-media thickness with cardiovascular events and death in non-dialysis-dependent patients with CKD. Although sufficient evidence suggests that these biomarkers may be used for prognostication, the diagnostic utility of cTnT, BNP, and NT-pro-BNP remain challenging in patients with CKD. Decreased renal clearance may affect the plasma levels of these biomarkers, and upper reference limits were originally derived in patients without CKD. Until better data are available, higher cutoffs, or a rise in level compared with previous values, have been proposed to help distinguish acute myocardial infarction from chronic elevations of cTnT in symptomatic patients with CKD. Additionally, it is not known whether these biomarkers are modifiable and amenable to interventions that could change hard clinical outcomes in patients with CKD not yet undergoing long-term dialysis.
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MESH Headings
- Biomarkers/blood
- Calcinosis/diagnostic imaging
- Carotid Intima-Media Thickness
- Coronary Artery Disease/complications
- Coronary Artery Disease/diagnostic imaging
- Humans
- Hypertrophy, Left Ventricular/blood
- Hypertrophy, Left Ventricular/complications
- Hypertrophy, Left Ventricular/diagnostic imaging
- Kidney Failure, Chronic/blood
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/therapy
- Natriuretic Peptide, Brain/blood
- Peptide Fragments/blood
- Renal Dialysis
- Tomography, X-Ray Computed
- Troponin T/blood
- Ventricular Dysfunction, Left/blood
- Ventricular Dysfunction, Left/complications
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Affiliation(s)
| | | | - James A de Lemos
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - S Susan Hedayati
- Division of Nephrology and Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, Texas
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Russo D, Morrone LF, Errichiello C, De Gregorio MG, Imbriaco M, Battaglia Y, Russo L, Andreucci M, Di Iorio BR. Impact of BMI on cardiovascular events, renal function, and coronary artery calcification. Blood Purif 2014; 38:1-6. [PMID: 25196674 DOI: 10.1159/000362862] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS High BMI increases the risk of cardiovascular events (CVEs) in the general population. Conflicting results have been reported on the role of BMI on CVEs and on decline of renal function in patients with chronic kidney disease not on dialysis (CKD). This study evaluates the impact of BMI on CVEs, dialysis initiation, and coronary artery calcification (CAC) in CKD patients. METHODS CKD patients were divided in normal-BMI and high-BMI patients. CVEs, initiation of dialysis, and extent and progression of CAC were assessed. Univariate and multivariable analysis were performed (adjustment variables: age, diabetes, hypertension, gender, CKD stage, serum concentration of hemoglobin, parathyroid hormone, calcium, phosphorus, albumin, C-reactive protein, LDL-cholesterol, total calcium score, 24-hour proteinuria). Patients were followed to the first event (CVE, dialysis) or for 2 years. RESULTS 471 patients were evaluated. A CVE occurred in 13.5 and 21.3% (p < 0.05) of normal-BMI and high-BMI patients, respectively. High BMI did not increase the risk for CVEs in univariate (HR: 1.86; 95% CI: 0.97-3.54; p = 0.06) or multivariable analysis (HR: 1.36; 95% CI: 0.57-3.14; p = 0.50). High BMI did not increase the risk for initiation of dialysis in univariate (HR: 0.96; 95% CI: 0.58-1.60; p = 0.9) or multivariable analysis (HR: 1.77; 95% CI: 0.82-3.81; p = 0.14). Adding the interaction term (between BMI and glomerular filtration rate) to other variables, the risk of dialysis initiation significantly increased (HR: 3.06; 95% CI: 1.31-7.18; p = 0.01) in high-BMI patients. High BMI was not a predictor of CAC extent or progression. CONCLUSIONS High BMI was not a predictor of CVEs. High BMI increased the risk for dialysis initiation, but high BMI was not associated to CAC extent and progression. The presence of confounders may underestimate the impact of high BMI on dialysis initiation.
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Affiliation(s)
- Domenico Russo
- Department of Nephrology, University of Naples 'Federico II', Naples, Italy
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12
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Basile C, Lomonte C, Lisi P, Karohl C, Di Iorio B, Bellasi A. Physical activity in chronic kidney disease: a plausible approach to vascular calcification? Kidney Blood Press Res 2014; 39:154-63. [PMID: 25117909 DOI: 10.1159/000355791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2014] [Indexed: 11/19/2022] Open
Abstract
Vascular calcification (VC) is a prominent feature that affects up to 40 to 80% of Chronic Kidney Disease (CKD) patients depending on the degree of renal impairment. Though etiology and pathogenesis of the different types of VC are far from being elucidated, it is conceivable that an imbalance between promoters and inhibitors represents the condition that triggers VC deposition and progression. In addition to traditional cardiovascular risk factors, several lines of evidence suggest that specific factors may affect the arterial system and prognosis in CKD. Over the last decade, a few pharmacological strategies aimed at controlling different selected risk factors for VC have been investigated yielding conflicting results. In light of the complicated interplay between inhibitors and promoters as well as the fact that VC represents the result of cumulative and prolonged exposure to multiple risk factors, a more comprehensive risk modification approach such as lifestyle modification or physical activity (PA) may represent a valid strategy to attenuate VC deposition and progression.We herein aim at reviewing the rationale and current evidence on the potential for lifestyle modification with a specific focus on PA as a cost-effective strategy for VC treatment.
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Affiliation(s)
- Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti (BA), Italy
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13
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Stompór T. Coronary artery calcification in chronic kidney disease: An update. World J Cardiol 2014; 6:115-129. [PMID: 24772252 PMCID: PMC3999332 DOI: 10.4330/wjc.v6.i4.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/10/2014] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
Arterial calcification is a well-recognized complication of advanced atherosclerosis. Chronic kidney disease (CKD) is characterized by significantly more pronounced, disseminated and fast-progressing calcification of the vascular system, including the coronary arteries. New computed tomography-based imaging techniques allow for the noninvasive assessment and monitoring of calcification in different vascular sites. Coronary artery calcification (CAC) develops early in the course of CKD and is tightly associated with mineral and bone disorders, which include but are not limited to secondary hyperparathyroidism. In this review, recent data on the pathogenesis of CAC development and progression are discussed, with a special emphasis on fibroblast growth factor 23 and its co-receptor, klotho. The prevalence, progression and prognostic significance of CAC are reviewed separately for patients with end-stage renal disease treated with dialysis, kidney transplant recipients and patients with earlier stages of CKD. In the last section, therapeutic considerations are discussed, with special attention paid to the importance of treatment that addresses mineral and bone disorders of CKD.
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14
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Kang K. Serum calcium and phosphate concentrations and intracranial atherosclerosis. Atherosclerosis 2014; 232:249-53. [DOI: 10.1016/j.atherosclerosis.2013.11.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/16/2013] [Accepted: 11/05/2013] [Indexed: 11/29/2022]
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15
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Adamidis KN, Pleros C, Oikonomaki T, Kyratzi I, Exarchos D, Metaxatos G, Drakopoulos S, Nikolopoulou N, Apostolou T. Progression of coronary artery calcification after kidney transplantation. Ren Fail 2013; 35:1075-8. [PMID: 23879313 DOI: 10.3109/0886022x.2013.815090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Calcification of coronary vessels progresses rapidly in hemodialysis (HD) patients and comprises a strong predictor of cardiovascular events. The aim of this prospective study was to evaluate the coronary artery calcification (CAC) in patients with end stage renal disease undergoing regular HD and to determine the effect of renal transplantation (RT) in the progression of CAC, using the Agatston technique for calcium scoring. The study included 20 patients with end-stage renal disease undergoing a regular HD treatment (16 males, 4 females) 54.1 ± 9.5 years old who had just received a renal transplant and 16 more HD patients (11 males, 5 females) 54.4 ± 13.8 years old as control group. The baseline evaluation showed a very high prevalence of CAC in both groups, which was positively correlated with age (p < 0.001) and CRP (p = 0.03). The second (follow-up) evaluation showed a significant slower progression of calcification after RT. In both groups, high calcium score values in the follow-up evaluation had a strong positive correlation with baseline calcium score (p < 0.001).
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Dharampal AS, de Feyter PJ. Coronary artery calcification: does it predict obstructive coronary artery disease? Neth Heart J 2013; 21:344-6. [PMID: 23846735 PMCID: PMC3722379 DOI: 10.1007/s12471-013-0436-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- A S Dharampal
- Department of Radiology, Erasmus MC, Room Ca 207a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands,
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Russo D, Morrone L, Imbriaco M, Pota A, Russo L, Scognamiglio B, Sorrentino R. Coronary Artery Calcification and Outcomes in Diabetic Patients with and without Chronic Kidney Disease. Blood Purif 2013; 36:17-20. [DOI: 10.1159/000350580] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Jiang J, Sun Y, Xiang MX, Dong L, Liu XB, Hu XY, Feng Y, Wang JA. Complex coronary lesions and rotational atherectomy: one hospital's experience. J Zhejiang Univ Sci B 2012; 13:645-51. [PMID: 22843185 DOI: 10.1631/jzus.b1201008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the safety and effectiveness of rotational atherectomy followed by drug eluting stent (DES) implantation in patients with complex coronary lesions. METHODS From August 2006 to August 2012, 253 consecutive patients with 289 lesions and who underwent rotational atherectomy in our center were enrolled in this study. RESULTS The overall procedure success rate was 98% with the cost of two (0.8%) coronary perforations, three (1.2%) dissections, five (2.0%) slow flows or no flows, three (1.2%) peri-procedure myocardial infarctions, and two (0.8%) in hospital deaths. During follow-up (mean three years), one (0.4%) patient died, two (0.8%) patients had acute myocardial infarction, 14 (5.5%) had restenosis, and target lesion revascularization occurred in eight patients (3.2%). CONCLUSIONS Rotational atherectomy followed by DES implantation is a safe and effective technique for patients with complex coronary lesions, especially calcified and non-dilatable lesions.
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Affiliation(s)
- Jun Jiang
- Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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19
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Yazbek D, de Carvalho A, Barros C, Marcassi A, Pestana J, Fachini F, Cassiolato J, Canziani M. Cardiovascular Disease in Early Kidney Transplantation: Comparison Between Living and Deceased Donor Recipients. Transplant Proc 2012. [DOI: 10.1016/j.transproceed.2012.03.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW The chronic kidney disease (CKD) mineral bone disorder syndrome encompasses a number of metabolic, bone as well as vascular abnormalities of which vascular calcification is a prominent feature. Several noninvasive imaging techniques provide physicians with useful prognostic information beyond traditional cardiovascular and CKD-specific risk factors. We review the most recent evidence on vascular calcification screening as a tool for risk stratification in CKD patients. RECENT FINDINGS Cardiovascular aging is accelerated and is associated with a poor prognosis in CKD patients. Numerous traditional and nontraditional risk factors have been associated with this outcome. Imaging markers and serological risk factors do not carry the same prognostic information. In fact, whereas serum biomarkers reflect the risk to which the individual is exposed at the time of measurement, imaging markers represent the cumulative result of prolonged exposure to one or multiple risk factors. As such, they have often been demonstrated to be better outcome predictors than serological markers. In some cases, imaging markers have been suggested as desirable targets of therapy or to guide treatment individualization. SUMMARY Recent evidence suggests that cardiovascular imaging allows for cardiovascular risk stratification and treatment individualization in CKD patients.
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Erbel R, Budoff M. Improvement of cardiovascular risk prediction using coronary imaging: subclinical atherosclerosis: the memory of lifetime risk factor exposure. Eur Heart J 2012; 33:1201-13. [PMID: 22547221 DOI: 10.1093/eurheartj/ehs076] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Deaths from diseases of the heart are decreasing. Cardiovascular diseases (CVD) will be the main cause of morbidity and mortality in 2015 according to a WHO report. The main problem is related to the long-time delay between the start of the development of atherosclerosis in young adults and the manifestation many decades later. Despite a recent decline in a CVD mortality rate in men and women, the main problem is related to the acute manifestation as the acute coronary syndrome, which leads 30-50% of subjects to sudden and fatal outcomes. In addition, about 20% of first and recurrent acute myocardial infarctions are silent. The lifetime risk of coronary artery disease after 40 years is 49% for men and 32% for women. That means, we are confronted with a major health care problem. This is even more obvious, when the rate of coronary heart disease deaths out of the hospital are taken into account which amount to 70% in 2007. These data are confirmed for Europe despite a strong decline of hospital deaths. Another problem is related to the fact that the number of sudden cardiac death amounts to >300 000 in the general US population. It is about 10 times higher than in those patients who are defined as prone to sudden death due to low ejection fraction, ventricular arrhythmias, and acute myocardial infarction. For cardiologists, this general topic becomes even more obvious, because even well-known cardiologists experienced early (≤65 years) sudden cardiac deaths such as RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline again what has been emphasized 15 years ago by the MONICA study that two-thirds of patients die outside the hospital and that we have to concentrate on primary and secondary prevention, also in memory of these colleagues. This review will demonstrate the potential value of coronary artery calcification screening which can be used as a sign of subclinical coronary arteriosclerosis for improved risk prediction, the first step to prevention. Subclinical atherosclerosis represents the vessel memory of risk factor exposure.
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Affiliation(s)
- Raimund Erbel
- Department of Cardiology, West-German Heart Center Essen, University Duisburg Essen, Hufelandstrasse 55, Essen, Germany.
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