Prevalence of subclinical atherosclerosis in asymptomatic patients with low-to-intermediate risk by 64-slice computed tomography

Use of Coronary Computed Tomography Angiography to Screen Hospital Employees with Cardiovascular Risk Factors

The objective of this study was to determine how coronary computed tomography angiography (CCTA) can be employed to detect coronary artery disease in hospital employees, enabling early treatment and minimizing damage. All employees of our hospital were assessed using the Framingham Risk Score. Those with a 10-year risk of myocardial infarction or death of >10% were offered CCTA; the Coronary Artery Disease Reporting and Data System (CAD-RADS) score was the outcome. A total of 3923 hospital employees were included, and the number who had received CCTA was 309. Among these 309, 31 (10.0%) had a CAD-RADS score of 3-5, with 10 of the 31 (32.3%) requiring further cardiac catheterization; 161 (52.1%) had a score of 1-2; and 117 (37.9%) had a score of 0. In the multivariate logistic regression, only age of ≥ 55 years (p < 0.05), hypertension (p < 0.05), and hyperlipidemia (p < 0.05) were discovered to be significant risk factors for a CAD-RADS score of 3-5. Thus, regular and adequate control of chronic diseases is critical for patients, and more studies are required to be confirmed if there are more significant risk factors.

New sequential algorithm using Mac-2 binding protein glycosylation isomer to detect advanced carotid artery atherosclerosis

Background

Although carotid artery sonography is widely performed, most guidelines do not recommend this procedure in the general population. Appropriate indications and effective algorithms are needed to detect advanced carotid artery atherosclerosis in a community setting.

Methods

This study was designed as cross-sectional study. Adult subjects (n=228) who underwent a health check-up at our healthcare centre were included in the final analysis. Mac-2 binding protein glycosylation isomer (M2BPGi) quantification was based on a lectin antibody sandwich immunoassay. Subclinical atherosclerosis was diagnosed by carotid ultrasonography.

Results

The prevalence of subclinical atherosclerosis and advanced atherosclerosis was 37.2% (85/228) and 11.8% (27/228), respectively, in a community-based setting. Serum M2BPGi level was significantly higher in subjects with calcified plaque (0.6317) and luminal stenosis (0.6373) than in control groups (0.4913, all P<0.05). Pearson correlation analysis between M2BPGi and atherosclerotic cardiovascular disease (ASCVD) risk index (R=0.410, P<0.001) showed a positive relationship. The AUROC of serum M2BPGi for identifying calcified plaque or luminal stenosis was 0.679. The sequential algorithm using ASCVD and M2BPGi showed good negative predictive value (NPV) (93.6%) and reasonable positive predictive value (PPV) (53.8%) for identifying calcified plaque or luminal stenosis. When the sequential algorithm was used as an indicator for carotid ultrasonography, 35.0% (14/40) of subjects with intermediate-risk by ASCVD (≥7.5%) could avoid unnecessary carotid ultrasonography.

Conclusions

The sequential algorithm using ASCVD (≥7.5) and M2BPGi (≥0.525) provided reasonable indication for carotid artery sonography in a community-based setting.

Cardiovascular RiskprofilE - IMaging and gender-specific disOrders (CREw-IMAGO): rationale and design of a multicenter cohort study

Background

Reproductive disorders, such as polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI) and hypertensive pregnancy disorders (HPD) like pre-eclampsia (PE), are associated with an increased risk of cardiovascular disease (CVD). Detection of early signs of cardiovascular disease (CVD), as well as identification of risk factors among women of reproductive age which improve cardiovascular risk prediction, is a challenge and current models might underestimate long-term health risks. The aim of this study is to assess cardiovascular disease in patients with a history of a reproductive disorder by low-dose computed tomography (CT).

Methods

Women of 45 - 55 years, who experienced a reproductive disorder (PCOS, POI, HPD), are invited to participate in this multicenter, prospective, cohort study. Women will be recruited after regular cardiovascular screening, including assessment of classical cardiovascular risk factors. CT of the coronary arteries (both coronary artery calcium scoring (CACS), and contrast-enhanced coronary CT angiography (CCTA)) and carotid siphon calcium scoring (CSC) is planned in 300 women with HPD and 300 women with PCOS or POI. In addition, arterial stiffness (non-invasive pulse wave velocity (PWV)) measurement and cell-based biomarkers (inflammatory circulating cells) will be obtained.

Discussion

Initial inclusion is focused on women of 45 - 55 years. However, the age range (40 - 45 years and/or ≥ 55 years) and group composition may be adjusted based on the findings of the interim analysis. Participants can potentially benefit from information obtained in this study concerning their current cardiovascular health and expected future risk of cardiovascular events. The results of this study will provide insights in the development of CVD in women with a history of reproductive disorders. Ultimately, this study may lead to improved cardiovascular prediction models and will provide an opportunity for timely adjustment of preventive strategies. Limitations of this study include the possibility of overdiagnosis and the average radiation dose of 3.5 mSv during coronary and carotid siphon CT, although the increased lifetime malignancy risk is negligible.

Trial registration

Netherlands Trial Register, NTR5531. Date registered: October 21st, 2015.

Quantifying the risk of heart disease following acute ischaemic stroke: a meta-analysis of over 50,000 participants

OBJECTIVE

Following an acute stroke, there is a high risk of recurrence. However, the leading cause of mortality following a stroke is due to coronary artery disease (CAD) and myocardial infarction (MI) but that risk has not been robustly quantified. We sought to reliably quantify the risk of ischaemic heart disease (IHD) in patients presenting with acute ischaemic stroke (AIS) in the absence of a known cardiac history.

SETTING

A meta-analysis study. PubMed, MEDLINE, EMBASE and Google Scholar were searched for potential studies up to October 2015. Included studies reported an acute cerebral ischaemic event and followed for CAD or MI within 1 year in patients without known IHD. Using arcsine transformed proportions for meta-analysis, studies were combined using a generic inverse variance random-effects model to calculate the pooled standardised mean difference and 95% CIs. These were interpreted as the percentage prevalence of CAD or incidence of MI following AIS.

RESULTS

17 studies with 4869 patients with AIS demonstrated a mean average of asymptomatic CAD in 52%. Anatomical methods of CAD detection revealed a prevalence of asymptomatic ≥ 50% coronary stenosis in 32% (95% CI 19% to 47%; p<0.00001). 8 studies with 47229 patients with ischaemic stroke revealed an overall risk of MI in the year following stroke of 3% (95% CI 1% to 5%; p<0.00001) despite the absence of any cardiac history.

CONCLUSIONS

One-third of patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis and 3% are at risk of developing MI within a year. Our findings provide a reliable quantitative measure of the risk of IHD following AIS in patients with no cardiac history.

Determinants of future cardiovascular health in women with a history of preeclampsia

Women who develop preeclampsia have an increased risk of cardiovascular disease (CVD) later in life. However, current guidelines on cardiovascular risk assessment and prevention are unclear on how and when to screen these women postpartum, and about the role of a positive history of preeclampsia in later-life CVD risk management. The aim of this review is to discuss the present knowledge on commonly used cardiovascular screening modalities available to women with a history of preeclampsia, and to discuss recent developments in early detection of CVD using cardiovascular imaging. Furthermore, we explore how female-specific risk factors may have additional value in cardiovascular screening, in particular in relatively young women, although their implementation in clinical practice is challenged by inconsistent results and lack of long-term outcome data. Non-invasive imaging techniques, e.g., coronary artery intima-media thickness (CIMT), can be helpful to detect subclinical atherosclerotic disease, and coronary artery calcium scoring (CACS) has shown to be effective in early detection of cardiovascular damage. However, while more short-term and long-term follow-up studies are becoming available, few studies have investigated women with a history of preeclampsia in the fourth and fifth decade of life, when early signs of premature CVD are most likely to become apparent. Further studies are needed to inform new and improved clinical practice guidelines, and provide long-term strategies to effectively prevent CVD, specifically targeted at women with a history of preeclampsia. Additionally, evaluation of feasibility, cost-effectiveness, and implementation of CVD screening and prevention initiatives targeted at former preeclampsia patients are needed.

Decreased bone mineral density is associated with coronary atherosclerosis in healthy postmenopausal women

Objective

This study aimed to assess the association between bone mineral density (BMD) and coronary atherosclerosis in healthy postmenopausal women.

Methods

We performed a retrospective review of 252 postmenopausal women who had visited a health promotion center for a routine checkup. BMD of the lumbar spine (L1-L4) and femoral neck was evaluated using dual-energy X-ray absorptiometry, and coronary atherosclerosis was assessed using 64-row multidetector computed tomography. Participants were divided into normal BMD and osteopenia-osteoporosis groups, according to the T-scores of their lumbar spine or femoral neck.

Results

Participants with osteopenia-osteoporosis had a significantly higher proportion of coronary atherosclerosis than did those with normal BMD at the lumbar spine (P=0.003) and femoral neck (P=0.004). Osteopenia-osteoporosis at the lumbar spine (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.12 to 7.27) or femoral neck (OR, 3.35; 95% CI, 1.07 to 10.57) was associated with coronary atherosclerosis, after controlling for age and cardiovascular risk factors.

Conclusion

Decreased BMD is associated with coronary atherosclerosis in healthy postmenopausal women, independent of age and cardiovascular risk factors. Postmenopausal women with decreased BMD may have a higher risk of developing coronary atherosclerosis.

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Beyond Coronary Stenosis: Coronary Computed Tomographic Angiography for the Assessment of Atherosclerotic Plaque Burden

Coronary computed tomographic angiography (CCTA) is emerging as a key non-invasive method for assessing cardiovascular risk by measurement of coronary stenosis and coronary artery calcium (CAC). New advancements in CCTA technology have led to the ability to directly identify and quantify the so-called "vulnerable" plaques that have features of positive remodeling and low density components. In addition, CCTA presents a new opportunity for noninvasive measurement of total coronary plaque burden that has not previously been available. The use of CCTA needs also to be balanced by its risks and, in particular, the associated radiation exposure. We review current uses of CCTA, CCTA's ability to measure plaque quantity and characteristics, and new developments in risk stratification and CCTA technology. CCTA represents a quickly developing field that will play a growing role in the non-invasive management of cardiovascular disease.

Carotid Doppler ultrasonography as a surrogate for coronary CT angiography to exclude subclinical coronary atherosclerosis in asymptomatic patients with a negative coronary calcium score

PURPOSE

To evaluate the diagnostic accuracy of carotid Doppler ultrasonography (CDU) to predict the presence of subclinical coronary atherosclerosis in asymptomatic subjects with a zero coronary calcium score.

METHODS

Retrospective study of CDU and coronary CT angiography (CTA) findings in 118 asymptomatic subjects with a zero calcium score. CDU was considered abnormal when carotid intima-media thickness was >75 percentile or was ≥ 1 mm, or in presence of carotid plaque(s). We analyzed the diagnostic accuracy of CDU to predict the presence of non-calcified coronary plaque in comparison with coronary CTA.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of abnormal CDU to identify the presence of non-calcified coronary plaque on coronary CTA were 82.4% [(14/17); 95% confidence interval (CI), 56.6%-96.2%], 53.5% [(54/101); 95% CI, 43.3%-63.5%], 23.0% [(14/61); 95% CI, 13.1%-35.6%], and 94.7% [(54/57); 95% CI, 85.4%-98.9%], respectively.

CONCLUSIONS

Although CDU has a low PPV for identifying the presence of non-calcified plaque on coronary CTA, its NPV is high to exclude subclinical coronary atherosclerosis in asymptomatic subjects with a zero calcium score.

Coronary CT angiography: how should physicians use it wisely and when do physicians request it appropriately?

Coronary CT angiography has been increasingly used in the diagnosis of coronary artery disease due to rapid technological developments, which are reflected in the improved spatial and temporal resolution of the images. High diagnostic accuracy has been achieved with 64- and more slice CT scanners and in selected patients, coronary CT angiography is regarded as a reliable alternative to invasive coronary angiography. Although the tremendous contributions of coronary CT angiography to cardiac imaging are acknowledged, appropriate use of cardiac CT as the first line technique by physicians has not been well established. Optimal selection of cardiac CT is essential to ensure acquisition of valuable diagnostic information and avoid unnecessary invasive procedures. This is of paramount importance since cardiac CT not only involves patient risk assessment, prediction of major cardiac events, but also impacts physician decision-making on patient management. Applications of CT in cardiac imaging include coronary artery calcium scoring for predicting the patient risk of developing major cardiac events, followed by coronary CT angiography which is commonly used to determine the diagnostic and prognostic accuracy in the coronary artery disease. This review presents an overview of the applications of CT in cardiac imaging in terms of coronary calcium scoring and coronary CT angiography. Judicious use of both cardiac CT tools will be discussed with regard to their value in different patient risk groups with the aim of identifying the appropriate criteria for choosing a cardiac CT modality. An effective diagnostic pathway is finally recommended to physicians for appropriate selection of cardiac CT in clinical practice.

Computed tomography-coronary angiography in the detection of coronary artery disease

Computed tomography-coronary angiography (CT-CA) is a well-tolerated and reliable non-invasive imaging technique and can now be achieved at low levels of radiation exposure. CT-CA is highly valuable to exclude coronary artery disease, but due to over- and underestimation of the severity of coronary lesions, CT-CA cannot replace invasive coronary angiography. Coronary calcium scoring has an incremental independent prognostic value beyond traditional risk factor scores (Framingham, European Score) and may be useful to reclassify risk in asymptomatic individuals at intermediate risk. Appropriate indications for CT-CA are evolving, but studies are lacking to demonstrate that CT coronary imaging improves patient outcome.