Coronary Artery Calcium Scoring in Cardiovascular Risk Assessment

Associations of Neighborhood Environments and Socioeconomic Status With Subclinical Atherosclerosis: An Integrative Review

BACKGROUND

A limited understanding exists on the associations of neighborhood environment with subclinical atherosclerosis and its progression.

PURPOSE

The purpose of this integrative review was to explore associations of neighborhood environments and socioeconomic status (SES) with subclinical atherosclerosis and its long-term progression.

RESULTS

Three themes were identified: environmental exposure affects the natural history of atherosclerosis, neighborhood characteristics are associated with subclinical atherosclerosis, and individual SES is associated with development and progression of subclinical atherosclerosis more so than neighborhood SES. Some variations in results were noted based on the vascular site examined.

CLINICAL IMPLICATIONS

Disadvantaged neighborhoods and low SES are associated with greater subclinical atherosclerosis. Inconsistencies in a few studies seemed to be related to lack of coronary artery progression among the relatively young adults. This suggests further examination is needed of the contextual associations of neighborhood and SES with markers of generalized atherosclerosis, such as carotid intima-media thickness.

Advanced subclinical atherosclerosis: A novel category within the cardiovascular risk continuum with distinct treatment implications

Traditionally, guidelines divide patients into primary and secondary prevention for atherosclerotic cardiovascular disease (ASCVD) risk management. However, the modern understanding of the biological progression of atherosclerosis is inconsistent with this binary approach. Therefore, a new approach demonstrating both atherosclerosis and ASCVD risk as a continuum is needed to give clinicians a framework for better matching risk and intensity of therapy. Advances in coronary imaging have most clearly brought this problem into view, as for example coronary artery calcium (CAC) scoring has shown that some individuals in the primary prevention have equal or higher ASCVD risk as certain subgroups in secondary prevention. This article introduces "advanced subclinical atherosclerosis" as a new and distinct clinical group that sits between the traditional groups of primary and secondary prevention. Importantly, this article also introduces a new graphic to visualize this intermediate population that is explicitly based on plaque burden. The aim of the graphic is both to educate and to allow for better identification of a patient's cardiovascular risk and guide more effective risk-based management.

Association between gastroesophageal reflux disease and coronary atherosclerosis

Background and aim

Gastroesophageal reflux disease (GERD) typically presents with symptoms of heartburn and acid regurgitation but occasionally manifests as atypical chest pain. Coronary artery disease (CAD) and GERD share some risk factors, such as smoking and obesity. The aims of this study were to evaluate the association between GERD and coronary atherosclerosis and to assess the risk factors for coronary atherosclerosis in GERD patients.

Methods

A total of 16616 subjects who underwent upper gastrointestinal endoscopy from 2003 to 2017 and a cardiac computed tomography (CT) scan within one year were included in this study. Coronary atherosclerosis was evaluated by the coronary artery calcium score (CACS). The severity of GERD was evaluated based on endoscopic findings using the Los Angeles classification.

Results

The proportion of high CACSs (≥100) increased significantly in subjects with severe GERD (p = 0.008). However, the presence of a high CACS did not increase the risk of GERD (OR = 1.007, 95% CI 0.857–1.182), nor did that of GERD increase the risk of a high CACS (OR = 1.018, 95% CI 0.865–1.198). The risk factors for a high CACS in GERD patients included age (OR = 1.087, 95% CI 1.066–1.109), male sex (OR = 5.645, 95% CI 2.561–12.446), hypertension (OR = 1.800, 95% CI 1.325–2.446), and hypercholesterolemia (OR = 1.684, 95% CI 1.213–2.338).

Conclusions

Although the presence of a high CACS did not increase the risk of GERD or vice versa, the proportion of high CACSs was significantly higher in subjects with severe GERD. Therefore, it might be helpful to assess the CACS in GERD patients with multiple risk factors.

Feasibility of spectral shaping for detection and quantification of coronary calcifications in ultra-low dose CT

Objectives

To evaluate detectability and quantification of coronary calcifications for CT with a tin filter for spectral shaping.

Methods

Phantom inserts with 100 small and 9 large calcifications, and a moving artificial artery with 3 calcifications (speed 0–30 mm/s) were placed in a thorax phantom simulating different patient sizes. The phantom was scanned in high-pitch spiral mode at 100 kVp with tin filter (Sn100 kVp), and at a reference of 120 kVp, with electrocardiographic (ECG) gating. Detectability and quantification of calcifications were analyzed for standard (130 HU) and adapted thresholds.

Results

Sn100 kVp yielded lower detectability of calcifications (9 % versus 12 %, p = 0.027) and lower Agatston scores (p < 0.008), irrespective of calcification, patient size and speed. Volume scores of the moving calcifications for Sn100 kVp at speed 10–30 mm/s were lower (p < 0.001), while mass scores were similar (p = 0.131). For Sn100 kVp with adapted threshold of 117 HU, detectability (p = 1.000) and Agatston score (p > 0.206) were similar to 120 kVp. Spectral shaping resulted in median dose reduction of 62.3 % (range 59.0–73.4 %).

Conclusions

Coronary calcium scanning with spectral shaping yields lower detectability of calcifications and lower Agatston scores compared to 120 kVp scanning, for which a HU threshold correction should be developed.

Key points

• Sn100kVp yields lower detectability and lower Agatston scores compared to 120kVp

• Adapted HU threshold for Sn100kVp provides Agatston scores comparable to 120kVp

• Sn100 kVp considerably reduces dose in calcium scoring versus 120 kVp

Association of pooled cohort risk scores with vascular inflammation and coronary artery calcification in Korean adults

OBJECTIVES

A new pooled cohort risk equation to estimate atherosclerotic cardiovascular disease (CVD) risk was recently published, but the equation is based primarily on data from Caucasian populations. The relationship of this new risk scoring system with vascular inflammation and calcification has yet to be examined.

METHODS

A total of 74 participants were retrospectively selected based on inclusion and exclusion criteria. All participants underwent (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and multi-detector computed tomography (MDCT) examination in the Korea University Guro Hospital between June 2009 and May 2013. Vascular inflammation of the carotid artery was measured as target-to-background ratio (TBR) using (18)F-FDG-PET/CT and coronary artery calcification was quantified as Agatston score by MDCT.

RESULTS

Agatston scores were not significantly associated with any metabolic risk factors, but maximum TBR values exhibited a significant positive correlation with body mass index (r=0.31, P=0.01), waist circumference (r=0.42, P<0.01), waist-to-hip ratio (r=0.49, P<0.01), and systolic (r=0.35, P<0.01) and diastolic blood pressure (r=0.39, P<0.01). Furthermore, maximum TBR values were significantly correlated with serum high-sensitivity C-reactive protein (hsCRP) levels (r=0.26, P=0.03), whereas Agatston scores had no correlation. When pooled cohort risk equation scores were divided into incremental tertiles, age, waist circumference, waist-to-hip ratio and systolic blood pressure showed significant incremental trends. In particular, pooled cohort risk scores exhibited a significant positive correlation with maximum TBR values (r=0.35, P<0.01), but not with Agatston scores (r=0.11, P=0.34).

CONCLUSIONS

The pooled cohort risk equation exhibited significant positive correlations with vascular inflammation but not with calcification in Asian subjects without CVD, suggesting that this novel risk equation may detect early inflammatory changes preceding the structural modification of vessel walls.

Clinical Considerations for the Association between Vascular Damage and Chronic Kidney Disease

Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease. Recently, noninvasive and simple morphological and functional methods have been introduced to assess atherosclerotic vascular damage. This review describes the association of CKD with vascular damage as assessed by these methods. Carotid intima-media thickness (IMT) and coronary artery calcium score (CACS) are morphological parameters of vascular damage, and an ankle-brachial index (ABI) <0.90 suggests the presence of peripheral arterial disease (i.e., it represents advanced atherosclerosis). Several prospective studies have demonstrated that CKD is a risk factor for an increased IMT, an increased CACS and a decreased ABI. While it has not been clarified whether measuring the IMT or CACS might be useful to predict the progression of renal function decline, a reduced ABI has been demonstrated as a predictor of accelerated renal function decline. On the other hand, pulse wave velocity (PWV) is a marker of arterial stiffness rather than atherosclerosis, reflecting functional abnormalities caused by vascular damage, and moderate-to-severe CKD may be a risk factor for the progression of arterial stiffness. The measurement of functional markers, especially of PWV or pulse pressure, has been demonstrated to be useful to predict the rate of progression of renal function decline. Thus, renal dysfunction and atherogenic states may be components of a vicious cycle, and vascular function abnormalities associated with atherosclerosis may accelerate this cycle. As the next step, we propose to examine whether improvement of vascular function abnormalities can interrupt this vicious cycle.

Famine in childhood and postmenopausal coronary artery calcification: a cohort study

OBJECTIVE

To assess the effects of famine exposure during childhood on coronary calcium deposition and, secondarily, on cardiac valve and aortic calcifications.

DESIGN

Retrospective cohort.

SETTING

Community.

PATIENTS

286 postmenopausal women with individual measurements of famine exposure during childhood in the Netherlands during World War II.

INTERVENTION/EXPOSURE

Famine exposure during childhood.

MAIN OUTCOME MEASURES

Coronary artery calcifications measured by CT scan and scored using the Agatston method; calcifications of the aorta and cardiac valves (mitral and/or aortic) measured semiquantitatively. Logistic regression was used for coronary Agatston score of >100 or ≤100, valve or aortic calcifications as the dependent variable and an indicator for famine exposure as the independent variable. These models were also used for confounder adjustment and stratification based on age groups of 0-9 and 10-17 years.

RESULTS

In the overall analysis, no statistically significant association was found between severe famine exposure in childhood and a high coronary calcium score (OR 1.80, 95% CI 0.87 to 3.78). However, when looking at specific risk periods, severe famine exposure during adolescence was related to a higher risk for a high coronary calcium score than non-exposure to famine, both in crude (OR 3.47, 95% CI 1.00 to 12.07) and adjusted analyses (OR 4.62, 95% CI 1.16 to 18.43). No statistically significant association was found between childhood famine exposure and valve or aortic calcification (OR 1.66, 95% CI 0.69 to 4.10).

CONCLUSIONS

Famine exposure in childhood, especially during adolescence, seems to be associated with a higher risk of coronary artery calcification in late adulthood. However, the association between childhood famine exposure and cardiac valve/aortic calcification is less clear.