Role of coronary artery calcium score in the primary prevention of cardiovascular disease

Correlation of neck circumference, coronary calcification severity and cardiovascular events in Chinese elderly patients with acute coronary syndromes

BACKGROUND AND AIMS

We aimed to investigate whether neck circumference (NC) can predict metabolic syndrome (MetS), coronary calcification and lesion, and major adverse cardiovascular events (MACEs).

METHODS

A total of 867 patients with acute coronary syndrome (ACS) over 60 years old from the Second Hospital of Shandong University, who had undergone coronary computed tomography, were randomly selected for a retrospective analysis. The subjects were divided into male and female groups, NC quartile 1-4 groups (Q1-Q4 groups), non-multivessel coronary disease (non-MVCD) and multi-vessel coronary disease (MVCD) groups.

RESULTS

After adjusting for potential confounders, NC was associated with risk factors promoting coronary artery disease (CAD) and coronary artery calcification score (CACS). The severity of CAD increased by 0.202 times and 0.372 times for each unit of NC in male and female groups, respectively. Compared with the lower CACS group, the risk of coronary calcification increased by 0.139 times, and MVCD increased 0.268 times, with each unit increase of NC. Except for all-cause death, there were significant differences between the Q1-Q4 groups in the prevalence of all primary endpoints, cardiogenic death, unexpected re-hospitalization of heart failure, ACS recurrence or unplanned revascularization, and non-fatal stroke (p log-rank <0.01). In view of the overall trend, with the increase of NC quartiles, the prevalence of MACEs gradually increased (all p < 0.01).

CONCLUSIONS

NC is closely associated with MetS and its components, coronary calcification and lesion degree, and MACEs. NC could be used as surrogate of CACS to predict the coronary condition and prognosis of elderly patients with ACS.

Small dense low-density lipoprotein cholesterol and coronary artery calcification in the Multi-Ethnic Study of Atherosclerosis

AIMS

Elevated small dense LDL cholesterol (sd-LDL-C) increases atherosclerotic cardiovascular disease (CVD) risk. Although coronary artery calcification (CAC) is widely used for predicting CVD events, few studies have examined the relationship between sd-LDL-C and CAC.

METHODS AND RESULTS

This study included 4672 individuals with directly measured baseline sd-LDL-C and CAC from the Multi-Ethnic Study of Atherosclerosis [mean (standard deviation) age: 61.9 (10.4) years; 52.5% women; 47.3% with baseline CAC (mean score >0)]. We used multi-variable general linear models and restricted cubic splines with the goodness of fit testing to evaluate the association of sd-LDL-C with the presence of CAC. Odds ratios [OR (95% confidence interval)] were adjusted for demographics and cardiovascular risk factors, including estimated total LDL-C. Higher quartiles of sd-LDL-C were associated with the presence of CAC, even after accounting for total LDL-C. Compared with the lowest quartile of sd-LDL-C, participants in Quartiles 2, 3, and 4 had higher odds for the presence of baseline CAC [Quartile 2 OR: 1.24 (1.00, 1.53); Quartile 3 OR: 1.51 (1.19, 1.93); and Quartile 4 OR 1.59 (1.17, 2.16)]. Splines suggested a quadratic curvilinear relationship of continuous sd-LDL-C with CAC after adjustment for demographics and CVD risk factors (quadratic vs. first-order sd-LDL-C terms likelihood ratio test: P = 0.015), but not after accounting for total LDL-C (quadratic vs. first-order terms: P = 0.156).

CONCLUSION

In a large, multi-ethnic sample without known CVD, higher sd-LDL-C was associated with the presence of CAC, above and beyond total LDL-C. Whether selective direct measurement of sd-LDL-C is indicated to refine cardiovascular risk assessment in primary prevention warrants further investigation.

Epidemiology and Prognostic Implications of Coronary Artery Calcium in Asymptomatic Individuals With Prediabetes: A Multicohort Study

OBJECTIVE

To describe the epidemiology and prognostic value of coronary artery calcium (CAC) in individuals with prediabetes.

RESEARCH DESIGN AND METHODS

We pooled participants free of clinical atherosclerotic cardiovascular disease (ASCVD) from four prospective cohorts: the Multi-Ethnic Study of Atherosclerosis, Heinz Nixdorf Recall Study, Framingham Heart Study, and Jackson Heart Study. Two definitions were used for prediabetes: inclusive (fasting plasma glucose [FPG] ≥100 to <126 mg/dL and hemoglobin A1c [HbA1c] ≥5.7% to <6.5%, if available, and no glucose-lowering medications) and restrictive (FPG ≥110 to <126 mg/dL and HbA1c ≥5.7% to <6.5%, if available, among participants not taking glucose-lowering medications).

RESULTS

The study included 13,376 participants (mean age 58 years; 54% women; 57% White; 27% Black). The proportions with CAC ≥100 were 17%, 22%, and 37% in those with euglycemia, prediabetes, and diabetes, respectively. Over a median (25th-75th percentile) follow-up time of 14.6 (interquartile range 7.8-16.4) years, individuals with prediabetes and CAC ≥100 had a higher unadjusted 10-year incidence of ASCVD (13.4%) than the overall group of those with diabetes (10.6%). In adjusted analyses, using the inclusive definition of prediabetes, compared with euglycemia, the hazard ratios (HRs) for ASCVD were 0.79 (95% CI 0.62, 1.01) for prediabetes and CAC 0, 0.70 (0.54, 0.89) for prediabetes and CAC 1-99, 1.54 (1.27, 1.88) for prediabetes and CAC ≥100, and 1.64 (1.39, 1.93) for diabetes. Using the restrictive definition, the HR for ASCVD was 1.63 (1.29, 2.06) for prediabetes and CAC ≥100.

CONCLUSIONS

CAC ≥100 is frequent among individuals with prediabetes and identifies a high ASCVD risk subgroup in which the adjusted ASCVD risk is similar to that in individuals with diabetes.

Distal Upper Extremity Arterial Calcification as a Predictor for Subclinical Coronary Artery Disease by Coronary Artery Calcium Scoring

Several studies have linked calcification of the thoracic and lower extremity arterial trunks to an increased risk of developing coronary artery disease (CAD). Calcifications of the radial and/or ulnar artery are regularly identified in hand/wrist x-rays; however, the clinical relevance of these findings as related to identifying subclinical CAD is not well understood. Associations between CAD and upper extremity calcifications have been reported, but the timeline is unclear. The purpose of this study was to evaluate the association between upper extremity arterial calcifications on hand radiographs with CAD by coronary artery calcification (CAC) scoring in patients with no known history of CAD. This is a pilot single-center, prospective, matched cohort study. We included patients with no known history of CAD, related symptoms, or major risk factors. We recruited five patients with calcifications (cal+) and five patients matched by age, race, sex, and medical history but without calcifications (cal-). CAC scores were determined from computed tomography scanning, and lipid profile was evaluated. In the cal+ group, the mean CAC total score was 244.1; in the control (cal-) group, it was 85.2. The mean total cholesterol levels were 220.8 mg per dL and 167 mg per dL in the cal+ and cal- groups, respectively. Two cal+ patients with CAC scores of 937 and 669 died shortly after being enrolled in our study. Preliminary findings suggest that calcifications in the radial or ulnar artery in otherwise asymptomatic patients with no history of CAD may be an independent sign of CAD.

A machine learning approach to predicting vascular calcification risk of type 2 diabetes: A retrospective study

BACKGROUND

Recently, patients with type 2 diabetes mellitus (T2DM) have experienced a higher incidence and severer degree of vascular calcification (VC), which leads to an increase in the incidence and mortality of vascular complications in patients with T2DM.

HYPOTHESIS

To construct and validate prediction models for the risk of VC in patients with T2DM.

METHODS

Twenty-three baseline demographic and clinical characteristics were extracted from the electronic medical record system. Ten clinical features were screened with least absolute shrinkage and selection operator method and were used to develop prediction models based on eight machine learning (ML) algorithms (k-nearest neighbor [k-NN], light gradient boosting machine, logistic regression [LR], multilayer perception [(MLP], Naive Bayes [NB], random forest [RF], support vector machine [SVM], XGBoost [XGB]). Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, and precision.

RESULTS

A total of 1407 and 352 patients were retrospectively collected in the training and test sets, respectively. Among the eight models, the AUC value in the NB model was higher than the other models (NB: 0.753, LGB: 0.719, LR: 0.749, MLP: 0.715, RF: 0.722, SVM: 0.689, XGB:0.707, p < .05 for all). The k-NN model achieved the highest sensitivity of 0.75 (95% confidence interval [CI]: 0.633-0.857), the MLP model achieved the highest accuracy of 0.81 (95% CI: 0.767-0.852) and specificity of 0.875 (95% CI: 0.836-0.912).

CONCLUSIONS

This study developed a predictive model of VC based on ML and clinical features in type 2 diabetic patients. The NB model is a tool with potential to facilitate clinicians in identifying VC in high-risk patients.

Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system

OBJECTIVES

Among primary prevention-type adults not on lipid-lowering therapy, conflicting results exist on the relationship between low-density lipoprotein cholesterol (LDL-C) and long-term mortality. We evaluated this relationship in a real-world evidence population of adults.

DESIGN

Retrospective cohort study.

SETTING

Electronic medical record data for adults, from 4 January 2000 through 31 December 2022, were extracted from the University of Pittsburgh Medical Center healthcare system.

PARTICIPANTS

Adults without diabetes aged 50-89 years not on statin therapy at baseline or within 1 year and classified as primary prevention-type patients. To mitigate potential reverse causation, patients who died within 1 year or had baseline total cholesterol (T-C) ≤120 mg/dL or LDL-C <30 mg/dL were excluded.

MAIN EXPOSURE MEASURE

Baseline LDL-C categories of 30-79, 80-99, 100-129, 130-159, 160-189 or ≥190 mg/dL.

MAIN OUTCOME MEASURE

All-cause mortality with follow-up starting 365 days after baseline cholesterol measurement.

RESULTS

177 860 patients with a mean (SD) age of 61.1 (8.8) years and mean (SD) LDL-C of 119 (31) mg/dL were evaluated over a mean of 6.1 years of follow-up. A U-shaped relationship was observed between the six LDL-C categories and mortality with crude 10-year mortality rates of 19.8%, 14.7%, 11.7%, 10.7%, 10.1% and 14.0%, respectively. Adjusted mortality HRs as compared with the referent group of LDL-C 80-99 mg/dL were: 30-79 mg/dL (HR 1.23, 95% CI 1.17 to 1.30), 100-129 mg/dL (0.87, 0.83-0.91), 130-159 mg/dL (0.88, 0.84-0.93), 160-189 mg/dL (0.91, 0.84-0.98) and ≥190 mg/dL (1.19, 1.06-1.34), respectively. Unlike LDL-C, both T-C/HDL cholesterol (high-density lipoprotein cholesterol) and triglycerides/HDL cholesterol ratios were independently associated with long-term mortality.

CONCLUSIONS

Among primary prevention-type patients aged 50-89 years without diabetes and not on statin therapy, the lowest risk for long-term mortality appears to exist in the wide LDL-C range of 100-189 mg/dL, which is much higher than current recommendations. For counselling these patients, minimal consideration should be given to LDL-C concentration.

Mammography-based deep learning model for coronary artery calcification

AIMS

Mammography, commonly used for breast cancer screening in women, can also predict cardiovascular disease. We developed mammography-based deep learning models for predicting coronary artery calcium (CAC) scores, an established predictor of coronary events.

METHODS AND RESULTS

We evaluated a subset of Korean adults who underwent image mammography and CAC computed tomography and randomly selected approximately 80% of the participants as the training dataset, used to develop a convolutional neural network (CNN) to predict detectable CAC. The sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), and overall accuracy of the model's performance were evaluated. The training and validation datasets included 5235 and 1208 women, respectively [mean age, 52.6 (±10.2) years], including non-zero cases (46.8%). The CNN-based deep learning prediction model based on the Resnet18 model showed the best performance. The model was further improved using contrastive learning strategies based on positive and negative samples: sensitivity, 0.764 (95% CI, 0.667-0.830); specificity, 0.652 (95% CI, 0.614-0.710); AUROC, 0.761 (95% CI, 0.742-0.780); and accuracy, 70.8% (95% CI, 68.8-72.4). Moreover, including age and menopausal status in the model further improved its performance (AUROC, 0.776; 95% CI, 0.762-0.790). The Framingham risk score yielded an AUROC of 0.736 (95% CI, 0.712-0.761).

CONCLUSION

Mammography-based deep learning models showed promising results for predicting CAC, performing comparably to conventional risk models. This indicates mammography's potential for dual-risk assessment in breast cancer and cardiovascular disease. Further research is necessary to validate these findings in diverse populations, with a particular focus on representation from national breast screening programmes.

The Zero Calcium Score Paradox

Our study presents a case of angina with a zero calcium score yet severe coronary stenosis from noncalcified plaque. We highlight the limitation of otherwise prognostically powerful coronary calcium score as a singular predictive tool especially when used in symptomatic patients.

The relationship between coronary artery calcium and layer-specific global longitudinal strain in patients with suspected coronary artery disease

PURPOSE

Layer-specific global longitudinal strain (GLS) may provide important insights in patients with suspected coronary artery disease (CAD). We aimed to investigate the association between layer-specific GLS and coronary artery calcium score (CACS) in patients suspected of CAD.

METHODS

We performed a retrospective study of patients suspected of CAD who underwent both an echocardiogram and cardiac computed tomography (median 42 days between). Layer-specific (endocardial-, whole-layer-, and epicardial-) GLS was measured using speckle tracking echocardiography. We assessed the continuous association between layer-specific GLS and CACS by negative binomial regression, and the association with high CACS (≥400) using logistic regression.

RESULTS

Of the 496 patients included (mean age 59 years, 56% male), 64 (13%) had a high CACS. Those with high CACS had reduced GLS in all layers compared to those with CACS < 400 (endocardial GLS: -20.5 vs. -22.7%, whole-layer GLS: -17.7 vs. -19.4%, epicardial GLS: -15.3 vs. -16.9%, p < .001 for all). Negative binomial regression revealed a significant continuous association showing increasing CACS with worsening GLS in all layers, which remained significant after multivariable adjustment including SCORE chart risk factors. All layers of GLS were associated with high CACS in univariable analyses, which was consistent after multivariable adjustment (endocardial GLS: OR = 1.11 (1.03-1.20); whole-layer GLS: OR = 1.14 (1.04-1.24); epicardial GLS: OR = 1.16 (1.05-1.29), per 1% absolute decrease).

CONCLUSION

In this study population with patients suspected of CAD and normal systolic function, impaired layer-specific GLS was continuously associated with increasing CACS, and decreasing GLS in all layers were associated with presence of high CACS.

Effect of dapagliflozin on epicardial fat volume in patients with acute coronary syndrome assessed by computed tomography

BACKGROUND AND AIM

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce cardiovascular outcomes; one of the target organs is epicardial adipose tissue, achieving a 10-20% change in patients with diabetes but excluding acute coronary syndrome (ACS), Therefore, the aim was to evaluate the effect of dapagliflozin on epicardial fat in patients with ACS assessed by non-contrast cardiac tomography (CT) and its association with major adverse cardiovascular events (MACE).

METHODS AND RESULTS

This cohort nested case-control study included 52 patients with type 2 diabetes (T2D) and acute myocardial infarction with and without ST-segment elevation. Cases were defined as all patients assigned to dapagliflozin 10 mg, and controls were patients assigned to placebo. Treatment was initiated in-hospital and after percutaneous coronary intervention, and non-contrasted CT was performed at baseline and after 12 months of treatment. In the dapagliflozin group, 4 MACE occurred and 10 in the placebo group (p=0.027), with an odds ratio (OR) of 0.317 (95% CI 0.114-0.882) for the dapagliflozin. Basal epicardial fat volume (EFV) was 117.20 ± 42.65 cm3 in the dapagliflozin group and 123.84 ± 46.9 cm3 in the placebo group, p= 0.596, with an OR of 1.016 (95% CI 0.999-1.033) for MACE. Final EFV was 128.30 ± 37.53 cm3 in the dapagliflozin group and 137.05 ± 50.59 cm3 in the placebo group, p= 0.520.

CONCLUSIONS

Epicardial fat is a risk factor for MACE and increased after 12 months of follow-up in patients with ACS and there was no effect on volume change with the use of dapagliflozin. (ClinicalTrials.gov NCT05998525).

Aortic calcification correlates with pseudoaneurysm or penetrating aortic ulcer of different etiologies

Chronic risk factors for pseudoaneurysm (PSA) or penetrating aortic ulcer (PAU) have not been fully clarified. This study aims to evaluate the association of aortic calcification with PSA or PAU of different etiologies. Totally 77 pseudoaneurysms, 80 PAU, and 160 healthy controls (HCs) were retrospectively included, of which 30 were infected, 34 were immunological, and 93 were atherosclerotic etiologies. The aortic calcification status, position of aortic tears/ulcers, and risk factors for disease or acute aortic syndrome (AAS) were identified. Atherosclerotic patients aged more than 65 and infective patients aged more than 60 had significantly higher calcification scores. The immunological group had a lower level of calcification in the infrarenal aorta. For patients of infective or atherosclerotic etiology, 60% (18/30) and 60.22% (56/93) of the tears/ulcers occurred at the aortic parts with the highest level of calcification. Patients with longitudinal calcification exceeding 1/3 of the aortic arch had an increased risk of acquiring diseases (OR = 13.231). The presence of longitudinal calcification of the descending aorta or cross-sectional calcification of the infrarenal aorta increased the risks of acquiring diseases (OR = 8.484 and 8.804). After adjusting for age, longitudinal calcification of the descending aorta exceeding 1/3 length was found to be associated with AAS (OR = 4.662). Tears/ulcers of pseudoaneurysm and PAU were both generally found at the part of the aorta with most calcification. Distinct aorta calcification characteristics were observed for lesions of different etiologies. Longitudinal thoracic and cross-sectional infrarenal abdominal aortic calcification increased the risk of acquiring diseases, and descending aortic calcification was associated with symptomatic patients.

Social disadvantage, coronary artery calcium, and their interplay in the prediction of atherosclerotic cardiovascular disease events

BACKGROUND AND AIMS

Social determinants of health (SDOH) are key for the identification of populations at increased risk of atherosclerotic cardiovascular disease (ASCVD). However, whether at the individual level SDOH improve current ASCVD risk prediction paradigms beyond traditional risk factors and the coronary artery calcium (CAC) score, is unknown. We evaluated the interplay between CAC and SDOH in ASCVD risk prediction.

METHODS

MESA is a prospective study of US adults free of clinical ASCVD at baseline. We used an SDOH index inclusive of 14 determinants from 5 domains. The index ranged 0-1 and was divided into quartiles, with higher ones representing worse SDOH. Cox regression was used to evaluate the adjusted associations between CAC, SDOH, their interplay, and ASCVD events. The C-statistic was computed to assess improvement in risk discrimination for prediction of ASCVD events.

RESULTS

We included 6479 MESA participants (50% with CAC = 0, 24% CAC>100). ASCVD incidence increased with increasing CAC scores across SDOH quartiles. The lowest incidence was noted in those with CAC = 0 and favourable SDOH (2/1000 person-years) and highest in those with CAC>100 and most unfavourable SDOH (20.6/1000 person-years). While CAC was strongly associated with ASCVD across SDOH quartiles, SDOH was weakly associated with ASCVD across CAC strata. CAC improved the discriminatory ability of all prediction models beyond traditional risk factors, the improvement in C-statistic ranging +0.02 - +0.05. Improvements with SDOH were smaller, and were none on top of CAC.

CONCLUSIONS

CAC improves ASCVD risk stratification across the spectrum of social vulnerability, while SDOH fail to improve risk prediction beyond traditional RFs and CAC.

The association of lipoprotein (a) with coronary artery calcification: A systematic review and meta-analysis

BACKGROUND AND AIMS

Coronary artery calcification (CAC) is a crucial pathophysiological characteristic of atherosclerosis. The association between lipoprotein (a) [Lp(a)] and CAC is inconsistent. We aimed to assess the relationship between Lp(a) and CAC by exploring the association between elevated Lp(a) and CAC prevalence, the relationship between Lp(a) level and CAC prevalence, and the correlation between elevated Lp(a) and CAC progression.

METHODS

We searched the PubMed, Web of Science, and EMBASE databases up to November 01, 2023. Studies exploring the association between serum Lp(a) and CAC (quantified using the Agatston score) were included. Association between Lp(a) level or elevated Lp(a) (higher than the cutoff values of 30 mg/dL, 50 mg/dL, or the highest quartile ranging from 33 to 38.64 mg/dL) and prevalence [CAC score >0 or >100, log (CAC score+1) >0] or progression (an increase in CAC score >0 or ≥100) of CAC were analysed. Odds ratios and 95% confidence intervals were calculated using a random-effects model.

RESULTS

40,073 individuals from 17 studies were included. Elevated Lp(a) was associated with a higher prevalence of CAC (OR, 1.31; 95% CI, 1.06 to 1.61; p = 0.01). As a continuous variable, Lp(a) level was positively correlated with the prevalence of CAC (OR, 1.05; 95% CI, 1.02 to 1.08; p = 0.003). Furthermore, elevated Lp(a) was associated with greater CAC progression (OR, 1.54; 95% CI, 1.23 to 1.92; p = 0.0002).

CONCLUSIONS

This meta-analysis suggested that Lp(a) is associated with prevalence and progression of CAC. Further studies are required to explore whether Lp(a)-lowering therapy could prevent or inhibit CAC, ultimately reducing coronary artery disease risk.

The incremental value of coronary artery calcium score in predicting long-term prognosis and defining the warranty period of normal adenosine stress-only myocardial perfusion imaging using CZT SPECT

BACKGROUND

Normal stress-only (SO) myocardial perfusion imaging (MPI) using SPECT reduces imaging time and radiation dose with a good prognosis. However, the long-term prognostic value of combining coronary artery calcium score (CACS) with SO MPI to determine the warranty period remains unknown. Hence, we assessed the incremental prognostic value of CACS and its impact on the warranty period of normal SO MPI using SPECT.

METHODS

We retrospectively included 1375 symptomatic patients without a history of coronary artery disease (CAD) and a normal SO MPI using adenosine who underwent simultaneous CAC scoring. Annual major adverse cardiac events (MACE) rates were calculated for CACS categories: 0, 1-399, 400-999, and ≥1000.

RESULTS

The mean age was 60.0 ± 11.8 years (66.9% female) with a median follow-up of 10.3 [IQR 9.6-10.9] years. The warranty period for annual MACE rate for normal SO SPECT extended the total follow-up time in years. MACE rate categorized by CAC categories demonstrated an increase in MACE rates with increasing CACS; CACS 0 and CACS 1-399 were associated with a 10-year warranty period, CACS 400-999 had a warranty period of 4 years and no warranty period could be given for CACS≥1000 (5.9 % at 1 year).

CONCLUSIONS

CACS as an adjunct to normal pharmacological SO MPI provides additional prognostic information and aids in determining a warranty period.

Predictors of long-term absence of coronary artery calcium in individuals with high blood pressure: results from the MESA study

BACKGROUND & AIMS

Individuals with high blood pressure (BP) have varying risks of cardiovascular events due to other coexisting factors. We aimed to identify the predictors of long-term absence of coronary artery calcium (CAC) in individuals with high BP, which is an indicator of healthy arterial aging and can guide preventive strategies.

METHODS

We analyzed data from participants with high BP (≥120/80 mm Hg) in the Multi-Ethnic Study of Atherosclerosis who had baseline CAC = 0 and underwent a second CAC scanning after 10 years. We used multivariable logistic regression to evaluate the association between various risk factors for atherosclerotic cardiovascular disease (ASCVD) and long-term CAC = 0. We also calculated the area under the receiver operating characteristic curve (AUC) to predict the phenotype of healthy arterial aging in this population.

RESULTS

We included 830 participants (37.6% male, mean ± SD age of 59.4 ± 8.7 years). During follow-up, 46.5% of participants (n = 386) had CAC = 0, and they were younger and had fewer metabolic syndrome components. Adding ASCVD risk factors to the demographic model (age, sex, and ethnicity) moderately increased the predictive value for long-term CAC = 0 (AUC: demographic model + ASCVD risk factors vs. demographic model alone, 0.653 vs. 0.597, p < .001; category net reclassification improvement = 0.104, p = .044; integrated discrimination improvement = 0.040, p < .001).

CONCLUSION

In individuals with high BP and initial CAC = 0, over 40% maintained CAC = 0 during a 10-year follow-up, which was associated with fewer ASCVD risk factors. These findings may have implications for preventive strategies in individuals with high BP.Clinical Trial registration number: The MESA was registered at clinical trials. gov as NCT00005487.KEY MESSAGESNearly half (46.5%) of individuals with high blood pressure (BP) maintained a long-term absence of coronary artery calcium (CAC) during a 10-year follow-up, and this was associated with a 66.6% lower risk of atherosclerotic cardiovascular disease (ASCVD) events compared to those who developed incident CAC.Individuals with high BP, who are usually assumed to have an increased risk of ASCVD, exhibit significant heterogeneity in their ASCVD risk; those who maintain CAC = 0 have a lower ASCVD risk.Adding overall ASCVD risk factors to demographic information resulted in a moderate improvement in predicting long-term CAC = 0.

Association between the homeostasis model assessment of insulin resistance and coronary artery calcification: a meta-analysis of observational studies

Background

Insulin resistance (IR), a risk factor for cardiovascular diseases, has garnered significant attention in scientific research. Several studies have investigated the correlation between IR and coronary artery calcification (CAC), yielding varying results. In light of this, we conducted a systematic review to investigate the association between IR as evaluated by the homeostasis model assessment (HOMA-IR) and CAC.

Methods

A comprehensive search was conducted to identify relevant studies in PubMed, Embase, Scopus, and Web of Science databases. In addition, preprint servers such as Research Square, BioRxiv, and MedRxiv were manually searched. The collected data were analyzed using either fixed or random effects models, depending on the heterogeneity observed among the studies. The assessment of the body of evidence was performed using the GRADE approach to determine its quality.

Results

The current research incorporated 15 studies with 60,649 subjects. The analysis revealed that a higher category of HOMA-IR was associated with a greater prevalence of CAC in comparison to the lowest HOMA-IR category, with an OR of 1.13 (95% CI: 1.06-1.20, I2 = 29%, P < 0.001). A similar result was reached when HOMA-IR was analyzed as a continuous variable (OR: 1.27, 95% CI: 1.14-1.41, I2 = 54%, P < 0.001). In terms of CAC progression, a pooled analysis of two cohort studies disclosed a significant association between increased HOMA-IR levels and CAC progression, with an OR of 1.44 (95% CI: 1.04-2.01, I2 = 21%, P < 0.05). It is important to note that the strength of the evidence was rated as low for the prevalence of CAC and very low for the progression of CAC.

Conclusion

There is evidence to suggest that a relatively high HOMA-IR may be linked with an increased prevalence and progression of CAC.

Urinary Metal Levels and Coronary Artery Calcification: Longitudinal Evidence in the Multi-Ethnic Study of Atherosclerosis (MESA)

Objective

Growing evidence indicates that exposure to metals are risk factors for cardiovascular disease (CVD). We hypothesized that higher urinary levels of metals with prior evidence of an association with CVD, including non-essential (cadmium , tungsten, and uranium) and essential (cobalt, copper, and zinc) metals are associated with baseline and rate of change of coronary artery calcium (CAC) progression, a subclinical marker of atherosclerotic CVD.

Methods

We analyzed data from 6,418 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with spot urinary metal levels at baseline (2000-2002) and 1-4 repeated measures of spatially weighted coronary calcium score (SWCS) over a ten-year period. SWCS is a unitless measure of CAC highly correlated to the Agatston score but with numerical values assigned to individuals with Agatston score=0. We used linear mixed effect models to assess the association of baseline urinary metal levels with baseline SWCS, annual change in SWCS, and SWCS over ten years of follow-up. Urinary metals (adjusted to μg/g creatinine) and SWCS were log transformed. Models were progressively adjusted for baseline sociodemographic factors, estimated glomerular filtration rate, lifestyle factors, and clinical factors.

Results

At baseline, the median and interquartile range (25th, 75th) of SWCS was 6.3 (0.7, 58.2). For urinary cadmium, the fully adjusted geometric mean ratio (GMR) (95%Cl) of SWCS comparing the highest to the lowest quartile was 1.51 (1.32, 1.74) at baseline and 1.75 (1.47, 2.07) at ten years of follow-up. For urinary tungsten, uranium, and cobalt the corresponding GMRs at ten years of follow-up were 1.45 (1.23, 1.71), 1.39 (1.17, 1.64), and 1.47 (1.25, 1.74), respectively. For copper and zinc, the association was attenuated with adjustment for clinical risk factors; GMRs at ten years of follow-up before and after adjustment for clinical risk factors were 1.55 (1.30, 1.84) and 1.33 (1.12, 1.58), respectively, for copper and 1.85 (1.56, 2.19) and 1.57 (1.33, 1.85) for zinc.

Conclusion

Higher levels of cadmium, tungsten, uranium, cobalt, copper, and zinc, as measured in urine, were associated with subclinical CVD at baseline and at follow-up. These findings support the hypothesis that metals are pro-atherogenic factors.

Computed Tomography-Based Coronary Artery Calcium Score Calculation at a Reduced Tube Voltage Utilizing Iterative Reconstruction and Threshold Modification Techniques: A Feasibility Study

BACKGROUND

The coronary artery calcium score (CACS) indicates cardiovascular health. A concern in this regard is the ionizing radiation from computed tomography (CT). Recent studies have tried to introduce low-dose CT techniques to assess CACS. We aimed to investigate the accuracy of iterative reconstruction (IR) and threshold modification while applying low tube voltage in coronary artery calcium imaging.

METHODS

The study population consisted of 107 patients. Each subject underwent an electrocardiogram-gated CT twice, once with a standard voltage of 120 kVp and then a reduced voltage of 80 kVp. The standard filtered back projection (FBP) reconstruction was applied in both voltages. Considering Hounsfield unit (HU) thresholds other than 130 (150, 170, and 190), CACS was calculated using the FBP-reconstructed 80 kVp images. Moreover, the 80 kVp images were reconstructed utilizing IR at different strength levels. CACS was measured in each set of images. The intraclass correlation coefficient (ICC) was used to compare the CACSs.

RESULTS

A 64% reduction in the effective dose was observed in the 80 kVp protocol compared to the 120 kVp protocol. Excellent agreement existed between CACS at high-level (strength level = 5) IR in low-kVp images and the standard CACS protocol in scores ≥ 11 (ICC > 0.9 and p < 0.05). Increasing the threshold density to 190 HU in FBP-reconstructed low-kVp images yielded excellent agreement with the standard protocol in scores ≥ 11 (ICC > 0.9 and p < 0.05) and good agreement in score zero (ICC = 0.84 and p = 0.02).

CONCLUSIONS

The modification of the density threshold and IR provides an accurate calculation of CACS in low-voltage CT with the potential to decrease patient radiation exposure.

Photon Counting CT: Technical Principles, Clinical Applications, and Future Prospects

Photon-counting computed tomography (PCCT) is a new technique that utilizes photon-counting detectors to convert individual X-ray photons directly into an electrical signal, which can achieve higher spatial resolution, improved iodine signal, radiation dose reduction, artifact reduction, and multienergy imaging. This review introduces the technical principles of PCCT, and summarizes its first-in-human experience and current applications in clinical settings, and discusses the future prospects of PCCT.

Coronary Artery Calcium Score as a Sensitive Indicator of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus: A Long-Term Cohort Study

BACKGRUOUND

Coronary artery calcium score (CACS) has become an important tool for evaluating cardiovascular disease (CVD). This study evaluated the significance of CACS for future CVD through more than 10 years of follow-up in asymptomatic Korean populations with type 2 diabetes mellitus (T2DM) known to have a relatively low CACS burden.

METHODS

We enrolled 981 asymptomatic T2DM patients without CVD at baseline who underwent CACS evaluation using multidetector computed tomography between January 2008 and December 2014. They were grouped into five predefined CACS categories based on Agatston scores and followed up by August 2020. The primary endpoint was incident CVD events, including coronary, cerebrovascular, and peripheral arterial disease.

RESULTS

The relative risk of CVD was significantly higher in patients with CACS ≥10, and the significance persisted after adjustment for known confounders. A higher CACS category indicated a higher incidence of future CVD: hazard ratio (95% confidence interval) 4.09 (1.79 to 9.36), 12.00 (5.61 to 25.69), and 38.79 (16.43 to 91.59) for 10≤ CACS <100, 100≤ CACS <400, and CACS ≥400, respectively. During the 12-year follow-up period, the difference in event-free survival more than doubled as the category increased. Patients with CACS below 10 had very low CVD incidence throughout the follow-up. The receiver operating characteristic analysis showed better area under curve when the CACS cutoff was 10 than 100.

CONCLUSION

CACS can be a sensitive marker of CVD risk. Specifically, CACS above 10 is an indicator of CVD high-risk requiring more intensive medical treatment in Koreans with T2DM.

Influence of sodium thiosulfate on coronary artery calcification of patients on dialysis: a meta-analysis

Coronary artery calcification (CAC) is common in dialysis patients and is associated with a higher risk of future cardiovascular events. Sodium thiosulfate (STS) is effective for calciphylaxis in dialysis patients; however, the influence of STS on CAC in dialysis patients remains unclear. This systematic review and meta-analysis were conducted to evaluate the effects of STS on CAC in patients undergoing dialysis. PubMed, Embase, Cochrane Library, CNKI, and Wanfang databases were searched from inception to 22 March 2023 for controlled studies comparing the influence of STS versus usual care without STS on CAC scores in dialysis patients. A random effects model incorporating the potential influence of heterogeneity was used to pool the results. Nine studies, including two non-randomized studies and seven randomized controlled trials, were included in the meta-analysis. Among these, 365 patients on dialysis were included in the study. Compared with usual care without STS, intravenous STS for 3-6 months was associated with significantly reduced CAC scores (mean difference [MD] = -180.17, 95% confidence interval [CI]: -276.64 to -83.70, p < 0.001, I2 = 0%). Sensitivity analysis limited to studies of patients on hemodialysis showed similar results (MD: -167.33, 95% CI: -266.57 to -68.09, p = 0.001; I2 = 0%). Subgroup analyses according to study design, sample size, mean age, sex, dialysis vintage of the patients, and treatment duration of STS also showed consistent results (p for subgroup differences all > 0.05). In conclusion, intravenous STS may be effective in attenuating CAC in dialysis patients.

Correlation between TyG index and coronary atherosclerosis assessed by CCTA in elderly male patients: a cross-sectional study

BACKGROUND

Age is a major risk factor associated with the complexity of coronary artery disease (CAD), and the prognosis of elderly patients with coronary heart disease is relatively poor. Metabolic disturbances are prevalent in the elderly population and contribute to CAD morbidity and mortality. This study aimed to investigate the relationship between the triglyceride-glucose (TyG) index and total coronary atherosclerotic burden assessed non-invasively by Coronary Computed Tomography Angiogram (CCTA) in the elderly population.

METHODS

This retrospective cross-sectional study involved 427 patients who underwent CCTA. The patients were divided into two groups based on their Leiden score: ≥5 and < 5. Comparisons between groups were conducted using t-tests or Mann-Whitney U tests for continuous variables and chi-square tests for categorical variables. The correlation between TyG and Leiden score was assessed using Spearman's rank correlation coefficient. Univariable and multivariable logistic regression analyses were performed to assess the role of TyG in atherosclerosis risk, using clinical variables previously shown to independently predict a high Leiden score.

RESULTS

The levels of age and HbA1c% were significantly higher in patients with Leiden score ≥ 5. Patients with Leiden score ≥ 5 showed no significant difference in TyG index compared to those with Leiden score < 5. Pearson correlation analysis showed that HbA1c% (r = 0.44, p < 0.01), age (r = 0.34, p < 0.01), and FBG (r = 0.15, p = 0.01) were positively correlated with Leiden score, while TyG index had no correlation with Leiden score (r = 0.05, p = 0.42). Multiple linear regression analysis showed that HbA1c% (β = 2.92, 95%CI: 2.25-3.56, P < 0.01) was positively correlated with Leiden score, while TyG index had no correlation with Leiden score (β = 0.73, 95%CI: -3.27-4.72, P < 0.01). HbA1c% was found to be an influential factor for obstructive CVD (β = 1.86, 95%CI: 1.50-2.29, P < 0.01), while TyG index was not an independent risk factor for obstructive CVD (β = 0.39, 95%CI: 0.12-1.32, P = 0.13).

CONCLUSION

The TyG index did not show any significant correlation with the Leiden score and obstructive CVD as a risk factor in elderly male population. On the other hand, HbA1c% was identified as an influential factor for both the Leiden score and obstructive CVD.

Vitamin K supplementation and vascular calcification: a systematic review and meta-analysis of randomized controlled trials

Background

Vascular calcification (VC) is a complex process that has been linked to conditions including cardiovascular diseases and chronic kidney disease. There is an ongoing debate about whether vitamin K (VK) can effectively prevent VC. To assess the efficiency and safety of VK supplementation in the therapies of VC, we performed a systematic review and meta-analysis of recent studies.

Methods

We searched major databases, including PubMed, the Cochrane Library, Embase databases, and Web of Science up until August 2022. 14 randomized controlled trials (RCTs) describing the outcomes of treatment for VK supplementation with VC have been included out of 332 studies. The results were reported in the change of coronary artery calcification (CAC) scores, other artery and valve calcification, vascular stiffness, and dephospho-uncarboxylated matrix Gla protein (dp-ucMGP). The reports of severe adverse events were recorded and analyzed.

Results

We reviewed 14 RCTs, comprising a total of 1,533 patients. Our analysis revealed that VK supplementation has a significant effect on CAC scores, slowing down the progression of CAC [I² = 34%, MD= -17.37, 95% CI (-34.18, -0.56), p = 0.04]. The study found that VK supplementation had a significant impact on dp-ucMGP levels, as compared to the control group, where those receiving VK supplementation had lower values [I² = 71%, MD = -243.31, 95% CI (-366.08, -120.53), p = 0.0001]. Additionally, there was no significant difference in the adverse events between the groups [I² = 31%, RR = 0.92, 95% CI (-0.79,1.07), p = 0.29].

Conclusion

VK may have therapeutic potential for alleviating VC, especially CAC. However, more rigorously designed RCTs are required to verify the benefits and efficacy of VK therapy in VC.

Gender Medicine in Clinical Radiology Practice

Gender Medicine is rapidly emerging as a branch of medicine that studies how many diseases common to men and women differ in terms of prevention, clinical manifestations, diagnostic-therapeutic approach, prognosis, and psychological and social impact. Nowadays, the presentation and identification of many pathological conditions pose unique diagnostic challenges. However, women have always been paradoxically underestimated in epidemiological studies, drug trials, as well as clinical trials, so many clinical conditions affecting the female population are often underestimated and/or delayed and may result in inadequate clinical management. Knowing and valuing these differences in healthcare, thus taking into account individual variability, will make it possible to ensure that each individual receives the best care through the personalization of therapies, the guarantee of diagnostic-therapeutic pathways declined according to gender, as well as through the promotion of gender-specific prevention initiatives. This article aims to assess potential gender differences in clinical-radiological practice extracted from the literature and their impact on health and healthcare. Indeed, in this context, radiomics and radiogenomics are rapidly emerging as new frontiers of imaging in precision medicine. The development of clinical practice support tools supported by artificial intelligence allows through quantitative analysis to characterize tissues noninvasively with the ultimate goal of extracting directly from images indications of disease aggressiveness, prognosis, and therapeutic response. The integration of quantitative data with gene expression and patient clinical data, with the help of structured reporting as well, will in the near future give rise to decision support models for clinical practice that will hopefully improve diagnostic accuracy and prognostic power as well as ensure a more advanced level of precision medicine.

Nomograms Based on the Albumin/Neutrophil-to-Lymphocyte Ratio Score for Predicting Coronary Artery Disease or Subclinical Coronary Artery Disease

Purpose

To develop and validate two nomograms incorporating the albumin/neutrophil-to-lymphocyte ratio score (ANS) for predicting the risk of coronary artery disease (CAD) or subclinical CAD.

Patients and Methods

Four hundred fifty patients with suspected CAD who underwent coronary computed tomographic angiography were consecutively enrolled between September 2015 and June 2017. Nomograms were established based on independent predictors of CAD or subclinical CAD.

Results

In total, 437 patients with suspected CAD who underwent coronary computed tomographic angiography were included. Male sex, age ≥65 years, smoking, hypertension, diabetes, dyslipidemia, ischemic stroke, and ANS were independent predictors of CAD and subclinical CAD. The areas under the curve of each nomogram were 0.799 (95% CI: 0.752-0.846) and 0.809 (95% CI: 0.762-0.856), respectively. The calibration curve and decision curve analysis showed good performance for the diagnostic nomograms. The prediction of CAD or subclinical CAD by the ANS was not modified by the independent predictors (all, p for interaction >0.05).

Conclusion

Our ANS-based nomograms can provide accurate and individualized risk predictions for patients with suspected CAD or subclinical CAD.

Heterogeneity in the Association Between the Presence of Coronary Artery Calcium and Cardiovascular Events: A Machine-Learning Approach in the MESA Study

BACKGROUND

Coronary artery calcium (CAC) has been widely recognized as an important predictor of cardiovascular disease (CVD). Given the finite resources, it is important to identify individuals who would receive the most benefit from detecting positive CAC by screening. However, the evidence is limited as to whether the burden of positive CAC on CVD differs by multidimensional individual characteristics. We sought to investigate the heterogeneity in the association between positive CAC and incident CVD.

METHODS

This cohort study included adults from MESA (Multi-Ethnic Study of Atherosclerosis) ages ≥45 years and free of cardiovascular disease. After propensity score matching in a 1:1 ratio, we applied a machine learning causal forest model to (1) evaluate the heterogeneity in the association between positive CAC and incident CVD, and (2) predict the increase in CVD risk at 10-years when CAC>0 (versus CAC=0) at the individual level. We then compared the estimated increase in CVD risk when CAC>0 to the absolute 10-year atherosclerotic CVD (ASCVD) risk calculated by the 2013 American College of Cardiology/American Heart Association pooled cohort equations.

RESULTS

Across 3328 adults in our propensity score-matched analysis, our causal forest model showed the heterogeneity in the association between CAC>0 and incident CVD. We found a dose-response relationship of the estimated increase in CVD risk when CAC>0 with higher 10-year ASCVD risk. Almost all individuals (2293 of 2428 [94.4%]) with borderline risk of ASCVD or higher showed ≥2.5% increase in CVD risk when CAC>0. Even among 900 adults with low ASCVD risk, 689 (69.2%) showed ≥2.5% increase in CVD risk when CAC>0; these individuals were more likely to be male, Hispanic, and have unfavorable CVD risk factors than others.

CONCLUSIONS

The expected increases in CVD risk when CAC>0 were heterogeneous across individuals. Moreover, nearly 70% of people with low ASCVD risk showed a large increase in CVD risk when CAC>0, highlighting the need for CAC screening among such low-risk individuals. Future studies are needed to assess whether targeting individuals for CAC measurements based on not only the absolute ASCVD risk but also the expected increase in CVD risk when CAC>0 improves cardiovascular outcomes.

AI-Supported Comprehensive Detection and Quantification of Biomarkers of Subclinical Widespread Diseases at Chest CT for Preventive Medicine

Automated image analysis plays an increasing role in radiology in detecting and quantifying image features outside of the perception of human eyes. Common AI-based approaches address a single medical problem, although patients often present with multiple interacting, frequently subclinical medical conditions. A holistic imaging diagnostics tool based on artificial intelligence (AI) has the potential of providing an overview of multi-system comorbidities within a single workflow. An interdisciplinary, multicentric team of medical experts and computer scientists designed a pipeline, comprising AI-based tools for the automated detection, quantification and characterization of the most common pulmonary, metabolic, cardiovascular and musculoskeletal comorbidities in chest computed tomography (CT). To provide a comprehensive evaluation of each patient, a multidimensional workflow was established with algorithms operating synchronously on a decentralized Joined Imaging Platform (JIP). The results of each patient are transferred to a dedicated database and summarized as a structured report with reference to available reference values and annotated sample images of detected pathologies. Hence, this tool allows for the comprehensive, large-scale analysis of imaging-biomarkers of comorbidities in chest CT, first in science and then in clinical routine. Moreover, this tool accommodates the quantitative analysis and classification of each pathology, providing integral diagnostic and prognostic value, and subsequently leading to improved preventive patient care and further possibilities for future studies.

Klotho Ameliorates Vascular Calcification via Promoting Autophagy

Vascular calcification (VC) is regarded as a common feature of vascular aging. Klotho deficiency reportedly contributes to VC, which can be ameliorated by restoration of Klotho expression. However, the specific mechanisms involved remain unclear. Here, we investigated the role of autophagy in the process of Klotho-inhibiting VC. The clinical study results indicated that, based on Agatston score, serum Klotho level was negatively associated with aortic calcification. Then, Klotho-deficient mice exhibited aortic VC, which could be alleviated with the supplementation of Klotho protein. Moreover, autophagy increased in the aorta of Klotho-deficient mice and protected against VC. Finally, we found that Klotho ameliorated calcification by promoting autophagy both in the aorta of Klotho-deficient mice and in mouse vascular smooth muscle cells (MOVAS) under calcifying conditions. These findings indicate that Klotho deficiency induces increased autophagy to protect against VC and that Klotho expression further enhances autophagy to ameliorate calcification. This study is beneficial to exploring the underlying mechanisms of Klotho regulating VC, which has important guiding significance for future clinical studies in the treatment of VC.

Extra-coronary Calcification and Cardiovascular Events: What Do We Know and Where Are We Heading?

PURPOSE OF REVIEW

The coronary artery calcium score is a guideline-endorsed aid for further risk stratification in the primary prevention of atherosclerotic cardiovascular disease. The non-contrast scan performed for detection of coronary artery calcium also gives an opportunity to visualize calcifications in the thoracic aorta and in the heart valves, at no additional cost or radiation exposure. The purpose of this review was to discuss the potential clinical value of measuring thoracic aortic calcification, aortic valve calcification, and mitral annulus calcification.

RECENT FINDINGS

After two decades of active research, all three calcifications have been extensively evaluated, across various cohorts. We discuss classic and recent studies, current knowledge gaps, and future directions in this space. The added value of these measurements has traditionally been considered modest at best, and they are not currently discussed in relevant primary prevention guidelines in North America and Europe. However, recent studies evaluating high thoracic calcification thresholds and younger populations have further enriched this space. Specifically, some studies suggest that detection of severe thoracic aortic calcification may be helpful in further risk assessment and that detection of aortic valve calcifications may have important prognostic implications in younger individuals. Although more research is needed, particularly in larger young-to-middle-aged cohorts, future guidelines might consider including these features as risk-enhancing factors.

Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease

The most recent primary cardiovascular disease (CVD) prevention clinical guidelines used in Europe, Italy, the USA, China, and South Korea differ in aspects of their approach to CVD risk assessment and reduction. Low dose aspirin use is recommended in certain high-risk patients by most but not all the countries. Assessment of traditional risk factors and which prediction models are commonly used differ between countries. The assessments and tools may not, however, identify all patients at high risk but without manifest CVD. The use of coronary artery calcium (CAC) score to guide decisions regarding primary prevention aspirin therapy is recommended only by the US primary prevention guidelines and the 2021 European Society of Cardiology guidelines. A more consistent and comprehensive global approach to CVD risk estimation in individual patients could help to personalize primary CVD prevention. Wider detection of subclinical atherosclerosis, together with structured assessment and effective mitigation of bleeding risk, may appropriately target patients likely to gain net benefit from low dose aspirin therapy.

Comparison of cardiac CT angiography coronary artery dimensions and ethnicity in Trinidad: the CADET pilot study

Background

This study aimed to determine if there were any significant differences in coronary artery (CA) dimensions at prespecified segments during cardiac CT angiography (CCTA) compared with ethnicity at an academic tertiary medical centre in Trinidad and Tobago.

Methods

Patients (n=170) who underwent CCTA from July 2016 to June 2021 at the Eric Williams Medical Sciences Complex were selected based on predefined selection criteria. The size of the left main and proximal, mid and distal diameters of the left anterior descending, left circumflex and right coronary artery (RCA) were measured using quantitative coronary angiography, syngo.CT Coronary Analysis (Siemens Healthineers AG, Erlangen, Germany). Routine medical history, cardiovascular medications and anthropometric data were also recorded. Comparisons were performed using an independent sample t-test and analysis of variance for continuous variables.

Results

One hundred and seventy participants were enrolled in this study. There were no statistically significant associations between gender and CA dimensions; however, there were significant associations between South Asian and Caribbean black ethnicities for almost all CA dimensions except for the distal RCA segment. These findings were replicated when the analysis was adjusted for body surface area with the addition of the mid-RCA segment, which was bordering near-significance (p value 0.051).

Conclusions

Significantly smaller CA dimensions were observed in South Asian patients compared with Caribbean black patients undergoing CCTA. This pilot study could be clinically significant for Trinidadian patients at risk of developing coronary artery disease.

Trial registration number

NCT04774861.

Lifetime Cardiovascular Disease Risk by Coronary Artery Calcium Score in Individuals With and Without Diabetes: An Analysis From the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

To assess lifetime cardiovascular disease (CVD) risk by coronary artery calcium (CAC) score in individuals with diabetes from the Multi-Ethnic Study of Atherosclerosis (MESA) and compare risk with that in individuals without diabetes.

RESEARCH DESIGN AND METHODS

We developed a microsimulation model with well, diabetes, post-CVD, and death health states using multivariable time-dependent Cox regression with age as time scale. We initially used 10-year follow-up data of 6,769 MESA participants, including coronary heart disease (CHD) (n = 272), heart failure (n = 201), stroke (n = 186), and competing death (n = 619) and assessed predictive validity at 15 years. We externally validated the model in matched National Health and Nutrition Examination Survey (NHANES) participants. Subsequently, we predicted CVD risk until age 100 years by diabetes, 10-year pooled cohort equations risk, and CAC score category (0, 1-100, or 100+).

RESULTS

The model showed good calibration and discriminative performance at 15 years, with discrimination indices 0.71-0.78 across outcomes. In the NHANES cohort, predicted 15-year mortality risk corresponded well with Kaplan-Meier risk, especially for those with diabetes: 29.6% (95% CI 24.9-34.8) vs. 32.4% (95% CI 27.2-37.2), respectively. Diabetes increased lifetime CVD risk, similar to shifting one CAC category upward (from 0 to 1-100 or from 1-100 to 100+). Patients with diabetes and CAC score of 0 had a lifetime CVD risk that overlapped with that of individuals without diabetes who were at low 10-year pooled cohort equations risk (<7.5%).

CONCLUSIONS

Patients with diabetes carry a spectrum of CVD risk. CAC scoring may improve decisions for preventive interventions for patients with diabetes by better delineating lifetime CVD risk.

Determinants of Incident Atherosclerotic Cardiovascular Disease Events Among Those With Absent Coronary Artery Calcium: Multi-Ethnic Study of Atherosclerosis

BACKGROUND

The 2018 American Heart Association/American College of Cardiology/Multisociety cholesterol guideline states that statin therapy may be withheld or delayed among intermediate-risk individuals in the absence of coronary artery calcium (CAC=0). We evaluated whether traditional cardiovascular risk factors are associated with incident atherosclerotic cardiovascular disease (ASCVD) events among individuals with CAC=0 over long-term follow-up.

METHODS

We included participants with CAC=0 at baseline from the MESA (Multi-Ethnic Study of Atherosclerosis), a prospective cohort study of individuals free of clinical ASCVD at baseline. We used multivariable-adjusted Cox proportional hazards models to study the association between cardiovascular risk factors (cigarette smoking, diabetes, hypertension, preventive medication use [aspirin and statin], family history of premature ASCVD, chronic kidney disease, waist circumference, lipid and inflammatory markers) and adjudicated incident ASCVD outcomes.

RESULTS

We studied 3416 individuals (mean [SD] age 58 [9] years; 63% were female, 33% White, 31% Black, 12% Chinese American, and 24% Hispanic). Over a median follow-up of 16 years, there were 189 ASCVD events (composite of coronary heart disease and stroke) of which 91 were coronary heart disease, 88 were stroke, and 10 were both coronary heart disease and stroke events. The unadjusted event rates of ASCVD were ≤5 per 1000 person-years among individuals with CAC=0 for most risk factors with the exception of current cigarette smoking (7.3), diabetes (8.9), hypertension (5.4), and chronic kidney disease (6.8). After multivariable adjustment, risk factors that were significantly associated with ASCVD included current cigarette smoking: hazard ratio, 2.12 (95% CI, 1.32-3.42); diabetes: hazard ratio, 1.68 (95% CI, 1.01-2.80); and hypertension: hazard ratio, 1.57 (95% CI, 1.06-2.33).

CONCLUSIONS

Current cigarette smoking, diabetes, and hypertension are independently associated with incident ASCVD over a 16-year follow-up among those with CAC=0.

Emerging Roles of Circular RNAs in Vascular Smooth Muscle Cell Dysfunction

Atherosclerosis is the major pathophysiological basis of cerebrovascular and cardiovascular diseases. Vascular smooth muscle cells (VSMCs) constitute the main structure of vasculature and play important roles in maintaining vascular tone and blood pressure. Many biological processes and cellular signaling events involved in atherosclerogenesis have been shown to converge on deregulating VSMC functions. However, the molecular mechanisms underlying dysfunctional VSMC in atherosclerosis are still poorly defined. Recent evidence revealed that circular RNAs (circRNAs) are closely related to diseases such as degenerative diseases, tumor, congenital diseases, endocrine diseases and cardiovascular diseases. Several studies demonstrated that circRNAs (e.g., circACTA2, Circ-SATB2, circDiaph3, circ_0020397, circTET3, circCCDC66) played critical roles in the regulation of VSMC proliferation, migration, invasion, and contractile-to-synthetic phenotype transformation by sponging microRNAs (e.g., miR-548f-5p, miR-939, miR-148a-5p, miR-138, miR-351-5p, miR-342-3p). This review describes recent progress in the profiling of circRNAs by transcriptome analysis in VSMCs and their molecular functions in regulating VSMC proliferation and migration.

Rationale and pathways forward in the implementation of coronary artery calcium-based enrichment of randomized trials

The Food and Drug Administration recommends prognostic enrichment of randomized controlled trials (RCTs), aimed at restricting the study population to participants most likely to have events and therefore derive benefit from a given intervention. The coronary artery calcium (CAC) score is powerful discriminator of cardiovascular risk, and in this review we discuss how CAC may be used to augment widely used prognostic enrichment paradigms of RCTs of add-on therapies in primary prevention. We describe recent studies in this space, with special attention to the ability of CAC to further stratify risk among guideline-recommended candidates for add-on risk-reduction therapies. Given the potential benefits in terms of sample size, cost reduction, and overall RCT feasibility of a CAC-based enrichment strategy, we discuss approaches that may help maximize its advantages while minimizing logistical barriers and other challenges. Specifically, use of already existing CAC data to avoid the need to re-scan participants with previously documented high CAC scores, use of increasingly available, large clinical CAC databases to facilitate the identification of potential RCT participants, and implementation of machine learning approaches to measure CAC in existing computed tomography images performed for other purposes, will most likely boost the implementation of a CAC-based enrichment paradigm in future RCTs.

Prevalence and significance of risk enhancing biomarkers in the United States population at intermediate risk for atherosclerotic disease: Risk Enhancing Factors in Intermediate Risk for ASCVD

BACKGROUND

Pooled cohort equations (PCEs) estimate 10-year risk for atherosclerotic cardiovascular disease (ASCVD) in US adults. One use is to guide statin eligibility. However, PCEs risk estimate is inaccurate in some US subpopulations.

OBJECTIVE

Recent cholesterol guidelines proposed addition of risk enhancing factors to improve risk assessment for selection of statin therapy. This study examines frequencies of several risk enhancing biomarkers in NHANES subjects at intermediate risk (7.5 -<20% 10-year risk for ASCVD) and considers how they may be used to better assess risk for individuals.

METHODS

Prevalence of the following biomarkers were determined; elevations in apolipoprotein B-containing lipoproteins, i.e., LDL cholesterol (LDL-C) (160-189 mg/dL), non-HDL-cholesterol (non-HDL-C) (190-219 mg/dL), or total apolipoprotein B (apoB) (≥ 130 mg/dL), serum triglyceride (≥175 mg/dL), hemoglobin A1c (5.7-6.4%), high sensitivity C-reactive protein (2-10 mg/L), and waist circumference ≥ 102 cm, and abnormal estimated glomerular filtration rate (15 - ≤ 60 mg/min/1.73 m²).

RESULTS

25% of NHANES population had intermediate risk. In this subpopulation, 85% had ≥ 1 biomarkers-similarly in women and men-with a third having ≥3 abnormal markers. Frequencies were not age-related, except in those 40-49 years, in whom > 40% had ≥3 abnormal biomarkers. It made little difference whether LDL-C, non-HDL-C or apoB was used as the atherogenic lipoprotein.

CONCLUSION

Three or more enhancing risk factors in intermediate risk subjects can complement PCE-estimated 10-year risk and guide the patient-provider discussion toward use of lipid-lowering medication. Future research is needed to integrate risk estimates by PCE and multiple risk enhancers.

Role of Coronary Artery Calcium Testing for Risk Assessment in Primary Prevention of Atherosclerotic Cardiovascular Disease: A Review

Importance

Current guidelines recommend a few different approaches to the use of coronary artery calcium (CAC) testing as a tool for risk assessment and decision-making regarding drug therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD).

Observations

Coronary artery calcium testing is not recommended for universal screening, particularly in patients at very low or high predicted risk for ASCVD, where its yield and utility for altering clinical decisions are limited. Use of CAC testing appears to be optimal when used in selected patients who are at intermediate or borderline risk of ASCVD as a sequential decision aid after initial quantitative risk assessment and consideration of individual patient risk-enhancing factors (eg, strong family history of premature ASCVD, chronic kidney disease). Although convincing clinical trials have not been completed, observational studies strongly suggest that, in those at intermediate risk, CAC testing can meaningfully reclassify risk and can support improved targeting of drug therapy to patients most likely to benefit.

Conclusions and Relevance

This narrative review summarizes the evidence available about the appropriate role of CAC testing for ASCVD risk assessment. Coronary artery calcium testing should be used selectively in patients who are at intermediate risk of ASCVD, when there is persistent uncertainty after performing standard risk assessment using traditional risk factors in a risk score, and after consideration of additional individual risk-enhancing factors. In these situations, the result of the CAC test can be helpful to clarify whether the patient's true risk is high enough to justify initiation of primary prevention medications, such as statins or aspirin.

Metformin for diabetes prevention: update of the evidence base

We have conducted a narrative review based on a structured search strategy, focusing on the effects of metformin on the progression of non-diabetic hyperglycemia to clinical type 2 diabetes mellitus. The principal trials that demonstrated a significantly lower incidence of diabetes in at-risk populations randomized to metformin (mostly with impaired glucose tolerance [IGT]) were published mainly from 1999 to 2012. Metformin reduced the 3-year risk of diabetes by -31% in the randomized phase of the Diabetes Prevention Program (DPP), vs. -58% for intensive lifestyle intervention (ILI). Metformin was most effective in younger, heavier subjects. Diminishing but still significant reductions in diabetes risk for subjects originally randomized to these groups were present in the trial's epidemiological follow-up, the DPP Outcomes Study (DPPOS) at 10 years (-18 and -34%, respectively), 15 years (-18 and -27%), and 22 years (-18 and -25%). Long-term weight loss was also seen in both groups, with better maintenance under metformin. Subgroup analyses from the DPP/DPPOS have shed important light on the actions of metformin, including a greater effect in women with prior gestational diabetes, and a reduction in coronary artery calcium in men that might suggest a cardioprotective effect. Improvements in long-term clinical outcomes with metformin in people with non-diabetic hyperglycemia ("prediabetes") have yet to be demonstrated, but cardiovascular and microvascular benefits were seen for those in the DPPOS who did not vs. did develop diabetes. Multiple health economic analyses suggest that either metformin or ILI is cost-effective in a community setting. Long-term diabetes prevention with metformin is feasible and is supported in influential guidelines for selected groups of subjects. Future research will demonstrate whether intervention with metformin in people with non-diabetic hyperglycemia will improve long-term clinical outcomes.

Implications of the 2019 American College of Cardiology/American Heart Association Primary Prevention Guidelines and potential value of the coronary artery calcium score among South Asians in the US: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study

BACKGROUND AND AIMS

South Asian (SA) ethnicity is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, the implications of considering SA ethnicity as a "risk-enhancing factor" per recent American College of Cardiology/American Heart Association guidelines are not fully understood.

METHODS

We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, a community-based cohort study of individuals of SA ancestry living in the US. The Pooled Cohort Equations were used to estimate 10-year ASCVD risk. Metabolic risk factors and coronary artery calcium (CAC) scores were assessed.

RESULTS

Among 1114 MASALA participants included (median age 56 years, 48% women), 28% were already using a statin at baseline, 25% had prevalent diabetes, and 59% qualified for 10-year ASCVD risk assessment for statin allocation purposes. The prevalence of low, borderline, intermediate, and high estimated ASCVD risk was 65%, 11%, 20% and 5%, respectively. Among participants at intermediate risk, 30% had CAC = 0 and 37% had CAC>100, while among participants at borderline risk, 54% had CAC = 0 and 13% had CAC>100. Systematic consideration of intermediate and, particularly, of borderline risk individuals as statin candidates would enrich the statin-consideration group with CAC = 0 participants up to 35%. Prediabetes and abdominal obesity were highly prevalent across all estimated risk strata, including among those with CAC = 0.

CONCLUSIONS

Our findings suggest that systematic consideration of borderline risk SAs as statin candidates might result in considerable overtreatment, and further risk assessment with CAC may help better personalize statin allocation in these individuals. Early, aggressive lifestyle interventions aimed at reducing the risk of incident diabetes should be strongly recommended in US SAs, particularly among those considered candidates for statin therapy for primary prevention. Longitudinal studies are needed to confirm the favorable prognosis of CAC = 0 in SAs.