External validity of a cardiovascular screening including a coronary artery calcium examination in middle-aged individuals from the general population

A Pragmatic Randomized Feasibility Trial of Influenza Vaccines

BACKGROUND: The relative vaccine effectiveness (rVE) of high-dose quadrivalent influenza vaccines (QIV-HD) versus standard-dose quadrivalent influenza vaccines (QIV-SD) against hospitalizations and mortality in the general older population has not been evaluated in an individually randomized trial. Because of the large sample size required, such a trial will need to incorporate innovative, pragmatic elements. METHODS: We conducted a pragmatic, open-label, active-controlled, randomized feasibility trial in Danish citizens aged 65 to 79 years during the 2021–2022 influenza season. Participants were randomly assigned 1:1 to receive QIV-HD or QIV-SD. Randomization was integrated into routine vaccination practice, and the trial relied solely on nationwide administrative health registries for data collection. Outcomes consisted of a feasibility assessment and descriptive rVE estimates. RESULTS: We invited 34,000 persons to participate. A total of 12,477 randomly assigned participants were included in the final analyses. Mean (±SD) age was 71.7±3.9 years, and 5877 (47.1%) were women. Registry-based data collection was feasible, with complete follow-up data for 99.9% of participants. Baseline characteristics were comparable to those of the overall Danish population aged 65 to 79 years. The incidence of hospitalization for influenza or pneumonia was 10 (0.2%) of 6245 in the QIV-HD group and 28 (0.4%) of 6232 in the QIV-SD group (rVE, 64.4%; 95% confidence interval, 24.4 to 84.6). All-cause death occurred in 21 (0.3%) and 41 (0.7%) participants in the QIV-HD and QIV-SD groups, respectively (rVE, 48.9%; 95% confidence interval, 11.5 to 71.3). CONCLUSIONS: Conducting a pragmatic randomized trial of QIV-HD versus QIV-SD using existing infrastructure and registry-based data collection was feasible. The findings of lower incidence of hospitalization for influenza or pneumonia and all-cause mortality in the QIV-HD group compared with the QIV-SD group require replication in a future, fully powered trial. (Funded by Sanofi; ClinicalTrials.gov number, NCT05048589.)

Improved pre-test likelihood estimation of coronary artery disease using phonocardiography

Aims

Current early risk stratification of coronary artery disease (CAD) consists of pre-test probability scoring such as the 2019 ESC guidelines on chronic coronary syndromes (ESC2019), which has low specificity and thus rule-out capacity. A newer clinical risk factor model (risk factor-weighted clinical likelihood, RF-CL) showed significantly improved rule-out capacity over the ESC2019 model. The aim of the current study was to investigate if the addition of acoustic features to the RF-CL model could improve the rule-out potential of the best performing clinical risk factor models.

Methods and results

Four studies with heart sound recordings from 2222 patients were pooled and distributed into two data sets: training and test. From a feature bank of 40 acoustic features, a forward-selection technique was used to select three features that were added to the RF-CL model. Using a cutoff of 5% predicted risk of CAD, the developed acoustic-weighted clinical likelihood (A-CL) model showed significantly (P < 0.05) higher specificity of 48.6% than the RF-CL model (specificity of 41.5%) and ESC 2019 model (specificity of 6.9%) while having the same sensitivity of 84.9% as the RF-CL model. Area under the curve of the receiver operating characteristic for the three models was 72.5% for ESC2019, 76.7% for RF-CL, and 79.5% for A-CL.

Conclusion

The proposed A-CL model offers significantly improved rule-out capacity over the ESC2019 model and showed better overall performance than the RF-CL model. The addition of acoustic features to the RF-CL model was shown to significantly improve early risk stratification of symptomatic patients suspected of having stable CAD.

Spectral analysis of heart sounds associated with coronary artery disease

Objective. The aim of this study was to find spectral differences of diagnostic interest in heart sound recordings of patients with coronary artery disease (CAD) and healthy subjects.Approach. Heart sound recordings from three studies were pooled, and patients with clear diagnostic outcomes (positive: CAD and negative: Non-CAD) were selected for further analysis. Recordings from 1146 patients (191 CAD and 955 Non-CAD) were analyzed for spectral differences between the two groups using Welch's spectral density estimate. Frequency spectra were estimated for systole and diastole segments, and time-frequency spectra were estimated for first (S1) and second (S2) heart sound segments. An ANCOVA model with terms for diagnosis, age, gender, and body mass index was used to evaluate statistical significance of the diagnosis term for each time-frequency component.Main results. Diastole and systole segments of CAD patients showed increased energy at frequencies 20-120 Hz; furthermore, this difference was statistically significant for the diastole. CAD patients showed decreased energy for the mid-S1 and mid-S2 segments and conversely increased energy before and after the valve sounds. Both S1 and S2 segments showed regions of statistically significant difference in the time-frequency spectra.Significance. Results from analysis of the diastole support findings of increased low-frequency energy from previous studies. Time-frequency components of S1 and S2 sounds showed that these two segments likely contain heretofore untapped information for risk assessment of CAD using phonocardiography; this should be considered in future works. Further development of features that build on these findings could lead to improved acoustic detection of CAD.

Prevalence and extent of coronary artery calcification in the middle-aged and elderly population

AIMS

Coronary artery calcification (CAC) measured on cardiac computed tomography (CT) is an important risk marker for cardiovascular disease (CVD) and has been included in the prevention guidelines. The aim of this study was to describe CAC score reference values in the middle-aged and elderly population and to develop a freely available CAC calculator.

METHODS AND RESULTS

All participants from two population-based cardiac CT screening cohorts (DanRisk and DANCAVAS) were included. The CAC score was measured as a part of a screening session. Positive CAC scores were log-transformed and non-parametrically regressed on age for each gender, and percentile curves were transposed according to proportions of zero CAC scores. Men had higher CAC scores than women, and the prevalence and extend of CAC increased steadily with age. An online CAC calculator was developed, http://flscripts.dk/cacscore. After entering sex, age, and CAC score, the CAC score percentile and the coronary age are depicted including a figure with the specific CAC score and 25%, 50%, 75%, and 90% percentiles. The specific CAC score can be compared to the entire background population or only those without prior CVD.

CONCLUSION

This study provides modern population-based reference values of CAC scores in men and woman and a freely accessible online CAC calculator. Physicians and patients are very familiar with blood pressure and lipids, but unfamiliar with CAC scores. Using the calculator makes it easy to see if a CAC value is low, moderate, or high, when a physician in the future communicate and discusses a CAC score with a patient.

Coronary artery disease risk reclassification by a new acoustic-based score

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low < 15%, intermediate 15–85% and high > 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p < 0.001). The reclassification increased the proportion of low PTP patients from 13.6% to 41.8%, reducing the proportion of intermediate PTP patients from 83.4% to 55.2%. Before reclassification 7 (3.1%) low PTP patients had CAD, whereas post-reclassification this number increased to 28 (4.0%) (p = 0.52). The net reclassification index was 0.209. Utilization of a low-cost acoustic device in patients with intermediate PTP could potentially reduce the number of patients referred for further testing, without a significant increase in the false negative rate, and thus improve the cost-effectiveness for patients with suspected stable CAD.

Impact of a cardiovascular disease risk screening result on preventive behaviour in asymptomatic participants of the ROBINSCA trial

Introduction

A teachable moment for preventive behavioural change can occur when asymptomatic individuals receive their cardiovascular disease screening result. This study investigated prevention-seeking behaviour and compliance with preventive treatment of participants of the population-based Risk Or Benefit IN Screening for CArdiovascular disease (ROBINSCA) trial after receiving a screening result.

Methods

Asymptomatic Dutch individuals ( n = 43,447) were randomly assigned (1:1:1) to screening for cardiovascular disease by either traditional risk assessment (intervention arm A), or determining the amount of coronary artery calcification (intervention arm B), or to usual care (control arm). A random sample ( n = 600) of ROBINSCA participants with a screening result (arms A and B) received an online questionnaire (in 2017) to measure the impact of a cardiovascular disease screening result in low and increased (arm A: risk > 10%; arm B: Agatston ≥ 100) risk groups.

Results

Of all respondents (438/600; 73%) 63.5% were men and the mean age ( ± standard deviation) was 63.8 ± 6.9 years. Individuals with an increased coronary artery calcification score consulted their general practitioner more often compared to increased risk individuals from arm A: 140/149 (94%) and 86/137 (62.8%), respectively ( P < 0.001). Current use of blood pressure and cholesterol-lowering drugs was significantly higher in the increased coronary artery calcification score group (108/140; 77.1%), compared to the group with an increased traditional risk (35/80, 43.8%; P < 0.001). Self-reported compliance was high (98.1–100%).

Conclusion

Receiving the screening result might be a teachable moment that can enhance cardiovascular disease prevention-seeking behaviour through consulting a general practitioner and high compliance with preventive treatment. The impact of the screening result was more profound in the increased coronary artery calcification score group. Trial registration number: NTR6471

Coronary artery calcium and carotid artery intima-media thickness for the prediction of stroke and benefit from statins

BACKGROUND

Current guidelines suggest treatment for many individuals who may never develop a stroke. We hypothesized that a combination of coronary artery calcification (CAC) and carotid artery intima-media thickness (C IMT) data could better individualize risk assessment for ischemic stroke and transient ischemic attack events.

METHODS

A total of 4720 individuals from the Multi-Ethnic Study of Atherosclerosis were evaluated for ischemic stroke and transient ischemic attack. Cox proportional hazards models for time to incident ischemic stroke/transient ischemic attack were used to examine CAC and CIMT as ischemic stroke/transient ischemic attack predictors in addition to traditional risk factors. We calculated the 10-year number needed to treat by applying the benefit observed in ASCOT-LLA to the observed event rates within CAC and CIMT strata.

RESULTS

Median follow-up was 13.1 years. Compared with individuals with no CAC and with CIMT ≤ 75th percentile, stroke/transient ischemic attack risk increased progressively with each CAC category (0, 1-100, >100) among individuals with CIMT > 75th percentile. Among participants eligible for statin therapy based on the 2013 atherosclerotic cardiovascular disease (ASCVD) guidelines (ASCVD risk of >5%), 739/2906 (25%) had no CAC and CIMT ≤ 75th percentile and an observed ischemic stroke/transient ischemic attack rate of 2.49 per 1000 person-years. The predicted 10-year number needed to treat was 292 for no CAC and CIMT ≤ 75th percentile and 57 for CAC > 100 and CIMT > 75th percentile.

CONCLUSION

The combination of CIMT and CAC could serve to further refine risk calculation for ischemic stroke/transient ischemic attack prevention and may prioritize those in most need of statin therapy to reduce ischemic stroke/transient ischemic attack risk.

Impact of socioeconomic status on coronary artery calcification

Background

Low socioeconomic status is associated with an increased risk of coronary artery disease, but few studies have investigated the potential link between living in an area with a low versus a high socioeconomic status and coronary artery calcification, a marker of subclinical coronary artery disease.

Design

The design of this study was a cross-sectional study.

Methods

We evaluated 1067 participants with no history of coronary artery disease from the pilot phase of the Swedish CArdioPulmonary bioImage Study (SCAPIS). Men and women aged 50–64 years were recruited from three high-socioeconomic status ( n = 541) and three low-socioeconomic status ( n = 526) areas in the city of Gothenburg (550,000 inhabitants). The coronary artery calcification score was assessed with the Agatston method using computed tomography, with individuals classified into either no coronary calcification ( n = 625; mean age, 57 years) or any coronary artery calcification ( n = 442; mean age, 59 years (men, 68.5%)).

Results

Coronary artery calcification was present in 244 (46.3%) and 198 (36.6%) individuals from the low- and high-socioeconomic status areas, respectively. Participants from the low-socioeconomic status areas had a significantly higher risk factor burden. In a multivariable logistic regression model with adjustment for age, sex and cardiovascular risk factors, the odds for coronary artery calcification were not significantly higher among persons living in low-socioeconomic status areas (odds ratio = 1.18, 95% confidence interval = 0.87–1.60).

Conclusion

In this relatively small cross-sectional study, we observed an association between living in a low-socioeconomic status area and coronary artery calcification. However, this was mostly explained by higher levels of cardiovascular disease risk factors, indicating that the effect of socioeconomic status on the atherosclerotic process works through an increased burden of cardiovascular disease risk factors.