Subclinical Coronary Atherosclerosis and Risk for Myocardial Infarction in a Danish Cohort : A Prospective Observational Cohort Study

BACKGROUND

Coronary atherosclerosis may develop at an early age and remain latent for many years.

OBJECTIVE

To define characteristics of subclinical coronary atherosclerosis associated with the development of myocardial infarction.

DESIGN

Prospective observational cohort study.

SETTING

Copenhagen General Population Study, Denmark.

PARTICIPANTS

9533 asymptomatic persons aged 40 years or older without known ischemic heart disease.

MEASUREMENTS

Subclinical coronary atherosclerosis was assessed with coronary computed tomography angiography conducted blinded to treatment and outcomes. Coronary atherosclerosis was characterized according to luminal obstruction (nonobstructive or obstructive [≥50% luminal stenosis]) and extent (nonextensive or extensive [one third or more of the coronary tree]). The primary outcome was myocardial infarction, and the secondary outcome was a composite of death or myocardial infarction.

RESULTS

A total of 5114 (54%) persons had no subclinical coronary atherosclerosis, 3483 (36%) had nonobstructive disease, and 936 (10%) had obstructive disease. Within a median follow-up of 3.5 years (range, 0.1 to 8.9 years), 193 persons died and 71 had myocardial infarction. The risk for myocardial infarction was increased in persons with obstructive (adjusted relative risk, 9.19 [95% CI, 4.49 to 18.11]) and extensive (7.65 [CI, 3.53 to 16.57]) disease. The highest risk for myocardial infarction was noted in persons with obstructive-extensive subclinical coronary atherosclerosis (adjusted relative risk, 12.48 [CI, 5.50 to 28.12]) or obstructive-nonextensive (adjusted relative risk, 8.28 [CI, 3.75 to 18.32]). The risk for the composite end point of death or myocardial infarction was increased in persons with extensive disease, regardless of degree of obstruction-for example, nonobstructive-extensive (adjusted relative risk, 2.70 [CI, 1.72 to 4.25]) and obstructive-extensive (adjusted relative risk, 3.15 [CI, 2.05 to 4.83]).

LIMITATION

Mostly White persons were studied.

CONCLUSION

In asymptomatic persons, subclinical, obstructive coronary atherosclerosis is associated with a more than 8-fold elevated risk for myocardial infarction.

PRIMARY FUNDING SOURCE

AP Møller og Hustru Chastine Mc-Kinney Møllers Fond.

Left ventricular hypertrophy identified by cardiac computed tomography and ECG in hypertensive individuals: a population-based study

OBJECTIVES

Screening of left ventricular hypertrophy (LVH) is a biomarker of organ damage in hypertensive individuals and associated with increased mortality. Cardiac computed tomography (CT) is widely expanding worldwide; however, the value of CT assessment of LVH is unknown. We aimed to identify individuals with LVH using both cardiac CT and electrocardiograms (ECG) and to explore potential differences between these phenotypical distinct diagnostic modalities.

METHODS

Participants in the Copenhagen General Population Study underwent 12-lead ECG and cardiac CT and were evaluated for the presence of LVH. Multiple ECG signs of LVH were compared with LVH by CT.

RESULTS

Out of 4942 participants, 1347 had untreated hypertension and in this group, 13% presented with anatomical LVH by CT and 10% by ECG with an overlap of 4%. ECG signs of LVH had negative predictive values between 87 and 89% compared with CT. Using a combination of the Sokolow-Lyon index, the Cornell voltage duration product and/or a Romhilt-Estes score at least 4, lead to an increased C-statistics (P < 0.001) compared with the use of any single ECG sign of LVH. Individuals with solely CT but not ECG signs of LVH had higher SBPs (152 vs. 144 mmHg, P < 0.001) and larger left atria (49 vs. 45 ml/m, P < 0.001) compared with individuals with solely ECG LVH.

CONCLUSION

CT and ECG identifies LVH in 19% of hypertensive individuals with only a small diagnostic overlap. Commonly used ECG criteria for LVH cannot safely rule out the presence of anatomical LV organ damage.

Clinical characteristics and lipid lowering treatment of patients initiated on proprotein convertase subtilisin-kexin type 9 inhibitors: a nationwide cohort study

OBJECTIVES

Given the novelty of proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i), little is known regarding overall implementation or clinical characteristics among patients who initiate treatment. We aimed to assess the total number of patients initiated on PCSK9i along with a description of the clinical characteristics and lipid lowering treatment (LLT) of such patients.

SETTING

A register-based descriptive cohort study of patients receiving a PCSK9i in the time period from 01 January 2016 to 31 March 2017 using a cross linkage between three nationwide Danish registers. Information regarding PCSK9i prescriptions, patient demographics, concurrent pharmacotherapy, comorbidities and previous coronary procedures was identified.

RESULTS

Overall, 137 patients initiated treatment with PCSK9i in the study period from 11 in the first quarter of 2016 to 40 in the first quarter of 2017. The majority had a history of ischaemic heart disease (IHD) (67.9%) with ischaemic stroke and diabetes mellitus being present in 7.3% and 16.8% of patients, respectively. All patients initiated on PCSK9i had been previously prescribed statin treatment with atorvastatin and simvastatin being most frequently prescribed in 53% and 36% of patients, respectively. The majority of patients had received both statins and ezetimibe (94.9%) and approximately half of these patients had also received bile acid sequestrant (45.3%). Clinical characteristics mainly differed in patients receiving triple LLT compared with patients not receiving triple LLT in the regards of heart failure.

CONCLUSION

Patients treated with PCSK9i were rare, characterised by having IHD and had received various and intensive conventional LLT prior to PCSK9i initiation in agreement with current international guidelines.