RESUMO
Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.
RESUMO
OBJECTIVE: The aim of this study was to assess the association of cardiovascular disease (CVD) risk scores and coronary artery plaque (CAP) progression in HIV-infected participants. METHODS: We studied men with and without HIV-infection enrolled in the Multicenter AIDS Cohort Study (MACS) CVD study. CAP at baseline and follow-up was assessed with cardiac computed tomography angiography (CCTA). We examined the association between baseline risk scores including pooled cohort equation (PCE), Framingham risk score (FRS), and Data collect of Adverse effects of anti-HIV drugs equation (D:A:D) and CAP progression. RESULTS: We studied 495 men (211 HIV-uninfected, 284 HIV-infected). The adjusted odds ratio (aOR) of total plaque volume (TPV) and noncalcified plaque volume (NCPV) progression in the highest relative to lowest tertile was 9.4 [95% confidence interval (95% CI) 2.4-12.1, Pâ<â0.001)] and 7.7 (95% CI 3.1-19.1, Pâ<â0.001) times greater, respectively, among HIV-uninfected men in the PCE atherosclerotic cardiovascular disease (ASCVD) high vs. low-risk category. Among HIV-infected men, the association for TPV and NCPV progression for the same PCE risk categories, odds ratio (OR) 2.8 (95% CI 1.4-5.8, Pâ<â0.01) and OR 2.4 (95% CI 1.2-4.8, Pâ<â0.05), respectively (P values for interaction by HIVâ=â0.02 and 0.08, respectively). Similar results were seen for the FRS risk scores. Among HIV-uninfected men, PCE high risk category identified the highest proportion of men with plaque progression in the highest tertile, although in HIV-infected men, high-risk category by D:A:D identified the greatest percentage of men with plaque progression albeit with lower specificity than FRS and PCE. CONCLUSION: PCE and FRS categories predict CAP progression better in HIV-uninfected than in HIV-infected men. Improved CVD risk scores are needed to identify high-risk HIV-infected men for more aggressive CVD risk prevention strategies.
Assuntos
Doenças Cardiovasculares , Doença da Artéria Coronariana , Infecções por HIV , Placa Aterosclerótica , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Vasos Coronários/diagnóstico por imagem , Infecções por HIV/complicações , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Placa Aterosclerótica/complicações , Placa Aterosclerótica/diagnóstico por imagem , Fatores de RiscoRESUMO
BACKGROUND: Carotid intima-media thickness (CIMT) is regarded as a controversial risk marker for cardiovascular disease (CVD). We aimed to evaluate the role of CIMT and carotid plaque progression as predictors for the progression of coronary plaque and compositions. METHODS: In the Garlic 4 study, asymptomatic patients with intermediate CVD risk (Framingham risk score 6-20%) were recruited for a serial carotid ultrasound, and coronary artery calcium score (CAC)/coronary computed tomography angiography (CCTA) studies for subclinical atherosclerosis at a baseline and 1 year. The association between progression of quantitatively measured coronary plaque compositions and the progression of CIMT/carotid plaque was analyzed. A P value <0.05 is considered as statistically significant. RESULTS: Forty-seven consecutive patients were included. The mean age was 58.5 ± 6.6 years, and 69.1 % were male. New carotid plaque appeared in 34.0 % (n = 16) of participants, and 55.3 % (n = 26) of subjects had coronary plaque progression. In multilinear regression analysis, adjusted by age, gender, and statin use, the development of new carotid plaque was significantly associated with an increase in noncalcified coronary plaque [ß (SE) 2.0 (0.9); P = 0.025] and necrotic core plaque (1.7 (0.6); P = 0.009). In contrast, CIMT progression was not associated with the progression of coronary plaque, or coronary artery calcium (CAC) (P = NS). CONCLUSION: Compared to CIMT, carotid plaque is a better indicator of coronary plaque progression. The appearance of a new carotid plaque is associated with significant progression of necrotic core and noncalcified plaque, which are high-risk coronary plaque components.
Assuntos
Espessura Intima-Media Carotídea , Fatores de Risco de Doenças Cardíacas , Placa Aterosclerótica/patologia , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Progressão da Doença , Feminino , Alho , Humanos , Masculino , Pessoa de Meia-Idade , Extratos Vegetais/farmacologia , Placa Aterosclerótica/diagnóstico por imagem , UltrassonografiaRESUMO
Current risk stratification strategies do not fully explain cardiovascular disease (CVD) risk. We aimed to evaluate the association of low-density lipoprotein (LDL-P) and high-density lipoprotein (HDL-P) particles with progression of coronary artery calcium and carotid wall injury. All participants in the Multi-Ethnic Study Atherosclerosis (MESA) with LDL-P and HDL-P measured by ion mobility, coronary artery calcium score (CAC), carotid intima-media thickness (IMT), and carotid plaque data available at Exam 1 and 5 were included in the study. CAC progression was annualized and treated as a categorical or continuous variable. Carotid IMT and plaque progression were treated as continuous variables. Fully adjusted regression models included established CVD risk factors, as well as traditional lipids. Mean (±SD) follow-up duration was 9.6 ± 0.6 years. All LDL-P subclasses as well as large HDL-P at baseline were positively and significantly associated with annualized CAC progression, however, after adjustment for established risk factors and traditional lipids, only the association with medium and very small LDL-P remained significant (ß -0.02, pâ¯=â¯0.019 and ß 0.01, pâ¯=â¯0.003, per 1 nmol/l increase, respectively). Carotid plaque score progression was positively associated with small and very small LDL-P (p <0.01 for all) and non-HDL-P (pâ¯=â¯0.013). Only the association with very small LDL-P remained significant in a fully adjusted model (pâ¯=â¯0.035). Mean IMT progression was not associated with any of the lipid particles. In conclusion, in the MESA cohort, LDL-P measured by ion mobility was significantly associated with CAC progression as well as carotid plaque progression beyond the effect of traditional lipids.
Assuntos
Doenças das Artérias Carótidas/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Lipoproteínas HDL/sangue , Lipoproteínas LDL/sangue , Placa Aterosclerótica/diagnóstico por imagem , Calcificação Vascular/diagnóstico por imagem , Idoso , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/sangue , Espessura Intima-Media Carotídea , Estudos de Coortes , Doença da Artéria Coronariana/sangue , Feminino , Humanos , Espectrometria de Mobilidade Iônica , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/sangue , Tomografia Computadorizada por Raios X , Calcificação Vascular/sangueRESUMO
BACKGROUND: Left ventricular (LV) diastolic dysfunction is recognized as playing a major role in the pathophysiology of heart failure; however, clinical tools for identifying diastolic dysfunction before echocardiography remain imprecise. OBJECTIVES: This study sought to develop machine-learning models that quantitatively estimate myocardial relaxation using clinical and electrocardiography (ECG) variables as a first step in the detection of LV diastolic dysfunction. METHODS: A multicenter prospective study was conducted at 4 institutions in North America enrolling a total of 1,202 subjects. Patients from 3 institutions (n = 814) formed an internal cohort and were randomly divided into training and internal test sets (80:20). Machine-learning models were developed using signal-processed ECG, traditional ECG, and clinical features and were tested using the test set. Data from the fourth institution was reserved as an external test set (n = 388) to evaluate the model generalizability. RESULTS: Despite diversity in subjects, the machine-learning model predicted the quantitative values of the LV relaxation velocities (e') measured by echocardiography in both internal and external test sets (mean absolute error: 1.46 and 1.93 cm/s; adjusted R2 = 0.57 and 0.46, respectively). Analysis of the area under the receiver operating characteristic curve (AUC) revealed that the estimated e' discriminated the guideline-recommended thresholds for abnormal myocardial relaxation and diastolic and systolic dysfunction (LV ejection fraction) the internal (area under the curve [AUC]: 0.83, 0.76, and 0.75) and external test sets (0.84, 0.80, and 0.81), respectively. Moreover, the estimated e' allowed prediction of LV diastolic dysfunction based on multiple age- and sex-adjusted reference limits (AUC: 0.88 and 0.94 in the internal and external sets, respectively). CONCLUSIONS: A quantitative prediction of myocardial relaxation can be performed using easily obtained clinical and ECG features. This cost-effective strategy may be a valuable first clinical step for assessing the presence of LV dysfunction and may potentially aid in the early diagnosis and management of heart failure patients.
Assuntos
Ecocardiografia/métodos , Aprendizado de Máquina , Contração Miocárdica/fisiologia , Volume Sistólico , Diagnóstico Precoce , Feminino , Insuficiência Cardíaca Diastólica/diagnóstico , Insuficiência Cardíaca Diastólica/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Processamento de Sinais Assistido por Computador , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Assessing thromboembolic risk is crucial for proper management of patients with atrial fibrillation. Left atrial volume is a promising predictor of cardiac thrombosis. To determine whether left atrial volume can predict left atrial appendage thrombus in patients with atrial fibrillation, we conducted a prospective study of 73 patients. Left atrial and ventricular volumes were evaluated by cardiac computed tomography with retrospective electrocardiographic gating and then indexed to body surface area. Left atrial appendage thrombus was confirmed or excluded by cardiac computed tomography with delayed enhancement. Seven patients (9.6%) had left atrial appendage thrombus; 66 (90.4%) did not. Those with thrombus had a significantly higher mean left atrial end-systolic volume index (139 ± 55 vs 101 ± 35 mL/m2; P =0.0097) and mean left atrial end-diastolic volume index (122 ± 45 vs 84 ± 34 mL/m2; P =0.0077). On multivariate logistic regression analysis, left atrial end-systolic volume index (per 10 mL/m2 increase) was significantly associated with left atrial appendage thrombus (odds ratio [OR]=1.24; 95% CI, 1.03-1.50; P =0.02); so too was the left atrial end-diastolic volume index (per 10 mL/m2 increase) (OR=1.29; 95% CI, 1.05-1.60; P =0.02). These findings suggest that increased left atrial volume increases the risk of left atrial appendage thrombus. Therefore, patients with atrial fibrillation and an enlarged left atrium should be considered for cardiac computed tomography with delayed enhancement to confirm whether thrombus is present.
Assuntos
Apêndice Atrial , Volume Cardíaco/fisiologia , Cardiopatias/diagnóstico , Trombose/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/fisiopatologia , Cardiopatias/etiologia , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos ProspectivosRESUMO
OBJECTIVE: Recent results from the Cardiovascular Trial of the Testosterone Trials showed that testosterone treatment of older men with low testosterone was associated with greater progression of noncalcified plaque (NCP). We evaluated the effect of anthropometric measures and cardiovascular biomarkers on plaque progression in individuals in the Testosterone Trial. METHODS: The Cardiovascular part of the trial included 170 men aged 65 years or older with low testosterone. Participants received testosterone gel or placebo gel for 12 months. The primary outcome was change in NCP volume from baseline to 12 months, as determined by coronary computed tomography angiography (CCTA). We assayed several markers of cardiovascular risk and analyzed each marker individually in a model as predictive variables and change in NCP as the dependent variable. RESULTS: Of 170 enrollees, 138 (73 testosterone, 65 placebo) completed the study and were available for the primary analysis. Of 10 markers evaluated, none showed a significant association with the change in NCP volume, but a significant interaction between treatment assignment and waist-hip ratio (WHR) (P = 0.0014) indicated that this variable impacted the testosterone effect on NCP volume. The statistical model indicated that for every 0.1 change in the WHR, the testosterone-induced 12-month change in NCP volume increased by 26.96 mm3 (95% confidence interval, 7.72-46.20). CONCLUSION: Among older men with low testosterone treated for 1 year, greater WHR was associated with greater NCP progression, as measured by CCTA. Other biomarkers and anthropometric measures did not show statistically significant association with plaque progression.
Assuntos
Doença da Artéria Coronariana/induzido quimicamente , Doença da Artéria Coronariana/diagnóstico , Terapia de Reposição Hormonal/efeitos adversos , Hipogonadismo/tratamento farmacológico , Testosterona/efeitos adversos , Idoso , Antropometria , Biomarcadores/sangue , Doença da Artéria Coronariana/sangue , Progressão da Doença , Fatores de Risco de Doenças Cardíacas , Humanos , Hipogonadismo/complicações , Masculino , Placa Aterosclerótica/sangue , Placa Aterosclerótica/induzido quimicamente , Placa Aterosclerótica/diagnóstico , Testosterona/uso terapêuticoRESUMO
BACKGROUND: The purpose of this study is to determine if a new score calculated with coronary artery calcium (CAC) density and volume is associated with total coronary artery plaque burden and composition on coronary CT angiography (CCTA) compared to the Agatston score (AS). METHODS: We identified 347 men enrolled in the Multicenter AIDS cohort study who underwent contrast and non-contrast CCTs, and had CAC>0. CAC densities (mean Hounsfield Units [HU]) per plaque) and volumes on non-contrast CCT were measured. A Density-Volume Calcium score was calculated by multiplying the plaque volume by a factor based on the mean HU of the plaque (4, 3, 2 and 1 for 130-199, 200-299, 300-399, and ≥400HU). Total Density-Volume Calcium score was determined by the sum of these individual scores. The semi-quantitative partially calcified and total plaque scores (PCPS and TPS) on CCTA were calculated. The associations between Density-Volume Calcium score, PCPS and TPS were examined. RESULTS: Overall, 2879 CAC plaques were assessed. Multivariable linear regression models demonstrated a stronger association between the log Density-Volume Calcium score and both the PCPS (ß 0.99, 95%CI 0.80-1.19) and TPS (ß 2.15, 95%CI 1.88-2.42) compared to the log of AS (PCPS: ß 0.77, 95%CI 0.61-0.94; TPS: ß 1.70, 95%CI 1.48-1.94). Similar results were observed for numbers of PC or TP segments. CONCLUSION: The new CAC score weighted towards lower density demonstrated improved correlation with semi-quantitative PC and TP burden on CCTA compared to the traditional AS, which suggests it has utility as an alternative measure of atherosclerotic burden.
Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Placa Aterosclerótica , Calcificação Vascular/diagnóstico por imagem , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Estados UnidosRESUMO
Aims: Coronary artery calcium (CAC) scoring is an established tool for cardiovascular risk stratification. However, the lack of widespread availability and concerns about radiation exposure have limited the universal clinical utilization of CAC. In this study, we sought to explore whether machine learning (ML) approaches can aid cardiovascular risk stratification by predicting guideline recommended CAC score categories from clinical features and surface electrocardiograms. Methods and results: In this substudy of a prospective, multicentre trial, a total of 534 subjects referred for CAC scores and electrocardiographic data were split into 80% training and 20% testing sets. Two binary outcome ML logistic regression models were developed for prediction of CAC scores equal to 0 and ≥400. Both CAC = 0 and CAC ≥400 models yielded values for the area under the curve, sensitivity, specificity, and accuracy of 84%, 92%, 70%, and 75%, and 87%, 91%, 75%, and 81%, respectively. We further tested the CAC ≥400 model to risk stratify a cohort of 87 subjects referred for invasive coronary angiography. Using an intermediate or higher pretest probability (≥15%) to predict CAC ≥400, the model predicted the presence of significant coronary artery stenosis (P = 0.025), the need for revascularization (P < 0.001), notably bypass surgery (P = 0.021), and major adverse cardiovascular events (P = 0.023) during a median follow-up period of 2 years. Conclusion: ML techniques can extract information from electrocardiographic data and clinical variables to predict CAC score categories and similarly risk-stratify patients with suspected coronary artery disease.
RESUMO
BACKGROUND: Increased arterial stiffness is reportedly associated with cardiac remodelling, including the left atrium and left ventricle, in middle-aged and older adults. However, little is known about this association in young adults. METHODS: In total, 73 patients (44 (60%) men) aged 25 to 45 years with suspected coronary artery disease were included in the analysis. The left atrial volume index (LAVI), left ventricular volume index (LVVI), and left ventricular mass index (LVMI) were measured using coronary computed tomography angiography (CCTA). Arterial stiffness was assessed with the cardio-ankle vascular index (CAVI). An abnormally high CAVI was defined as that above the age- and sex-specific cut-off points of the CAVI. RESULTS: Compared with patients with a normal CAVI, those with an abnormally high CAVI were older and had a greater prevalence of diabetes mellitus, higher diastolic blood pressure, greater coronary artery calcification score, and a greater LAVI (33.5±10.3 vs. 43.0±10.3mL/m2, p <0.01). In contrast, there were no significant differences in the LVVI or LVMI between the subgroups with a normal CAVI and an abnormally high CAVI. Multivariate linear regression analysis showed that the LAVI was significantly associated with an abnormally high CAVI (standardised regression coefficient=0.283, p=0.03). CONCLUSIONS: The present study demonstrated that increased arterial stiffness is associated with the LAVI, which reflects the early stages of cardiac remodelling, independent of various comorbidity factors in young adults with suspected coronary artery disease.
Assuntos
Angiografia por Tomografia Computadorizada , Doença da Artéria Coronariana , Ventrículos do Coração , Rigidez Vascular , Adulto , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Warfarin, a vitamin K antagonist, is associated with systemic vascular calcification. We evaluated whether rivaroxaban (a direct oral factor Xa inhibitor with no interaction with vitamin K) will slow the progression in coronary plaque volumes compared with warfarin in patients with nonvalvular atrial fibrillation using coronary computed tomography angiography.
Assuntos
Aterosclerose/tratamento farmacológico , Doença da Artéria Coronariana/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Rivaroxabana/administração & dosagem , Varfarina/administração & dosagem , Administração Oral , Anticoagulantes/administração & dosagem , Aterosclerose/diagnóstico , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Relação Dose-Resposta a Droga , Inibidores do Fator Xa/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND AIMS: The association between minimally elevated coronary artery calcification (CAC) and cerebrovascular disease is not well known. We assessed whether individuals with minimal CAC (Agatston scores of 1-10) have higher ischemic stroke or transient ischemic attack (TIA) frequencies compared with those with no CAC. We also investigated the relative prevalence of carotid atherosclerosis in these two groups. METHODS: A total of 3924 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) without previous cardiovascular events, including stroke, and with baseline CAC scores of 0-10 were followed for the occurrence of incident ischemic stroke/TIA. We used carotid ultrasound to detect carotid artery plaques and to measure the intima-media thickness (IMT). RESULTS: During a median follow-up of 13.2 years, 130 participants developed incident ischemic stroke/TIA. There was no significant difference in the ischemic stroke/TIA incidence between those with minimal CAC and no CAC (3.7 versus 2.7 per 1000 person-years). In participants with minimal CAC, we observed a significant association of the condition with an internal carotid artery (ICA) that had a greater-than-average IMT (ICA-IMT; ßâ¯=â¯0.071, pâ¯=â¯0.001) and a higher odds ratio (OR) for carotid artery plaques (OR 1.46; with a 95% confidence interval [CI] of 1.18-1.80; pâ¯<â¯0.001). CONCLUSIONS: A CAC score of 0-10 is associated with a low rate of ischemic stroke/TIA, and thus a minimal CAC score is not a valuable predictive marker for ischemic stroke/TIA. A minimal CAC score may, however, provide an early and asymptomatic sign of carotid artery disease.
Assuntos
Isquemia Encefálica/etnologia , Doenças das Artérias Carótidas/etnologia , Doença da Artéria Coronariana/etnologia , Ataque Isquêmico Transitório/etnologia , Acidente Vascular Cerebral/etnologia , Calcificação Vascular/etnologia , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Isquemia Encefálica/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Humanos , Incidência , Ataque Isquêmico Transitório/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores de Tempo , Estados Unidos/epidemiologia , Calcificação Vascular/diagnóstico por imagemRESUMO
OBJECTIVES: The aim of this study was to determine whether coronary artery calcium (CAC) progression was associated with coronary plaque progression on coronary computed tomographic angiography. BACKGROUND: CAC progression and coronary plaque characteristics are associated with incident coronary heart disease. However, natural history of coronary atherosclerosis has not been well described to date, and the understanding of the association between CAC progression and coronary plaque subtypes such as noncalcified plaque progression remains unclear. METHODS: Consecutive patients who were referred to our clinic for evaluation and had serial coronary computed tomography angiography scans performed were included in the study. Coronary artery plaque (total, fibrous, fibrous-fatty, low-attenuation, densely calcified) volumes were calculated using semiautomated plaque analysis software. RESULTS: A total of 211 patients (61.3 ± 12.7 years of age, 75.4% men) were included in the analysis. The mean interval between baseline and follow-up scans was 3.3 ± 1.7 years. CAC progression was associated with a significant linear increase in all types of coronary plaque and no plaque progression was observed in subjects without CAC progression. In multivariate analysis, annualized and normalized total plaque (ß = 0.38; p < 0.001), noncalcified plaque (ß = 0.35; p = 0.001), fibrous plaque (ß = 0.56; p < 0.001), and calcified plaque (ß = 0.63; p = 0.001) volume progression, but not fibrous-fatty (ß = 0.03; p = 0.28) or low-attenuation plaque (ß = 0.11; p = 0.1) progression, were independently associated with CAC progression. Plaque progression did not differ between the sexes. A significantly increased total and calcified plaque progression was observed in statin users. CONCLUSIONS: In a clinical practice setting, progression of CAC was significantly associated with an increase in both calcified and noncalcified plaque volume, except fibrous-fatty and low-attenuation plaque. Serial CAC measurements may be helpful in determining the need for intensification of preventive treatment.
Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Placa Aterosclerótica , Calcificação Vascular/diagnóstico por imagem , Idoso , Automação , Doença da Artéria Coronariana/terapia , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Interpretação de Imagem Radiográfica Assistida por Computador , Fatores de Risco , Fatores de Tempo , Calcificação Vascular/terapiaRESUMO
BACKGROUND AND AIM: The association of HIV with coronary atherosclerosis has been established; however, the progression of coronary atherosclerosis over time among participants with HIV is not well known. The Multicenter AIDS Cohort Study Quantitative Coronary Plaque Progression Study is a large prospective multicenter study quantifying progression of coronary plaque assessed by serial coronary computed tomography angiography (CTA). PATIENTS AND METHODS: HIV-infected and uninfected men who were enrolled in the Multicenter AIDS Cohort Study Cardiovascular Substudy were eligible to complete a follow-up contrast coronary CTA 3-6 years after baseline. We measured coronary plaque volume and characteristics (calcified and noncalcified plaque including fibrous, fibrous-fatty, and low attenuation) and vulnerable plaque among HIV-infected and uninfected men using semiautomated plaque software to investigate the progression of coronary atherosclerosis over time. CONCLUSION: We describe a novel, large prospective multicenter study investigating incidence, transition of characteristics, and progression in coronary atherosclerosis quantitatively assessed by serial coronary CTAs among HIV-infected and uninfected men.
Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Infecções por HIV/epidemiologia , Placa Aterosclerótica/diagnóstico por imagem , Calcificação Vascular/diagnóstico por imagem , Síndrome da Imunodeficiência Adquirida/epidemiologia , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana/epidemiologia , Progressão da Doença , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/epidemiologia , Estudos Prospectivos , Calcificação Vascular/epidemiologiaRESUMO
Vitamin K antagonists (VKAs) are known to increase vascular calcification, suggesting increased cardiovascular disease events. Apixaban is an oral direct factor Xa inhibitor superior to warfarin at preventing stroke or systemic embolism and may stabilize coronary atherosclerosis. The potential benefits of avoiding VKA therapy and the favorable effects of factor Xa inhibitors could contribute to cardiovascular disease event reduction. We hypothesized that apixaban inhibits vascular calcification and coronary atherosclerosis progression compared with warfarin in patients with atrial fibrillation (AF). This study is a single-center, prospective, randomized, open-label study. From May 2014 to December 2015, 66 patients with nonvalvular AF who experienced VKA therapy were enrolled. Patients were randomized into either warfarin or apixaban cohorts and followed for 52 weeks. The primary objective is to compare the rate of change in coronary artery calcification (CAC) from baseline to follow-up in apixaban vs warfarin cohorts. The key secondary objective is to compare the rate of incident plaques and quantitative changes in plaque types between patients randomized to either warfarin or apixaban cohorts using serial coronary computed tomography angiography. Expert readers will blindly assess CAC and coronary artery plaques. It is thought that this trial will result in significant differences in CAC and coronary artery plaque progression between the VKA and apixaban. The results are anticipated to provide a novel insight into treatment selection for AF patients. The study is registered at http://www.clinicaltrials.gov (NCT 02090075).
Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Doença da Artéria Coronariana/tratamento farmacológico , Vasos Coronários/efeitos dos fármacos , Inibidores do Fator Xa/uso terapêutico , Placa Aterosclerótica , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Calcificação Vascular/tratamento farmacológico , Varfarina/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Protocolos Clínicos , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/patologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Progressão da Doença , Eletrocardiografia , Inibidores do Fator Xa/efeitos adversos , Feminino , Humanos , Los Angeles , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Projetos de Pesquisa , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/patologia , Varfarina/efeitos adversos , Adulto JovemRESUMO
Although single photon emission computed tomography-myocardial perfusion image (SPECT-MPI) and fractional flow reserve (FFR) derived from coronary computed tomographic angiography (CCTA) (FFRCT) have permitted functional assessment of coronary artery disease (CAD), the concordance between these modalities has not been well described. The aim of this study is to compare SPECT-MPI and anatomical stenosis by CCTA and invasive coronary angiography to FFRCT for assessing functional significance of CAD. We identified 62 patients with suspected CAD who underwent ≥64 slice coronary CTA and SPECT-MPI within 3 months. FFRCT was analyzed from CCTA data using the computational fluid dynamic techniques. The association between SPECT-MPI ischemia and FFRCT (≤0.80) was evaluated. Out of 62 patients, 186 vessels were evaluated. On a per-vessel analysis, accuracy, sensitivity and specificity of SPECT-MPI to predict FFRCT ≤ 0.80 was 74.2, 45.0 and 77.7%, respectively. The area under the curve (AUC) by receiver-operating characteristic curve analysis for SPECT-MPI demonstrated a modest performance for predicting FFRCT ≤ 0.80 (AUC 0.56). Among patients with suspected CAD who were assessed by non-invasive functional modalities, SPECT-MPI showed modest concordance with FFRCT.
Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Tomografia Computadorizada Multidetectores , Imagem de Perfusão do Miocárdio/métodos , Tomografia Computadorizada de Emissão de Fóton Único , Área Sob a Curva , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Prevention and management of coronary artery disease (CAD) is of great concern in patients with diabetes mellitus. Although the impact of coronary atherosclerosis is described well for subjects older than 40 years, the prevalence and types of coronary atherosclerosis in young patients are not well known. The aim of this study was to evaluate the prevalence, extent, severity, and volumes of coronary plaque in type 2 diabetes mellitus (T2DM) population younger than of 40 years. This prospective study enrolled 181 subjects (25-40 year old) undergoing coronary computed tomography angiography, with 86 T2DM and 95 nondiabetic age/gender-matched subjects. Coronary artery calcium (CAC), plaque assessment including total segment stenosis (sum of individual segmental stenosis), total plaque scores (sum of semiquantitative segmental plaque burden), segment involvement scores (number of segments with plaque) were evaluated. In addition, we quantitatively measured plaque volumes in total, fibrous, fibrous fatty, dense calcified, and low-attenuation plaque using novel plaque software. Compared with nondiabetic patients, the prevalence of CAD, calcified, and noncalcified plaques was higher in patients with T2DM (19% vs 58%; p <0.001). In patients with a zero CAC, T2DM had a higher prevalence (46%) of noncalcified plaque (p <0.0001). In multivariate linear regression models after adjusting for traditional cardiovascular risk factors, increased total segmental stenosis, total plaque scores, and segment involvement scores were associated with T2DM. Regarding quantitative plaque assessment, all volumes in noncalcified plaque type were approximately threefold higher in patients with T2DM. In conclusion, young patients with T2DM are susceptible to premature CAD with more calcified and noncalcified plaques. Early prevention program using computed tomography angiography might be helpful in identifying young diabetic patients with subclinical atherosclerosis.
Assuntos
Aterosclerose/diagnóstico , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Diabetes Mellitus Tipo 2/complicações , Placa Aterosclerótica/diagnóstico , Adulto , Aterosclerose/complicações , Aterosclerose/epidemiologia , California/epidemiologia , Estudos de Casos e Controles , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Placa Aterosclerótica/complicações , Placa Aterosclerótica/epidemiologia , Prevalência , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: The cardio-ankle vascular index (CAVI) is a new noninvasive index to evaluate arterial stiffness. We investigated whether CAVI can predict severity, extent, and burden of coronary artery disease by comparing results with cardiac computed tomographic angiography (CCTA). HYPOTHESIS: CAVI may predict the presence of subclinical atherosclerosis. METHODS: We prospectively enrolled 95 patients (66% male; mean age, 50 ± 16 years) who underwent both CCTA and CAVI consecutively. We evaluated if CAVI correlated with (1) severe stenosis (≥50%); (2) plaque extent, determined by a segment-involvement score (SIS), defined by the total number of coronary artery segments containing any plaque; and (3) plaque burden, determined by a segment-stenosis score (SSS), defined by the extent of obstruction of coronary luminal diameter in individual coronary artery segments. RESULTS: Bivariate analysis showed a statistically significant relationship not only between CAVI and SIS, but also between CAVI and SSS (r2 = 0.4, P < 0.0001 for SIS; r2 = 0.36, P < 0.0001 for SSS). Multivariable logistic analysis demonstrated that CAVI is significantly associated with SSS >5 (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.1-7.8, P = 0.03) and SIS >5 (OR: 2.3, 95% CI: 1.1-5.8, P = 0.02), but not severe stenosis (OR: 1.7, 95% CI: 0.9-4.3, P = 0.13), after adjusting for age, sex, chest pain, hypertension, dyslipidemia, family history, diabetes, and current smoking. CONCLUSIONS: We demonstrated that CAVI had a significant relationship with subclinical coronary atherosclerosis evaluated by CCTA, especially in relation to plaque burden and plaque extent, but not severe stenosis. Thus, CAVI may reflect coronary atherosclerosis burden more than severity.
Assuntos
Índice Tornozelo-Braço , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Adulto , Idoso , Doenças Assintomáticas , Distribuição de Qui-Quadrado , Doença da Artéria Coronariana/fisiopatologia , Estenose Coronária/fisiopatologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Projetos Piloto , Placa Aterosclerótica , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
OPINION STATEMENT: A multitude of studies now support the understanding that an increased coronary artery calcium (CAC) score represents advanced atherosclerosis and high risk for cardiovascular disease (CVD) and, as such, should be treated with conventional therapies for those considered high risk. Data is now available to guide treatment with aspirin, statins, and lifestyle management. The new ACC/AHA 2013 guidelines support intensifying statin therapy when the CAC is ≥75th percentile for age, sex, and ethnicity/race or when the calcium score is ≥300 Agatston units. This allows for aggressive management of those at the highest risk, matching intensity of therapy with intensity of risk. Most importantly, the asymptomatic person rarely needs to undergo evaluation for obstructive disease, even when CAC scores are high, as revascularization with percutaneous coronary interventions does not improve outcomes in asymptomatic persons with preserved left ventricular function. Treatment should be relegated to improvement in lifestyle, diet, exercise, aspirin, statins, and blood pressure control.
RESUMO
Importance: Recent studies have yielded conflicting results as to whether testosterone treatment increases cardiovascular risk. Objective: To test the hypothesis that testosterone treatment of older men with low testosterone slows progression of noncalcified coronary artery plaque volume. Design, Setting, and Participants: Double-blinded, placebo-controlled trial at 9 academic medical centers in the United States. The participants were 170 of 788 men aged 65 years or older with an average of 2 serum testosterone levels lower than 275 ng/dL (82 men assigned to placebo, 88 to testosterone) and symptoms suggestive of hypogonadism who were enrolled in the Testosterone Trials between June 24, 2010, and June 9, 2014. Intervention: Testosterone gel, with the dose adjusted to maintain the testosterone level in the normal range for young men, or placebo gel for 12 months. Main Outcomes and Measures: The primary outcome was noncalcified coronary artery plaque volume, as determined by coronary computed tomographic angiography. Secondary outcomes included total coronary artery plaque volume and coronary artery calcium score (range of 0 to >400 Agatston units, with higher values indicating more severe atherosclerosis). Results: Of 170 men who were enrolled, 138 (73 receiving testosterone treatment and 65 receiving placebo) completed the study and were available for the primary analysis. Among the 138 men, the mean (SD) age was 71.2 (5.7) years, and 81% were white. At baseline, 70 men (50.7%) had a coronary artery calcification score higher than 300 Agatston units, reflecting severe atherosclerosis. For the primary outcome, testosterone treatment compared with placebo was associated with a significantly greater increase in noncalcified plaque volume from baseline to 12 months (from median values of 204 mm3 to 232 mm3 vs 317 mm3 to 325 mm3, respectively; estimated difference, 41 mm3; 95% CI, 14 to 67 mm3; P = .003). For the secondary outcomes, the median total plaque volume increased from baseline to 12 months from 272 mm3 to 318 mm3 in the testosterone group vs from 499 mm3 to 541 mm3 in the placebo group (estimated difference, 47 mm3; 95% CI, 13 to 80 mm3; P = .006), and the median coronary artery calcification score changed from 255 to 244 Agatston units in the testosterone group vs 494 to 503 Agatston units in the placebo group (estimated difference, -27 Agatston units; 95% CI, -80 to 26 Agatston units). No major adverse cardiovascular events occurred in either group. Conclusions and Relevance: Among older men with symptomatic hypogonadism, treatment with testosterone gel for 1 year compared with placebo was associated with a significantly greater increase in coronary artery noncalcified plaque volume, as measured by coronary computed tomographic angiography. Larger studies are needed to understand the clinical implications of this finding. Trial Registration: clinicaltrials.gov Identifier: NCT00799617.