Cardiovascular Risk in Men with Prostate Cancer: Insights from the RADICAL PC Study.

PURPOSE: We describe the cardiovascular risk profile in a representative cohort of patients with prostate cancer treated with or without androgen deprivation therapy. MATERIALS AND METHODS: We prospectively characterized in detail 2,492 consecutive men (mean age 68 years) with prostate cancer (newly diagnosed or with a plan to prescribe androgen deprivation therapy for the first time) from 16 Canadian sites. Cardiovascular risk was estimated by calculating Framingham risk scores. RESULTS: Most men (92%) had new prostate cancer (intermediate risk 41%, high risk 50%). The highest level of education achieved was primary school in 12%. Most (58%) were current or former smokers, 22% had known cardiovascular disease, 16% diabetes, 45% hypertension, 31% body mass index 30 kg/m2 or greater, 24% low levels of physical activity, mean handgrip strength was 37.3 kg and 69% had a Framingham risk score consistent with high cardiovascular risk. Participants in whom androgen deprivation therapy was planned had higher Framingham risk scores than those not intending to receive androgen deprivation therapy, and this risk was abolished after adjustment for confounders. CONCLUSIONS: Two-thirds of men with prostate cancer are at high cardiovascular risk. There is a positive association between a plan to use androgen deprivation therapy and baseline cardiovascular risk factors. However, this association is explained by confounding factors.

Interatrial block and interatrial septal thickness in patients with paroxysmal atrial fibrillation undergoing catheter ablation: Long-term follow-up study.

BACKGROUND: Interatrial block (IAB) is a strong predictor of recurrence of atrial fibrillation (AF). IAB is a conduction delay through the Bachman region, which is located in the upper region of the interatrial space. During IAB, the impulse travels from the right atrium to the interatrial septum (IAS) and coronary sinus to finally reach the left atrium in a caudocranial direction. No relation between the presence of IAB and IAS thickness has been established yet. OBJECTIVE: To determine whether a correlation exists between the degree of IAB and the thickness of the IAS and to determine whether IAS thickness predicts AF recurrence. METHODS: Sixty-two patients with diagnosis of paroxysmal AF undergoing catheter ablation were enrolled. IAB was defined as P-wave duration ≥120 ms. IAS thickness was measured by cardiac computed tomography. RESULTS: Among 62 patients with paroxysmal AF, 45 patients (72%) were diagnosed with IAB. Advanced IAB was diagnosed in 24 patients (39%). Forty-seven patients were male. During a mean follow-up period of 49.8 ± 22 months (range 12-60 months), 32 patients (51%) developed AF recurrence. IAS thickness was similar in patients with and without IAB (4.5 ± 2.0 mm vs. 4.0 ± 1.4 mm; p = .45) and did not predict AF. Left atrial size was significantly enlarged in patients with IAB (40.9 ± 5.7 mm vs. 37.2 ± 4.0 mm; p = .03). Advanced IAB predicted AF recurrence after the ablation (OR: 3.34, CI: 1.12-9.93; p = .03). CONCLUSIONS: IAS thickness was not significantly correlated to IAB and did not predict AF recurrence. IAB as previously demonstrated was an independent predictor of AF recurrence.

The association of carotid plaque burden and composition and the coronary artery calcium score in intermediate cardiovascular risk patients.

Both the carotid ultrasound and coronary artery calcium (CAC) score quantify subclinical atherosclerosis and are associated with cardiovascular disease and events. This study investigated the association between CAC score and carotid plaque quantity and composition. Adult participants (n = 43) without history of cardiovascular disease were recruited to undergo a carotid ultrasound. Maximum plaque height (MPH), total plaque area (TPA), carotid intima-media thickness (CIMT), and plaque score were measured. Grayscale pixel distribution analysis of ultrasound images determined plaque tissue composition. Participants then underwent CT to determine CAC score, which were also categorized as absent (0), mild (1-99), moderate (100-399), and severe (400+). Spearman correlation coefficients between carotid variables and CAC scores were computed. The mean age of participants was 63 ± 11 years. CIMT, TPA, MPH, and plaque score were significantly associated with CAC score (ρ = 0.60, p < 0.0001; ρ = 0.54, p = 0.0002; ρ = 0.38, p = 0.01; and ρ = 0.49, p = 0.001). Echogenic composition features %Calcium and %Fibrous tissue were not correlated to a clinically relevant extent. There was a significant difference in the TPA, MPH, and plaque scores of those with a severe CAC score category compared to lesser categories. While carotid plaque burden was associated with CAC score, plaque composition was not. Though CAC score reliably measures calcification, carotid ultrasound gives information on both plaque burden and composition. Carotid ultrasound with assessment of plaque features used in conjunction with traditional risk factors may be an alternative or additive to CAC scoring and could improve the prediction of cardiovascular events in the intermediate risk population.

Cancer and cardiovascular disease: can understanding the mechanisms of cardiovascular injury guide us to optimise care in cancer survivors?

Cancer and cardiovascular disease (CVD) are the leading causes of morbidity and mortality. Therefore, CVD deaths in cancer survivors remain a major challenge in improving cancer outcomes, especially in low and middle income countries (LMICs). Cancer and CVD share many common risk factors, both modifiable risk factors (obesity, diabetes and smoking) and non-modifiable factors such as inflammation. Additionally, some cancer therapies are associated with cardiac toxicity. These mechanisms drive increased CVD outcomes in cancer survivors, and understanding this relationship allows us to target therapies to combat such risks. Several commonly used pharmacotherapies for CVD demonstrate promise in cancer survivors for both primary and secondary prevention. Beta blockers and Angiotensin converting enzyme (ACE)-inhibitors have been shown in several studies to improve left ventricular ejection fraction (LVEF) in patients with already established LVEF decline following cancer therapy. Statin use during chemotherapy was associated with lower risk of heart failure and smaller declines in LVEF. Recent studies into the effects of anti-inflammatory medications on cardiovascular events in the non-cancer population have demonstrated promising results and may prove to be an area of further investigation and possible benefit in the cancer population [Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) and Colchicine Cardiovascular Outcomes Trial (COLCOT)]. Additionally, several other medications including PCSK9 inhibitors, sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 (GLP-1) agonists have been shown to modify inflammation, and therefore may provide cardiovascular benefits. While common pharmacotherapies used in CVD show promise in cancer survivors, their exact mechanisms remain poorly understood. Few studies evaluate their clinical effectiveness specifically in cancer survivors, as this patient population is excluded from most studies. Further investigation is warranted with more representation of cancer survivors before cost-effective recommendations are made. This is especially true in LMICs where resources are sparse for primary and secondary prevention in order to optimise care in this unique, high-risk population for CVD.

Right common iliac aneurysm by peripheral computed tomographic angiography.

This is a 77-year-old diabetic woman with history of claudication (Rutherford Category 2). Due to fear of underestimating disease with ankle-brachial index in a person with diabetes and advancing age, a CT angiogram was performed. The right common iliac artery had aneurysmal disease (3.4 cm) and a thrombus of right internal iliac artery. There was also a 40% stenosis of right external iliac artery and a left subtotal internal iliac stenosis at the origin. Given it's non-invasive nature and high diagnostic accuracy, CTA is poised to become the noninvasive test of choice in patients with suspected PAD or in patients at risk for obstructive vascular disease.

Comparison of coronary artery calcium scores between electron beam computed tomography and 64-multidetector computed tomographic scanner.

OBJECTIVE: Because almost all data currently available with coronary calcium scanning are from electron beam tomography (EBT), we assessed whether scores obtained with 64-multidetector computed tomography (CT; MDCT) are similar. We evaluated the interscan variation in coronary artery calcium (CAC), Agatston score (AS), and volume score (VS) between EBT and 64-MDCT (VCT; GE, Milwaukee, Wis). MATERIALS AND METHODS: One hundred two patients (mean age, 61.1 years; 27 women) underwent dual CAC scanning with both EBT and 64-MDCT. The AS and VS were measured with the Aquarius workstation (TeraRecon, Inc, San Mateo, Calif). The correlation coefficient, Bland-Altman analysis, interscanner variation, and agreement in AS and VS scores between EBT and 64-MDCT were computed. RESULTS: Interscan agreement for presence of CAC was 99%. Median values were 286 and 268 mm for AS and 243 and 213 mm for VS with EBT and 64-MDCT, respectively (P > 0.05). There was significant linear relationship between scores from the 2 scanners (R = 0.98 in AS and R = 0.99 in VS; P < 0.001). The interscanner variability between EBT and 64-MDCT was 20.9% and 17.6% in AS and VS, respectively (P = NS). Bland-Altman analysis demonstrated a mean difference in scores of 8.3% for AS and 7.8% by VS. When compared with EBT, there were larger and more prevalent motion artifacts (P < 0.001) and larger mean Hounsfield units using 64-MDCT (P < 0.001). CONCLUSIONS: At CAC scanning, 64-MDCT and EBT were comparable in AS and VS. The interscan variability between scanners is similar to interscan variability of 2 calcium scores done on the same equipment. However, heart rate control was achieved for this study for calcium scores. Whether these results are repeatable without heart rate control needs to be further assessed.

Referral to Cardiology Following Postpartum Cardiovascular Risk Screening at the Maternal Health Clinic in Kingston, Ontario.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death globally among women, and certain pregnancy complications can be the earliest indicators of increased CVD risk. Nonetheless, there is no recommendation for follow-up of cardiovascular risk factors identified through postpartum screening programs. This study describes current referral practices and clinical course from the Maternal Health Clinic in Kingston, Ontario, for women deemed at high cardiovascular risk postpartum. METHODS: We investigated the cohort of women referred from the postpartum Maternal Health Clinic to cardiology for further assessment and management, specifically examining timing and recommended interventions to reduce CVD risk. RESULTS: Women referred to cardiology differed significantly from those not referred in history of hypertensive disorders of pregnancy (P < 0.05) and demonstrated a significantly worse CVD risk profile at 6 months postpartum (P < 0.0001). Life expectancy by the cardiometabolic model for women referred was 5 years shorter (P < 0.0001). Only half of the women referred to cardiology scheduled a visit; the median time to the scheduled appointment was 12 months. Of women seen by cardiology, 60% were deemed eligible for cardiac rehabilitation. CONCLUSIONS: Although women at highest risk for CVD are being identified and referred to cardiology, the existing system is not designed for this demographic. Too many women are missing their appointments or being seen beyond 1 year postpartum. To initiate lifestyle changes and/or therapeutic interventions, we suggest that CVD prevention programming begins within 1 year of delivery. Future studies should investigate the viability of traditional cardiac rehabilitation programs among this unique population.

Association of hospital and physician case volumes with cardiac monitoring and cardiotoxicity during adjuvant trastuzumab treatment for breast cancer: a retrospective cohort study.

BACKGROUND: Adjuvant trastuzumab is the standard of care for patients with HER2 overexpressing breast cancer, but use of trastuzumab may lead to cardiotoxicity. Our goal was to evaluate the relationship between hospital and physician case volume and cardiac outcomes in this population. METHODS: In this retrospective cohort study, we identified all female patients in Ontario with a breast cancer diagnosis in 2003-2009 who underwent treatment with trastuzumab through a provincial drug-funding program and linked these patients to administrative databases to ascertain patient demographics, treating hospital and physician characteristics, admissions to hospital, cardiac risk factors, cardiac imaging and comorbidities. Insufficient cardiac monitoring was defined as per the Canadian Trastuzumab Working Group guideline. Cardiotoxicity was defined as receiving fewer than 16 of 18 doses of trastuzumab because of heart failure admission, heart failure diagnosis or discontinuation of the drug after cardiac imaging. We constructed hierarchical multivariable logistic regression models to evaluate the effect of annual hospital volume, cumulative physician volume and treatment period on cardiac monitoring and cardiotoxicity. RESULTS: Of 3777 women treated by 214 oncologists at 68 hospitals, 918 (24.3%) had insufficient cardiac monitoring and cardiotoxicity developed in 640 (16.9%). Cardiotoxicity occurred in 389 (42.4%) and 251 (8.8%) patients in the insufficient- and sufficient-monitoring groups, respectively. Higher annual hospital and cumulative physician volumes, and more recent calendar period, were all independent predictors for decreased cardiotoxicity. Adjustment for rates of cardiac monitoring annulled the relationships between case volume and cardiotoxicity. INTERPRETATION: Greater hospital and physician case volumes are associated with reduced rates of trastuzumab-related cardiotoxicity, most likely because of better cardiac monitoring at higher volume centres.

The Temporal Risk of Heart Failure Associated With Adjuvant Trastuzumab in Breast Cancer Patients: A Population Study.

BACKGROUND: The late cardiac effect of adjuvant trastuzumab and its potential interaction with anthracycline have not been well-studied on a population level. METHODS: In this retrospective population-based cohort study, female breast cancer patients in Ontario, diagnosed between 2003 and 2009, were identified by the Ontario Cancer Registry and linked to administrative databases to ascertain demographics, cardiac risk factors, comorbidities, and use of adjuvant trastuzumab and other chemotherapy. Patients with pre-existing heart failure (HF) were excluded. The main endpoint was new diagnosis of HF. Analyses included Kaplan-Meier (KM) survival analysis, multivariable piecewise Cox regression, and competing risk and propensity score analyses. All statistical tests were two-sided. RESULTS: Nineteen thousand seventy-four women with breast cancer treated with adjuvant chemotherapy were identified, of whom 3371 (17.7%) also received adjuvant trastuzumab. Anthracycline use was 84.9% overall. After a median follow-up of 5.9 years, patients treated with trastuzumab and chemotherapy were more likely to develop HF than patients on chemotherapy alone (5-year cumulative incidences of 5.2% vs 2.5%; log-rank P < .001). After adjusting for confounders, adjuvant trastuzumab remained independently associated with incident HF in the first 1.5 years (HR = 5.77, 95% CI = 4.38 to 7.62, P < .001), but not thereafter (HR = 0.87, 95% CI = 0.57 to 1.33, P = .53). Anthracycline use did not increase the risk of HF with trastuzumab synergistically, neither within (P interaction = .92) nor beyond 1.5 years (P interaction = .23). CONCLUSION: Adjuvant trastuzumab was associated with increased risk of new incidence of HF in breast cancer survivors during the period of adjuvant treatment but not thereafter. Routine intensive monitoring may not be necessary after completing adjuvant therapy.

Atrial thrombi detection prior to pulmonary vein isolation: diagnostic accuracy of cardiac computed tomography versus transesophageal echocardiography.

BACKGROUND: Patients routinely undergo transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) in order to rule out the presence of intra-atrial thrombi. Cardiac computed tomography (CCT) is also routinely conducted prior to the procedure to determine cardiac anatomy. Although it has been demonstrated that CCT can also rule out intra-atrial thrombi, the use of CCT for thrombi detection is controversial. The primary objective was to determine the utility of CCT for detection of atrial thrombi as compared to TEE. METHODS: Patients who underwent PVI between 2010 and 2011 with CTs and TEEs complet-ed within 3 days of each other were retrospectively identified. TEE reports were analyzed, while CCTs were interpreted by a cardiologist specializing in CCTs. Severe spontaneous echo contrast or thrombus detected on TEE were considered positive, as were filling defects found on CCT. RESULTS: A total of 51 patients undergoing PVI (mean age 59.4 ± 9.5 years; 75% male; ejection fraction 60 ± 12%) had both TEE and CCT in timely fashion. By TEE, 0 left atrial ap-pendage (LAA) thrombi were identified with mild to moderate spontaneous echo contrast in 4 patients. By CCT, 2 definite LAA thrombi were identified and thrombi in 4 patients could not be ruled out. Specificity, positive predictive value, and negative predictive value for CCT were 88%, 0%, and 100%, respectively. CONCLUSIONS: CCT is an effective tool in ruling out atrial thrombi prior to PVI. TEE should be completed only if CCT is positive.

Utility of cardiac computed tomography angiography to exclude clinically significant obstructive coronary artery disease in patients after myocardial perfusion imaging.

Patients with mildly abnormal or equivocal results on myocardial perfusion imaging (MPI) typically undergo diagnostic angiography or receive medical management for coronary artery disease. Catheterization is often required for either appropriate diagnosis or management. With its very high negative predictive rate, coronary computed tomographic angiography (CCTA) has great potential to rule out clinically significant coronary artery disease in this setting. The aim of this study was to analyze the clinical utility and cost implications of CCTA before invasive angiography in patients with abnormal or equivocal results on MPI. Consecutive patients referred by their physicians to our center with abnormal or equivocal results on MPI were reviewed. Patients with histories of myocardial infarction or of revascularization (coronary artery bypass grafting or percutaneous coronary intervention) were excluded. All patients underwent CCTA. Of 241 participants, only 66 (27%) of the studies with abnormal or equivocal nuclear findings revealed obstructive disease on CCTA (>50% stenosis). Fifty-five of 241 patients had normal coronary arteries, 97 patients had nonsignificant disease (<30%), and 23 patients had mild disease (30% to 50% stenosis) on CCTA, leading to diagnoses of noncardiac chest pain. Selective catheterization (for >50% stenosis on CCTA) demonstrated an average cost reduction of $1,295 per patient. Sensitivity analysis revealed cost savings to be preserved even if up to 70% of the patient cohort underwent catheterization after CCTA and across a wide range of procedural costs. In conclusion, CCTA after equivocal or mild or moderate abnormal MPI findings results in significant cost savings and a robust reduction in the need for cardiac catheterization and excludes obstructive coronary artery disease in almost 75% of patients.

Atherosclerotic plaque composition among patients with stenotic coronary artery disease on noninvasive CT angiography.

INTRODUCTION: Multidetector computed tomographic angiography (MDCTA) has emerged as a promising noninvasive tool to rule out significant coronary artery disease (CAD). In addition, MDCTA also provides additional information about atherosclerotic plaque composition. In this study, we aim to assess whether differences in plaque composition exist across patients with varying degree of stenotic CAD disease. METHODS: Four hundred and sixteen patients with chest pain or shortness of breath thought to be related to CAD (64% males, mean age: 61+/-13 years), with 61 (15%) reporting type 2 diabetes mellitus, who underwent contrast-enhanced MDCTA were studied. Enrolled patients had an intermediate pretest probability of obstructive disease. RESULTS: Overall 51 patients (12%) had normal coronaries without evidence of plaque. In the remaining 365 patients, 45 (12%) and 83 (23%) were found to have stenosis 50-70% and at least 70% in at-least one coronary artery segment, respectively. Those with a higher degree of stenotic CAD showed significantly more coronary segments with exclusively calcified and mixed plaques. With increasing severity of CAD (<50 vs. 50-70% vs. >70% stenosis), the overall proportion of plaque burden was more likely to be mixed (18 vs. 38% vs. 44%) in nature as well less likely to be exclusively noncalcified (39 vs. 20 vs. 16%). Only two of 108 (2%) patients without any underlying calcification had significant CAD (stenosis> or =50%). CONCLUSION: Significant differences in plaque composition according to severity of CAD were observed in our study. Individuals with a higher likelihood of stenotic CAD were more likely to have higher underlying burden of exclusively calcified and mixed plaque. These findings should stimulate further investigations to assess the prognostic value of plaque according to their underlying composition.

Noninvasive assessment of gender differences in coronary plaque composition with multidetector computed tomographic angiography.

To date, sparse data are available with regard to gender differences in plaque morphology and composition. The aim of the present report was to assess the differences in coronary plaque burden and composition in a noninvasive manner between women and men using multidetector computed tomographic angiography. The study population consisted of 416 patients (61 +/- 13 years), with 148 women (36%). A stenosis of >or=70% in at least one coronary segment was found in 11% of women compared to 25% of men (p <0.0001). Overall, women presented with a significantly lower mean number of segments containing calcified plaques (1.43 +/- 2.04 vs 2.25 +/- 2.30, p = 0.004) and mixed plaques (1.67 +/- 1.23 vs 2.25 +/- 2.30, p = 0.05). No such relation was seen with noncalcified plaques (0.72 +/- 1.01 vs 0.86 +/- 1.06, p = 0.21). In addition, the assessment of the overall proportion of the composition of plaque burden revealed relatively more noncalcified (40% vs 28%), less calcified (38% vs 43%), and mixed (23% vs 28%) plaques in women than in men (p <0.0001). On multivariate analysis of the total plaque burden, the women had a 19% (95% confidence interval 11% to 28%, p <0.0001) greater relative distribution of plaque that was noncalcified compared to the men, and the overall plaque burden was less likely to be calcified (p = 0.006) or mixed (p = 0.019). Similar results were seen in younger and older subjects. In conclusion, gender differences exist, not only in the atherosclerotic disease burden, but also in the underlying plaque composition. Women tended to have more exclusively noncalcified plaque and were less likely to have calcified or mixed plaques compared to men. Future studies are needed to elucidate whether these underlying differences in plaque composition might explain the reduced risk of cardiac events in women.

Ascending aortic aneurysm by cardiac CT angiography.

Thoracic aortic aneurysm (TAA) is an increasingly frequent and potentially life-threatening medical diagnosis. TAA is defined as a localized dilatation of the aorta to more than 50% of baseline. Patients are most commonly asymptomatic at the time of diagnosis. Diagnosis is made incidentally on chest radiography or echocardiography. Diagnosis is then confirmed by echocardiography, left ventricular angiography, cardiac computed tomography or cardiac magnetic resonance. Cardiac computed tomography angiography (CTA) is an excellent imaging modality for this purpose as it allows simultaneous analysis of the coronary artery tree, which is useful in determining the most suitable procedure for each patient.

Radiation reduction with prospective ECG-triggering acquisition using 64-multidetector Computed Tomographic angiography.

Current 64-multidetector Computed Tomographic scanners (MDCT) utilize retrospective overlapping helical acquisition (RS-OHA) which imparts a higher than desired radiation dose. Although the radiation burden of computed tomographic angiography (CTA) can be efficiently reduced by dose modulation and limiting field of view, a further decrease in radiation without compromising diagnostic image quality would be indeed very desirable. An alternative imaging mode is the axial prospective ECG-triggering acquisition (prospective gating). This study was done to compare the effective radiation dose and the image quality with two techniques to reduce radiation doses with CTA studies utilizing 64-MDCT scanners. The study included 149 consecutive patients (48 females and 101 males) 64-MDCT (mean age = 67 +/- 11 years, 72.2% male). Patients underwent CT coronary angiography using one of three algorithms: retrospective triggering with dose modulation; prospective triggering with padding (step and shoot acquisition with additional adjacent phases); and prospective triggering without padding (single phase acquisition only). Based on body habitus, two different voltages were utilized: 100 kVp (<85 kg) or 120 kVp (>85 kg). Radiation doses and image quality (signal to noise ratio) was measured for each patient, and compared between different acquisition protocols. The signal to-noise ratio of the ascending aorta (SNR-AA) was calculated from the mean pixel values of the contrast-filled left ventricular chamber divided by the standard deviation of these pixel values. Use of 100 kVp reduced radiation dose 41.5% using prospective triggering and 39.6% using retrospective imaging as compared to 120 kVp (P < 0.001). Use of prospective imaging reduced radiation exposure by 82.6% as compared to retrospective imaging (P < 0.001). Using both prospective imaging and 100 kVp without padding (single phase data, no other phases obtained), radiation dose was reduced by 90% (P < 0.001). In terms of image quality, the coefficient of variation of ascending aortic contrast enhancement between kVp of 120 and kVp of 100 was 6% (1.05, 95 CI 0.93-1.17), and 7.8% (0.9, 95% CI 0.7-1.2) at the pulmonary artery. The prospective ECG-Triggered acquisition and 100 kVp images were of diagnostic quality, allowing adequate assessment in all patients. CTA using PA and 100 kVp reduced the radiation dose by up to 90% without compromising the image quality.

Comparison of atherosclerotic plaque burden and composition between diabetic and non diabetic patients by non invasive CT angiography.

Type 2 diabetes mellitus (DM) is associated with a higher risk of cardiovascular disease and atherosclerotic burden. However little data exists in regards to plaque distribution and plaque composition in these patients. To assess for differences in the coronary plaques burden and composition among symptomatic patients with and without type 2 DM using multidetector computed tomography angiography (MDCTA). The 416 symptomatic patients (64% males, mean age: 61 +/- 13 years) with 61 (15%) reporting type 2 DM, who underwent contrast-enhanced MDCTA were studied. Enrolled patients had an intermediate to high pre-test probability of obstructive coronary artery disease. Multivariate analysis was used to correct for differences in age and gender. Patients with type 2 DM were more likely to have significant stenosis >or=70% in at least one coronary segments (33% in type 2 DM vs. 18% in non diabetic, P = 0.013), whereas 11% of both type 2 DM and non diabetics had stenosis of 50-70% (P = NS). Also type 2 DM patients had a higher number of coronary segments with mixed plaques compared to nondiabetic patients (1.67 +/- 2.01 vs. 1.23 +/- 1.61, P = 0.05), whereas no such differences were observed for non-calcified or calcified plaques. Nearly half (43%) of type 2 DM had coronary artery calcium scores (CACS) >or=400 vs. 29% in non diabetic patients (P = 0.03). Patients with type 2 DM tend to have atherosclerotic plaques which are more likely to be mixed in nature. Future studies need to elucidate the prognostic value of differences in plaque characteristics observed according to type 2 diabetic status.

Left ventricular pseudoaneurysm by cardiac CT angiography.

Although left ventricular (LV) pseudoaneurysm is seen infrequently, it should be recognized and distinguished from the common type of left ventricular aneurysm. The diagnosis can be difficult and the lesions are prone to rupture, thus the condition is associated with a high rate of morbidity and mortality. LV pseudoaneurysms are the result of a contained rupture of the free wall of the myocardium, with the containment being provided by adherent pericardium or scar tissue. Among patients dying of infarction, 17% have been found to have ruptured the heart through the infarcted area. Rupture of the free wall is four to five times more common than septal rupture and is usually immediately fatal. We present images of a LV pseudoaneurysm in a patient with a past history of coronary bypass grafting who underwent computed tomographic angiography for evaluation of his bypass vessels.