Cardiac Tamponade in Patients Treated with Direct Oral Anticoagulants.

BACKGROUND: Direct oral anticoagulants (DOACs) are the treatment of choice for patients with non-valvular atrial fibrillation; however, bleeding risk remains significant. We reported a single-center experience with 11 patients who presented with hemorrhagic cardiac tamponade while treated with DOACs. OBJECTIVES: To evaluate the characteristics and clinical outcomes of patients under DOACs with cardiac tamponade. METHODS: We retrospectively identified 11 patients treated with DOACs admitted with pericardial tamponade in our cardiology unit during 2018-2021. RESULTS: The mean age was 84 ± 4 years; 7 males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban (8 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 10 patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin complex concentrate and idarucizumab was given before the procedure to 6 patients treated with apixaban and one patient treated with dabigatran. One patient, initially treated with urgent pericardiocentesis, underwent pericardial window surgery due to re-accumulation of blood in the pericardium. The pericardial fluid analysis demonstrated hemopericardium. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (8 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (3 patients). No patient died during hospitalization. CONCLUSIONS: Hemorrhagic cardiac tamponade is a rare complication of DOACs. We found good short-term prognosis following pericardiocentesis.

Association between T wave morphology parameters and abnormal cardiac SPECT imaging.

BACKGROUND: T-wave morphology dispersion (TMD) described the electrocardiographic T-wave heterogeneity during a single cardiac cycle. Total cosine R-to-T (TCRT) is the average of the cosines of the angles between the QRS and T vectors on the ECG. We examine the predictive value of TMD and TCRT calculation to assess abnormal myocardial perfusion. METHODS: Retrospective single center cohort study including all patients referred for evaluation of ischemia by myocardial SPECT scanning with no known history of ischemic heart disease, from 1 January 2019 to 31 December 2019. Study endpoint was the correlation between the calculated TMD and TCRT values and detection of myocardial injury or ischemia by myocardial SPECT. RESULTS: Among 606 patients, calculated TCRT was 0.401 ± 0.53 for the normal group and 0.283 ± 0.62 for the abnormal group (p = 0.007). Measured TMD was 22.9 ± 16.6 degrees (p < 0.001) in the normal group, compared to 31.5 ± 22.8 degrees (p < 0.001) for the abnormal group. CONCLUSIONS: The results demonstrate a correlation between the decreased TCRT values and increase TMD and myocardial ischemia seen in SPECT results. The TCRT and TMD can be used as simple and non-invasive markers to predict abnormal SPECT results and ischemic heart disease in patients with no known cardiac history.

Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT myocardial imaging in patients with suspected cardiac amyloidosis.

INTRODUCTION: Assessment of myocardial uptake of Tc-99m-pyrophosphate (Tc-99m PYP) is pivotal in distinguishing transthyretin-associated cardiac amyloidosis (ATTR) from light chain amyloid (AL). It is often difficult to differentiate myocardial uptake from blood pool radioactivity with planar imaging or SPECT. We studied whether simultaneous dual-isotope Tc-99m PYP/Tl-201 SPECT improves assessment of Tc-99m PYP uptake compared to single-isotope SPECT. METHODS: Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT was acquired in 112 patients studied for possible cardiac amyloidosis. Visual interpretation was performed by two observers on single-isotope followed by dual-isotope SPECT. Heart-to-contralateral lung ratio (H/CL) of myocardial counts quantified by single-isotope and dual-isotope SPECT was compared between ATTR, AL, and no amyloidosis groups. RESULTS: In 112 patients (39 ATTR and 26 AL patients, and 47 no amyloidosis), a lower proportion of no amyloidosis and AL patients were classified visually as equivocal with dual-isotope SPECT compared to single-isotope SPECT (2% vs 19%, P = 0.02 and 8% vs 35%, P = 0.04, respectively). H/CL measurements with single-isotope and dual-isotope were lower in AL and no amyloidosis patients vs ATTR patients (P < 0.05). Interobserver agreement of visual assessment was improved with dual-isotope SPECT (P = 0.03). AUCs for detection of ATTR by visual assessment and H/CL quantification were higher with dual-isotope (0.94 and 0.95, respectively) compared to single-isotope SPECT (0.84, P = 0.001 and 0.92, P = 0.02). CONCLUSION: Tc-99m PYP/Tl-201 SPECT improves visual differentiation of ATTR and AL amyloidosis compared to single-isotope SPECT. Visual assessment and H/CL quantitation with dual-isotope SPECT provide similar discrimination between patients with ATTR and AL amyloidosis.

Risk of Stroke, Bleeding, and Death in Patients with Nonvalvular Atrial Fibrillation and Chronic Kidney Disease.

INTRODUCTION: Atrial fibrillation (AF) and chronic kidney disease (CKD) are both associated with increased risk of stroke, and CKD carries a higher bleeding risk. Oral anticoagulation (OAC) treatment is used to reduce the risk of stroke in patients with nonvalvular AF (NVAF); however, the risk versus benefit of OAC for advanced CKD is continuously debated. We aim to assess the management and outcomes of NVAF patients with impaired renal function within a population-based cohort. METHODS: We conducted a retrospective observational cohort study using ICD-9 healthcare coding. Patients with incident NVAF between 2004 and 2015 were identified stratified by CKD stage. We compared treatment strategies and estimated risks of stroke, death, or any major bleeding based on CKD stages and OAC treatment. RESULTS: We identified 85,116 patients with incident NVAF. Patients with impaired renal function were older and had more comorbidities. OAC was most common among stage 2 CKD patients (49%) and least in stages 4-5 CKD patients (27.6%). Higher CKD stages were associated with worse outcomes. Stroke rates increased from 1.04 events per 100 person-years (PY) in stage 1 CKD to 3.72 in stages 4-5 CKD. Mortality increased from 3.42 to 32.95 events/100 PY, and bleeding rates increased from 0.89 to 4.91 events/100 PY. OAC was associated with reduced stroke and intracranial bleeding risk regardless of CKD stage, and with a reduced mortality risk in stages 1-3 CKD. CONCLUSION: Among NVAF patients, advanced renal failure is associated with higher risk of stroke, death, and bleeding. OAC was associated with reduced stroke and intracranial bleeding risk, and with improved survival in stages 1-3 CKD.

A missing coronary guidewire mimicking aortic dissection-a case report.

Background: A retained coronary guidewire following coronary angiography is an extremely rare complication. We present a case of a retained coronary guidewire from a percutaneous coronary intervention done 2 years ago. Case summary: An 80-year-old asymptomatic man with a history of ischemic heart disease and moderate aortic stenosis presented to the echocardiography lab for routine follow-up. Transthoracic echocardiography showed Moderate aortic stenosis and a suspected linear echogenic structure in the ascending aorta. trans-esophageal echocardiography was performed to reveal a mobile and linear echogenic structure originating from the sinuses of Valsalva/Sinotubular junction and extending to the ascending aorta. An electrocardiogram gated cardiac computed tomography was performed and showed A linear well-defined structure originating from the ostium of the left main coronary artery and extending to the ascending aorta-a coronary guidewire from an earlier procedure. A second look at the last invasive coronary angiography record demonstrated the same finding. A multidisciplinary heart team discussion was obtained and concluded that the risk of surgical or endovascular intervention outweighed the potential benefit. The patient was discharged home for a close clinical and echocardiographic follow-up. Discussion: A retained coronary guidewire is a rare complication that operators should be aware of. Management should be case-specific depending on clinical presentation.

Association of fibromyalgia characteristics in patients with non-metastatic breast cancer and the protective role of resilience.

Cancer patients often complain about weakness, fatigue, and pain. The aim of this study was to assess the features of the fibromyalgia syndrome (FMS) characteristics in patients with non-metastatic breast cancer. The study group included 40 women whose age ranged from 40 to 70 years with Stages 0-3 breast cancer. The control group included 40 healthy women matched by age. A diagnosis of FMS was established based on medical history, physical examination, and the Fibromyalgia Impact Questionnaire (FIQ). Pain measures and functional factors were evaluated by the Brief Pain Inventory and the Sheehan Questionnaire. Resilience was assessed by Antanovsky's Sense of Coherence Questionnaire. Psychiatric disturbances were tested by the MINI Questionnaire and Hamilton questionnaires for depression and anxiety. The prevalence of chronic pain was higher in the study group. Statistically significant differences were also found between the group regarding pain, fatigue, and functional measures. The prevalence of depressive or anxious mood, measured by the Hamilton questionnaires, was strongly related to FMS characteristics reflected by FIQ scores (r = 0.79 between FIQ and the Hamilton Depression Index and r = 0.75 between FIQ and the Hamilton Anxiety Scale). The sense of coherence measure for these patients demonstrated an inverse correlation with pain, fatigue, and functional capability. Women with breast cancer tend to develop chronic widespread pain syndromes more often than do healthy women.

Low serum vitamin D concentrations in patients with schizophrenia.

BACKGROUND: Vitamin D is increasingly associated with the pathology of cognition and mental illness. Vitamin D receptors have been detected on neurons that regulate behavior. OBJECTIVE: To assess vitamin D serum concentrations in patients with major depression and schizophrenia as compared to healthy controls and to determine if a correlation exists between serum levels of vitamin D and disease activity. METHODS: We recruited 50 patients with schizophrenia and compared them to 33 patients with major depression and 50 controls with no major psychopathology. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia and the Hamilton Depression scale for depression were administered on the same day the blood samples were drawn. We used LIAISON 25-OH vitamin D (DiaSorin) immunoassay to measure serum concentrations of 25-OH vitamin D. RESULTS: Lower serum vitamin D concentrations were detected among patients with schizophrenia (15.0 +/- 7.3 ng/ml) compared to patients with depression (19.6 +/- 8.3 ng/ml) and to controls (20.2 +/- 7.8 ng/ml, P < 0.05). We found no correlation between disease activity, measured by the PANSS score, and vitamin D levels. CONCLUSIONS: Serum vitamin D levels were lower in patients with schizophrenia as compared to patients with depression and to healthy controls. No correlation was found between serum concentration and disease activity. Additional studies are needed to elucidate the role of vitamin D in the autoimmune mechanism and in the pathogenesis of schizophrenia.

Transcatheter Left Atrial Appendage Occlusion: A Multi-Center Real Life Experience.

(1) Background: left atrial appendage occlusion (LAAO) is considered an effective and relatively safe treatment for the prevention of thromboembolic events in patients with atrial fibrillation and a contra-indication for anticoagulation. We present a large multicenter real-world experience of transcatheter LAAO implementation in patients with atrial fibrillation who cannot be treated with chronic anti-coagulation; (2) Methods: included were atrial fibrillation patients who underwent transcatheter LAAO between 1 January 2016 and 30 June 2021. The study was conducted using the electronic health record database of Clalit Health Services (CHS). The primary outcomes included hemorrhagic and ischemic stroke following LAAO; (3) Results: included were 389 atrial fibrillation patients. During a median follow-up of 2.1 years, 13% patients had ischemic cerebrovascular accident (CVA), and 4.4% patients had hemorrhagic CVA. While the risk of ischemic stroke increased gradually over time, the risk of hemorrhagic CVA was highest during the first 3 months following the procedure. Moreover, previous ischemic stroke was the only significant predictor for both hemorrhagic and ischemic stroke following LAAO; (4) Conclusions: while the annual performance rate of transcatheter LAAO has increased significantly over the past years, post procedural long-term prognosis remains poor with a substantial risk of both thrombotic and bleeding events.

Identifying patients with atrial fibrillation with a single CHA2DS2-VASC risk factor who are at higher risk of stroke.

AIMS: Management of patients with a single CHA2DS2-VASc score risk factor is controversial. We attempt to identify the "truly low risk" AF patients who will not benefit from oral anticoagulation (OAC) treatment. METHODS: Retrospective cohort analysis, all incident non-valvular AF (NVAF) cases between 2004 and 2015, and age 21 and older, with up to one thromboembolic risk factor besides sex (CHA2DS2-VASc score of up to 1 for men and up to 2 for women). A "low risk" score was created for these patients using a logistic regression model on the incidence of stroke within 30-2500 days following the NVAF diagnosis. RESULTS: We identified 15,621 patients. Average age was 53.7 ± 12.3 years, 56.6% male. Mean follow-up was 5.5 years. Significant predictors of ischemic stroke were age 65-74 and diabetes (2 points each), hypertension, vascular disease, and chronic kidney disease stage 2-3 (1 point each). Stroke incidence ranged from 0.8% for score 0 and up to 3.4% for scores ≤ 2. Odds ratio for stroke among patient group with a score ≤ 2 was 4.3 (2.9-6.6) compared with score 0. Our risk score's area-under-the-curve (AUC) for prediction of stroke was 0.68 (0.65-0.71), compared with 0.60 (0.57-0.62) for the CHAD2S2-VASc score, within this low-risk group. CONCLUSION: Patients considered at low or intermediate risk using traditional risk stratification schemes, with ≥ 2 points using this proposed low-risk index (65-74 years old, diabetics or a combination of chronic renal failure and an additional risk factor), had an overall stroke risk that may justify anticoagulation therapy.

Analysis of foot and ankle kinematics after operative reduction of high-grade intra-articular fractures of the calcaneus.

BACKGROUND: High-grade calcaneal fractures represent a complex injury, with limited data to support the advisability of open reduction. Restoration of foot and ankle kinematics during walking, which has been previously shown to be significantly limited after nonoperative treatment, has never been studied after the operation. This study was designed to address this lack of information to assess the advisability of the operation in this respect. METHODS: Twenty patients with a minimum of 2 years after Open Reduction Internal Fixation (ORIF) for high-grade fractures were evaluated with a computerized gait analysis system, in addition to the radiographic assessment and functional questionnaires. Foot and ankle kinematic variables in the operated limbs were compared with contralateral limbs and with matched healthy control individuals. RESULTS: The kinematical gait analysis demonstrated recreation of normal ankle motions in operated patients. Subtalar motion demonstrated relative symmetry between operated and contralateral limbs, but it was still significantly limited compared with healthy controls. Bohler angle was between 15° and 35°. Functional questionnaires and rate of postoperative complications supported the generalizability of our operated group compared with previous literature assessing similar injuries. CONCLUSIONS: In high-grade calcaneal fractures, when recreation of gross calcaneal anatomy is obtained during the operation, walking ankle motion is recreated as well. However, subtalar motions, although recreated to a certain extent, still demonstrate limitations when compared with noninjured individuals. These results support the advisability of the operation in these complex injuries, but they demonstrate that subtalar motion is not completely normalized despite a favorable anatomic outcome.

Non-coronary cardiac calcifications and outcomes in patients with heart failure.

BACKGROUND: Calcium deposits on heart valves are considered a local manifestation of atherosclerosis and are associated with poor cardiovascular outcomes. The clinical significance of cardiac calcifications among heart failure (HF) patients, as assessed by echocardiography, is unknown. This study evaluated associations of cardiac calcifications with mortality and hospital admissions in this specific population. METHODS: Medical records of all patients who initiated ambulatory surveillance at our HF clinic during 2011-2018 were reviewed. Calcifications in the aortic valve, aortic root, or the mitral valve were evaluated. Patients with moderate to severe regurgitation or stenosis of the aortic or mitral valves were excluded. The primary endpoint was the composite of long-term all-cause mortality and HF hospitalizations. Secondary endpoints were long-term all-cause mortality and more than one hospitalization due to HF. RESULTS: This retrospective study included 814 patients (mean age 70.9 ± 13 years, 63.2% male). Of the total cohort, 350 (43%) had no cardiac calcifications and 464 (57%) had at least 1 calcified site. Considering the patients with no calcification as the reference group yielded a higher adjusted odds ratios for the composite endpoint, all-cause death, and recurrent HF hospitalizations, among patients with any cardiac calcification (OR = 1.68, 95%CI = 1.1-2.5, p = 0.01, OR=1.61, 95%CI = 1.1-2.3, p < 0.01, and OR = 1.50, 95%CI = 1.1-2.2, p < 0.01, respectively). CONCLUSIONS: We found an independent association between cardiac calcifications and the risk of death and HF hospitalizations among ambulatory HF patients. Cardiac calcifications evaluated during routine echocardiography may contribute to the risk stratification of patients with HF.

Relation of Intake of Saturated Fat to Atherosclerotic Risk Factors, Health Behaviors, Coronary Atherosclerosis, and All-Cause Mortality Among Patients Who Underwent Coronary Artery Calcium Scanning.

Although very brief questionnaires are commonly used to assess physical activity, an analogous approach for assessing diet quality within clinical practice has not been developed. Thus, we undertook an exploratory study to evaluate the association between a single-item questionnaire regarding dietary quality and patient risk profiles, lifestyle habits, lipid values, coronary artery calcium (CAC) scores and mortality. We assessed 15,368 patients who underwent CAC scanning, followed for a median of 12.1 years for all-cause mortality. Diet quality was assessed according to a single-item question regarding self-reported adherence to a low saturated fat diet (0 = never, 10 = always), with patients categorized into 4 dietary groups based on their response, ranging from low to very high saturated fat intake. We observed a significant stepwise association between reported saturated fat intake and smoking, exercise activity, obesity, and serum cholesterol, low density lipoprotein, and triglyceride values. Following adjustment for age and risk factors, patients reporting very high saturated fat intake had an elevated hazard ratio for mortality versus low saturated fat intake: 1.22 (95% confidence interval 1.04 to 1.44). The hazard ratio was no longer significant after further adjustment for exercise activity. Upon division of patients according to baseline CAC, a stepwise relationship was noted between increasing saturated fat intake and mortality among patients with CAC scores ≥400 (p = 0.002). Thus, within our cohort, just a single-item exploratory questionnaire regarding very high saturated fat intake revealed stepwise associations with health behaviors and cardiac risk factors, suggesting the basis for further development of a practical dietary questionnaire for clinical purposes.

Cardiovascular and All-Cause Mortality Risk by Coronary Artery Calcium Scores and Percentiles Among Older Adult Males and Females.

BACKGROUND: Coronary calcium is a marker of coronary atherosclerosis and established predictor of cardiovascular risk in general populations; however, there are limited studies examining its prognostic value among older adults (≥75 years) and even less regarding its utility in older males compared with females. Accordingly, we sought to examine the prognostic significance of both absolute and percentile coronary calcium scores among older adults. METHODS: The multicenter Coronary Artery Calcium Consortium consists of 66,636 asymptomatic patients without cardiovascular disease. Participants ages ≥75 were included in this study and stratified by sex. Multivariable Cox regression models were constructed to assess cardiovascular and all-cause mortality risk by Agatston coronary calcium scores and percentiles. RESULTS: Among 2,474 asymptomatic patients (mean age 79 years, 10.4-year follow-up), prevalence of coronary artery calcium was 92%. For both sexes, but in females more so than males, higher coronary calcium score and percentiles were associated with increased cardiovascular and all-cause mortality risk. Those at the lowest coronary calcium categories (0-9 and <25 percentile) had significantly lower risk of cardiovascular and all-cause mortality relative to the rest of the population. Multivariable analyses of traditional cardiovascular risk factors and coronary artery calcium variables revealed that age and coronary calcium were the strongest independent predictors for adverse outcomes. CONCLUSIONS: Both coronary artery calcium scores and percentiles are strongly predictive of cardiovascular and all-cause mortality among older adults, with greater risk-stratification among females than males. Both low coronary artery calcium scores 0-9 and <25th percentile define relatively low risk older adults.

Effects of tobacco smoke on immunity, inflammation and autoimmunity.

Smoking is a central factor in many pathological conditions. Its role in neoplasm, lung and cardiovascular diseases has been well established for years. However it is less acknowledged the cigarette smoking affects both the innate and adoptive immune arms. Cigarette smoke was shown to augment the production of numerous pro-inflammatory cytokines such as TNF-alpha, IL-1, IL-6, IL-8 GM-CSF and to decrease the levels of anti-inflammatory cytokines such as IL-10. Tobacco smoke via multiple mechanisms leads to elevated IgE concentrations and to the subsequent development of atopic diseases and asthma. Cigarette smoke has also been shown activate in many ways macrophage and dendritic cell activity. While it is better evident how cigarette smoke evokes airway diseases more mechanisms are being revealed linking this social hazard to autoimmune disorders, for instance via the production of antibodies recognizing citrullinated proteins in rheumatoid arthritis or by the elevation of anti-dsDNA titers in systemic lupus erythematosus. The current review underlines the importance of smoking prevention and eradication not only in respiratory disorders but also in autoimmune conditions as well.

Associations Among Self-reported Physical Activity, Coronary Artery Calcium Scores, and Mortality Risk in Older Adults.

OBJECTIVE: To assess whether self-reported physical activity during daily life reduces the mortality risk associated with atherosclerotic burden, as measured by coronary artery calcium (CAC) scanning. METHODS: We assessed 2318 patients aged 65 to 84 years who underwent CAC scanning from August 31, 1998, through November 16, 2016, and had daily life physical activity assessed by a single-item question that was used to divide patients by low, moderate, and high physical activity levels. Patients were followed for a mean ± SD of 10.6±4.9 years for the occurrence of all-cause mortality. RESULTS: The results indicated a graded relationship between the magnitude of CAC abnormality and mortality and an inverse relationship between physical activity and mortality. Of patients with low CAC scores (0-99), those with low, moderate, and high physical activity levels had similarly low mortality rates. Of patients with high CAC scores (≥400), however, there was a stepwise increase in mortality with decreasing physical activity. Patients with CAC scores of 400 or greater but reporting high physical activity had a mortality rate that was similar vs that observed in patients with CAC scores of only 0 to 99 and low physical activity (19.9 vs 16.3 per 1000 person-years; P=.60). CONCLUSION: Combining CAC score with self-reported physical activity level provides a synergistic means for predicting clinical risk in older patients, with high physical activity level substantially attenuating the mortality risk associated with elevated CAC scores. Moreover, the useful prognostic information afforded by just a single-item physical activity questionnaire supports current initiatives to make such assessments into a "fifth vital sign."

Hepatotoxicity rates do not differ in patients with rheumatoid arthritis and psoriasis treated with methotrexate.

OBJECTIVE: MTX hepatotoxicity is considered to occur more frequently in patients with psoriasis than in patients with RA. However, toxicity guidelines are based on reports from studies with small sample sizes and limited follow-up periods. The current study's objective was to examine the long-term risk of MTX hepatotoxicity based on a database review of patients with RA or psoriasis, and to examine whether the two populations differed. METHODS: We conducted a retrospective cohort review among members of a large health maintenance organization (HMO) in Israel who were diagnosed with either RA (n = 119) or psoriasis (n = 690) and who had purchased at least one dose of MTX. Liver function analyses were performed serially in these patients during the follow-up. All abnormal assays were recorded in the computerized database of the HMO. RESULTS: Both groups had hepatic enzyme elevation; the pre-disposing factors predictive of liver damage were female gender and a higher cumulative dose of MTX (hazard ratios, 1.46 and 1.07, respectively, P < 0.001). Age, concurrent diseases and type of disease had no influence on susceptibility to liver damage. No statistically significant difference was detected in any abnormal liver function test among patients with either RA or psoriasis. CONCLUSION: Our study did not corroborate previous findings of significant differences between psoriasis patients and RA patients concerning susceptibility to hepatotoxicity from MTX therapy. The only significant factor predicting a higher risk of hepatic damage was female gender.

Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: Experience from the real world.

BACKGROUND: Oral anticoagulation (OAC) is effective in stroke prevention in elderly patients with nonvalvular atrial fibrillation (AF), but older patients are also at higher risk of bleeding. OBJECTIVE: We aimed to examine whether OAC has net clinical benefit (NCB) in elderly patients with AF. METHODS: This is a retrospective cohort study of patients with AF, aged 75 years and older, who were diagnosed from January 1, 2013, through December 31, 2015. Incidences of stroke and intracranial hemorrhage (ICH) were estimated as the number of events per 100 person-years. The NCBs were estimated with respect to time in therapeutic range (TTR) (<60% or ≥60%) and treatment type (warfarin and low or high dose of direct oral anticoagulants [DOACs]). RESULTS: We included 11,760 patients, of whom 4982 (42.4%) were treated with OACs: 2042 (17.4%) with warfarin and 2940 (25.0%) with DOACs. Among patients treated with warfarin, those who achieved TTR ≥ 60% had a lower incidence of stroke (2.54 per 100 person-years vs 5.21 per 100 person-years; P = .01) but without a statistically significant lower incidence of ICH (0.68 per 100 person-years vs 1.10 per 100 person-years; P = .45) and a higher NCB (9.78 vs 6.52) than did those with TTR < 60%. Among patients treated with DOACs, patients treated with the high dose had a statistically significant similar incidence of stroke (8.40 per 100 person-years vs 9.81 per 100 person-years; P = .67), a statistically significant lower incidence of ICH (0.33 per 100 person-years vs 1.20 per 100 person-years; P = .02), and a higher NCB (4.42 vs 1.78) than did patients treated with the low dose. CONCLUSION: A large proportion of elderly patients are not treated with OACs. We found that the NCB of OAC in the elderly is positive, with the highest benefit in elderly patients treated with warfarin who achieved TTR ≥ 60% or high dose of DOACs.

Decrease in LDL-C is associated with decrease in all components of noncalcified plaque on coronary CTA.

BACKGROUND AND AIMS: LDL-C reduction has been associated with a decrease in noncalcified plaque (NCP) by serial quantitative coronary CT angiography (CTA). We evaluated the effect of LDL-C reduction on specific components of noncalcified plaque (NCP). METHODS: We analyzed 154 patients undergoing serial CTAs (118 men, 60 ±â€¯10 years, interval 4 ±â€¯2 years) with baseline LDL-C≥70 mg/dl. Semi-automated software was used for quantifying plaque components based on CT attenuation in Hounsfield units (HU): 30-75, low attenuation plaque (LAP); 76-130, medium-low attenuation plaque (MLAP); 131-350, medium attenuation plaque (MAP); >350, calcified plaque (CP). Decrease in LDL-C was defined as a reduction >10% of baseline LDL-C. Plaque volume changes were compared between patients with (n = 85) and without (n = 69) LDL-C decrease. RESULTS: There was interval reduction in total plaque, LAP, MLAP, and MAP volumes in patients with LDL-C decrease vs. patients without LDL-C decrease before and after adjusting for differences between the two groups (all p ≤ 0.001). An increase in CP volume occurred in both groups (p = 0.42). CONCLUSIONS: Decrease in LDL-C was associated with reduction in all components of NCP measured by quantitative CTA. Change in total NCP volume may be the optimal measurement for assessing changes over time of coronary plaque on CTA.

Age- and gender-adjusted percentiles for number of calcified plaques in coronary artery calcium scanning.

BACKGROUND: Age- and gender-adjusted percentiles of coronary artery calcium (CAC) score are commonly reported to compare a patient's coronary atherosclerosis burden to that of others of the same age and gender. The number of calcified plaques (numCP) detected on CAC scanning, a measure of plaque diffusivity, is associated with increased cardiovascular risk and, in the intermediate CAC range, adds to the CAC score in predicting mortality. This study aims to develop adjusted percentiles for numCP to provide a better context for understanding CAC scan findings. METHODS AND RESULTS: Using nonparametric modeling techniques, the distribution of numCP was analyzed in 70,320 consecutive, asymptomatic patients without prior clinically-diagnosed cardiovascular disease who were part of the Coronary Artery Calcium Consortium and supplemented by additional patients referred for clinical CAC scanning in a single center between 1998 and 2016. Nomograms for age-adjusted numCP percentiles for each gender were generated using quantile regression. The prevalence and average number of calcified coronary plaque were found to be higher in men than women. Distribution of numCP in women was found to closely mirror that of men approximately a decade younger. NumCP increased consistently across age groups in both men and women for each quantile category. CONCLUSIONS: A nomogram for age and gender-adjusted percentiles for the numCP on CAC scans has been developed in a large population of asymptomatic patients studied across multiple centers. This numCP nomogram may provide an additional tool for refining physician recommendations regarding treatment and expressing to patients how their CAC findings relate to others of similar age and gender. The numCP percentiles may also provide a meaningful way to evaluate and report the rate of progression of CAC on serial studies.