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.

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.

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.

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.