Inversion recovery and saturation recovery pulmonary vein MR angiography using an image based navigator fluoro trigger and variable-density 3D cartesian sampling with spiral-like order.

Contrast enhanced pulmonary vein magnetic resonance angiography (PV CE-MRA) has value in atrial ablation pre-procedural planning. We aimed to provide high fidelity, ECG gated PV CE-MRA accelerated by variable density Cartesian sampling (VD-CASPR) with image navigator (iNAV) respiratory motion correction acquired in under 4 min. We describe its use in part during the global iodinated contrast shortage. VD-CASPR/iNAV framework was applied to ECG-gated inversion and saturation recovery gradient recalled echo PV CE-MRA in 65 patients (66 exams) using .15 mmol/kg Gadobutrol. Image quality was assessed by three physicians, and anatomical segmentation quality by two technologists. Left atrial SNR and left atrial/myocardial CNR were measured. 12 patients had CTA within 6 months of MRA. Two readers assessed PV ostial measurements versus CTA for intermodality/interobserver agreement. Inter-rater/intermodality reliability, reproducibility of ostial measurements, SNR/CNR, image, and anatomical segmentation quality was compared. The mean acquisition time was 3.58 ± 0.60 min. Of 35 PV pre-ablation datasets (34 patients), mean anatomical segmentation quality score was 3.66 ± 0.54 and 3.63 ± 0.55 as rated by technologists 1 and 2, respectively (p = 0.7113). Good/excellent anatomical segmentation quality (grade 3/4) was seen in 97% of exams. Each rated one exam as moderate quality (grade 2). 95% received a majority image quality score of good/excellent by three physicians. Ostial PV measurements correlated moderate to excellently with CTA (ICCs range 0.52-0.86). No difference in SNR was observed between IR and SR. High quality PV CE-MRA is possible in under 4 min using iNAV bolus timing/motion correction and VD-CASPR.

Mitral annular calcification as a predictor of stroke in the multiethnic study of atherosclerosis.

BACKGROUND: Mitral annular calcification (MAC) is associated with an increased risk for cardiovascular morbidity and mortality. This study provides recent data on the association between cardiac computed tomography (CT) derived MAC and 15 years of stroke risk in a racially diverse cohort. METHODS: All multiethnic studies of atherosclerosis participants ( n  = 6814) who completed a cardiac CT at baseline were included in this analysis. MAC score was calculated from cardiac CT using the Agatston and volume score methods. Multivariable Cox proportional hazard regression models were used to compute hazard ratios for the association between MAC and stroke after adjusting for traditional cardiovascular risk factors, inflammatory markers, coronary artery calcium score, atrial fibrillation, and left atrial size. RESULTS: Overall, 9% of participants (644/6814) had MAC at baseline. Over a surveillance period of 15 years, 304 strokes occurred, and 79% were ischemic strokes. After adjusting for age, sex, race/ethnicity, SBP, diabetes, smoking, fibrinogen, IL-6, high-sensitivity C-reactive protein, and coronary artery calcium score, baseline MAC was associated with increased risk for all strokes [hazard ratio 1.68; 95% confidence interval (CI) 1.22-2.30: P  = 0.0013]. When atrial fibrillation/flutter and left atrial size were included in the final multivariable model, MAC remained a predictor of all strokes (hazard ratio 1.93; 95% CI 1.22-3.05: P  < 0.0051) and ischemic stroke (hazard ratio 2.03; 95% CI 1.24-3.31: P  < 0.0046). CONCLUSION: MAC is an independent predictor of long-term stroke risk in a racially diverse population beyond conventional cardiovascular risk factors and atrial fibrillation.

Harmonizing multimodality imaging results using Bayesian analysis: the case of CT coronary angiography and CT-derived fractional flow reserve.

Coronary computed tomographic angiography (CCTA) may provide both anatomic and CT fractional flow reserve data (CTFFR). The objective is to use Bayesian analysis to develop a model wherein the probability of significant coronary artery disease (CAD) by CTFFR can be determined given the prior probability (P) of the combined clinical and CCTA result. 172 patients referred for CCTA and subsequently underwent coronary angiography were automatically referred to CTFFR analysis. A clinical P risk score (CRS) was calculated per patient. CCTA exams were scored using CAD-RADS classification. CTFFR results were generated. CAD was defined as ≥ 3 RAD class for CCTA and ≤ .80 by CTFFR. P was calculated using CCTA and CTFFR accuracy from a prior clinical trial: post-test P for the CCTA result used the CRS as the prior risk, and CTFFR P used the post-test CRS + CCTA P as the prior risk (tri-variable). Patients were classified for each model into low (< 5%), intermediate, (5-70%) and high (> 70%) risk groups. There were 100 patients (58%), who had significant CAD at angiography. 58 patients had discordant CCTA/CTFFR results. The inclusion of the CRS and CRS + CCTA in the prior progressively reduced the intermediate risk cohort from 83 to 41% (p < 0.0001). Correct classifications (low-risk, negative angiogram plus high-risk, positive angiogram) increased by model: CRS = 12%, CRS + CCTA = 25%, CRS + CTFFR = 33%, CRS + CCTA + CTFFR = 44% (p < 0.001). Incorrect classifications were reduced to 15%. The tri-variable model performed better than either CCTA or CTFFR alone for all patients and for the sub-group with discordant imaging results. Discrepant CCTA and CTFFR results are present in one third of patients. The use of both the CRS and CCTA as the prior risk synergistically maximized the accuracy of the accuracy of the CTFFR technique.

Arterial stiffness and left ventricular structure assessed by cardiac computed tomography in a multiethnic population.

BACKGROUND: Arterial stiffness expressed by cardio-ankle vascular index (CAVI) is a marker of arteriosclerosis. It can increase vascular load, which in turn may affect the viscoelastic myocardial properties and the left ventricular compliance. In the present study, we sought to investigate the association between CAVI and left ventricular structure assessed by cardiac computed tomography (CT) in a multiethnic adult cohort. METHODS: CAVI was measured using the vascular screening system VaSera VS-1500 AU (Fukuda Denshi, Japan). The average of right and left CAVI values was utilized for the analysis. Left ventricular mass and volume were computed on mid-diastolic cardiac CTA images and indexed to body surface area (BSA) to obtain left ventricular mass index (LVMI) and left ventricular volume index (LVVI). The association between CAVI, LVMI and LVVI was assessed by multiple linear regression analysis. RESULTS: The study cohort was composed of 255 individuals (mean age 56.2 ±â€Š13.4, 66% men). An abnormal CAVI value was defined as at least 8. One hundred and seventy-one individuals had CAVI values at least 8: they were older (P < 0.0001), more affected by of hypertension (P < 0.0001), dyslipidaemia (P = 0.0002), diabetes mellitus (P < 0.0001), previous history of myocardial infarction (P = 0.0246) or angioplasty (P = 0.0143), had higher CAC score (P < 0.0001) and prevalence of obstructive coronary artery disease (P = 0.001). When analysing CT-derived left ventricular geometry parameters, we found that individuals with abnormal CAVI had significantly smaller LVVI (P < 0.0001). This association remained valid after adjustments for age, sex, ethnicity (P = 0.0002), hypertension, dyslipidaemia, CAC score (P = 0.0004) and diabetes mellitus (P = 0.0034). The association between abnormal CAVI and LVMI was not significant in the unadjusted model (P = 0.593). CONCLUSION: Reduced vascular distensibility in an adult multiethnic population is associated with smaller LVVI beyond traditional cardiovascular risk factors suggesting that impaired left ventricular compliance mainly parallels increased arterial stiffness.

Association of flow mediated vasodilation and burden of subclinical atherosclerosis by coronary CTA.

BACKGROUND AND AIMS: Endothelial dysfunction and atherosclerosis are linked by multiple mechanisms. Brachial artery flow-mediated dilation (FMD) rate is used to evaluate endothelial function and has been independently associated with adverse cardiac outcomes. The relationship between brachial artery FMD rate and severity of subclinical atherosclerosis by coronary computed tomography angiography (CCTA) is not understood. We hypothesized that brachial FMD is inversely associated with burden of subclinical atherosclerosis measured by CCTA. METHODS: This is a retrospective study of 100 participants with intermediate cardiac risk and atypical symptoms to examine association between brachial artery FMD rate and surrogate markers of severity of subclinical atherosclerosis on CCTA. Multivariate linear regression analysis was used to understand the relationship between brachial artery FMD rate and markers of plaque burden on CCTA including coronary artery calcium (CAC) score, segment involvement score (SIS; total number of segments with any plaque), segment stenosis score (SSS, sum of maximal stenosis score per segment), and total plaque score (TPS, the sum of all segments plaque burden). RESULTS: 52 participants (42%) were female. Mean age of the cohort was 59.3 ± 10.4 years. After adjusting for traditional risk factors, brachial artery FMD rate was inversely associated with higher CAC, TPS, SIS and SSS (p < 0.05 for all). FMD <4.5 predicted the presence of CAC >0 and ≤ 100 most effectively, with a sensitivity of 62.2% and a specificity of 66.7%, respectively (area under the curve (AUC) of 0.5729, p = 0.0302). FMD <2.7 predicted the presence of CAC >100 most effectively, with a sensitivity of 34% and a specificity of 83% respectively (AUC of 0.6226, p = 0.0095). CONCLUSIONS: Brachial FMD is independently associated with the presence and extent of subclinical atherosclerosis on CCTA. Our findings provide more detailed evidence that mechanistically, FMD, a surrogate marker of systemic endothelial dysfunction is a correlate of atherosclerotic burden, assessed by CCTA and CAC.

Association of high-density lipoprotein levels with baseline coronary plaque volumes by coronary CTA in the EVAPORATE trial.

BACKGROUND AND AIMS: Dyslipidemia with elevated triglycerides (TGL) and low high-density lipoprotein cholesterol (HDL-C) predicts residual cardiovascular risk, despite goal LDL-C levels and optimal statin therapy. Coronary plaque characterization by CCTA can provide mechanistic understanding of coronary artery disease and associated prognosis. The role of HDL-C in the pathogenesis of atherosclerosis is not well understood in statin-treated patients with elevated TGL. We sought to examine the association of HDL-C levels with baseline coronary plaque volumes, namely total plaque (TP) and total non-calcified plaque (TNCP) volumes by CCTA in participants enrolled in the EVAPORATE trial. METHODS: We analyzed 80 participants who were enrolled in the trial. Linear regression analysis as a univariate and multivariate model adjusted for significant cardiovascular risk factors was performed to evaluate independent association of HDL-C and baseline coronary plaque volumes. In an exploratory analysis, stratified by sex, we compared the association of serum HDL-C levels with baseline coronary plaque volumes in males and females. RESULTS: Mean (SD) age of participants (n = 80) was 57.1 (8.6) years and 43% were male. Median (Inter Quartile Range/IQR) log-TNCP volume was 83.0 (0.1-7.3) mm3 and median (IQR) log-TP volume was 144.8 (0.1-7.1) mm3. After adjustment for relevant clinical covariates including age, gender, BMI, hypertension, diabetes, past smoking and baseline TGL levels, increasing levels of HDL-C remain independently associated with lower baseline log-TNCP volumes (ß: 0.043 ± 0.021, p = 0.042) and baseline log-TP volumes (ß: 0.046 ± 0.022, p = 0.035) on CCTA. On stratifying by sex in a multivariable regression analysis, HDL-C levels were inversely associated with baseline log-TNCP volumes (ß: 0.066 ± 0.026, p = 0.018) and log-TP volumes (ß: 0.077 ± 0.025, p = 0.004) in females, but not in males (log-TNCP volumes ß: 0.038 ± 0.034, p = 0.282) and log-TP volumes (ß: -0.033 ± 0.036, p = 0.364). CONCLUSIONS: In a cohort of statin treated patients with known atherosclerosis and residually elevated TGL, there was a significant inverse relationship between HDL-C levels and baseline coronary plaque, TP and TNCP volumes on CCTA. Our findings provide more detailed mechanistic evidence regarding the protective role of HDL-C in coronary atherosclerosis in a high-risk cohort. Further investigation to evaluate the interaction of HDL-C levels and coronary plaque volumes on differential CVD risk in statin-treated patients with elevated TGL levels is warranted.

Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis.

INTRODUCTION: Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. METHODS: We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. RESULTS: Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants' ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ (2)=7.7; p=0.005). CONCLUSIONS: We found that HIV-related stigma compromised participants' abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.