Meta-analysis assessing the sensitivity and specificity of 18F-FDG PET/CT for the diagnosis of prosthetic valve endocarditis (PVE) using individual patient data (IPD).

IMPORTANCE: The use of 18F-FDG PET/CT in diagnostic algorithms for PVE has increased since publication of studies and guidelines advocating its use. The assessment of test accuracy has been limited by small study sizes. We undertook a systematic review using individual patient data (IPD) meta-analysis techniques. OBJECTIVE: To estimate the summary sensitivity and specificity of 18F-FDG PET/CT in diagnosing PVE. We also assessed the effect of patient factors on test accuracy as defined by changes in the odds ratios associated with each factor. The effect of the PET/CT study on the final diagnosis was also assessed when compared to the preliminary Duke classification to determine in which patient group 18F-FDG PET/CT had the greatest utility. STUDY SELECTION: Studies were included if PET/CT was performed for suspicion of PVE and IPD of both the PET/CT result and final diagnosis defined by a gold-standard assessment was available. There were 3 possible final diagnoses ("definite PVE," "possible PVE," and "rejected PVE"). RESULTS: Seventeen studies were included with IPD available for 537 patients (from 538 scans). The summary sensitivity and specificity were 85% (95% CI 74.2%-91.8%) and 86.5% (95% CI 75.8%-92.9%) respectively when patients with final diagnosis of "possible PVE" were classified as positive for PVE. When this group was classified as negative for PVE, sensitivity was 87.4% (95% CI 80.4%-92.1%) and specificity was 84.9% (95% CI 71.5%-92.6%). Patients with a known pathogen (especially coagulase negative staphylococcal species), elevated CRP, a biological or aortic valve infection appeared more likely to have an accurate PET/CT diagnosis. Those with a mechanical valve, prior antibiotic treatment or a transcatheter aortic valve replacement valve were less likely to have an accurate test. Time since valve implantation and the presence of surgical adhesive did not appear to affect test accuracy. Of the patients with a preliminary Duke classification of "possible PVE," 84% received a more conclusive final diagnosis of "definite" or "rejected" PVE after the PET/CT study. CONCLUSIONS AND RELEVANCE: 18F-FDG PET/CT has high sensitivity and specificity in diagnosing PVE and the diagnostic utility is greatest in patients with a preliminary Duke classification of "possible PVE." Some patient factors appear to affect test accuracy, though these results should be interpreted with caution given low patient numbers for subgroup analyses.

Evaluation of deep-learning image reconstruction for chest CT examinations at two different dose levels.

AIMS: The aims of the present study were to, for both a full-dose protocol and an ultra-low dose (ULD) protocol, compare the image quality of chest CT examinations reconstructed using TrueFidelity (Standard kernel) with corresponding examinations reconstructed using ASIR-V (Lung kernel) and to evaluate if post-processing using an edge-enhancement filter affects the noise level, spatial resolution and subjective image quality of clinical images reconstructed using TrueFidelity. METHODS: A total of 25 patients were examined with both a full-dose protocol and an ULD protocol using a GE Revolution APEX CT system (GE Healthcare, Milwaukee, USA). Three different reconstructions were included in the study: ASIR-V 40%, DLIR-H, and DLIR-H with additional post-processing using an edge-enhancement filter (DLIR-H + E2). Five observers assessed image quality in two separate visual grading characteristics (VGC) studies. The results from the studies were statistically analyzed using VGC Analyzer. Quantitative evaluations were based on determination of two-dimensional power spectrum (PS), contrast-to-noise ratio (CNR), and spatial resolution in the reconstructed patient images. RESULTS: For both protocols, examinations reconstructed using TrueFidelity were statistically rated equal to or significantly higher than examinations reconstructed using ASIR-V 40%, but the ULD protocol benefitted more from TrueFidelity. In general, no differences in observer ratings were found between DLIR-H and DLIR-H + E2. For the three investigated image reconstruction methods, ASIR-V 40% showed highest noise and spatial resolution and DLIR-H the lowest, while the CNR was highest in DLIR-H and lowest in ASIR-V 40%. CONCLUSION: The use of TrueFidelity for image reconstruction resulted in higher ratings on subjective image quality than ASIR-V 40%. The benefit of using TrueFidelity was larger for the ULD protocol than for the full-dose protocol. Post-processing of the TrueFidelity images using an edge-enhancement filter resulted in higher image noise and spatial resolution but did not affect the subjective image quality.

Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population.

BACKGROUND: Early detection of coronary atherosclerosis using coronary computed tomography angiography (CCTA), in addition to coronary artery calcification (CAC) scoring, may help inform prevention strategies. We used CCTA to determine the prevalence, severity, and characteristics of coronary atherosclerosis and its association with CAC scores in a general population. METHODS: We recruited 30 154 randomly invited individuals age 50 to 64 years to SCAPIS (the Swedish Cardiopulmonary Bioimage Study). The study includes individuals without known coronary heart disease (ie, no previous myocardial infarctions or cardiac procedures) and with high-quality results from CCTA and CAC imaging performed using dedicated dual-source CT scanners. Noncontrast images were scored for CAC. CCTA images were visually read and scored for coronary atherosclerosis per segment (defined as no atherosclerosis, 1% to 49% stenosis, or ≥50% stenosis). External validity of prevalence estimates was evaluated using inverse probability for participation weighting and Swedish register data. RESULTS: In total, 25 182 individuals without known coronary heart disease were included (50.6% women). Any CCTA-detected atherosclerosis was found in 42.1%; any significant stenosis (≥50%) in 5.2%; left main, proximal left anterior descending artery, or 3-vessel disease in 1.9%; and any noncalcified plaques in 8.3% of this population. Onset of atherosclerosis was delayed on average by 10 years in women. Atherosclerosis was more prevalent in older individuals and predominantly found in the proximal left anterior descending artery. Prevalence of CCTA-detected atherosclerosis increased with increasing CAC scores. Among those with a CAC score >400, all had atherosclerosis and 45.7% had significant stenosis. In those with 0 CAC, 5.5% had atherosclerosis and 0.4% had significant stenosis. In participants with 0 CAC and intermediate 10-year risk of atherosclerotic cardiovascular disease according to the pooled cohort equation, 9.2% had CCTA-verified atherosclerosis. Prevalence estimates had excellent external validity and changed marginally when adjusted to the age-matched Swedish background population. CONCLUSIONS: Using CCTA in a large, random sample of the general population without established disease, we showed that silent coronary atherosclerosis is common in this population. High CAC scores convey a significant probability of substantial stenosis, and 0 CAC does not exclude atherosclerosis, particularly in those at higher baseline risk.

Long-term exposure to air pollution, coronary artery calcification, and carotid artery plaques in the population-based Swedish SCAPIS Gothenburg cohort.

Long-term exposure to air pollution is associated with cardiovascular events. A main suggested mechanism is that air pollution accelerates the progression of atherosclerosis, yet current evidence is inconsistent regarding the association between air pollution and coronary artery and carotid artery atherosclerosis, which are well-established causes of myocardial infarction and stroke. We studied associations between low levels of long-term air pollution, coronary artery calcium (CAC) score, and the prevalence and area of carotid artery plaques, in a middle-aged population-based cohort. The Swedish CArdioPulmonary bioImage Study (SCAPIS) Gothenburg cohort was recruited during 2013-2017 and thoroughly examined for cardiovascular risk factors, including computed tomography of the heart and ultrasonography of the carotid arteries. In 5070 participants (age 50-64 years), yearly residential exposures to air pollution (PM2.5, PM10, PMcoarse, NOx, and exhaust-specific PM2.5 1990-2015) were estimated using high-resolution dispersion models. We used Poisson regression to examine associations between long-term (26 years' mean) exposure to air pollutants and CAC score, and prevalence of carotid artery plaques, adjusted for potential confounders. Among participants with carotid artery plaques, we also examined the association with plaque area using linear regression. Mean exposure to PM2.5 was low by international standards (8.5 µg/m3). There were no consistent associations between long-term total PM2.5 exposure and CAC score or presence of carotid artery plaques, but an association between total PM2.5 and larger plaque area in participants with carotid plaques. Associations with traffic-related air pollutants were consistently positive for both a high CAC score and bilateral carotid artery plaques. These associations were independent of road traffic noise. We found stronger associations among men and participants with cardiovascular risk factors. The results lend some support to atherosclerosis as a main modifiable pathway between low levels of traffic-related ambient air pollution and cardiovascular disease, especially in vulnerable individuals.

Minimal risk of contrast-induced kidney injury in a randomly selected cohort with mildly reduced GFR.

OBJECTIVES: Previous large studies of contrast-induced or post-contrast acute kidney injury (CI-AKI/PC-AKI) have been observational, and mostly retrospective, often with patients undergoing non-enhanced CT as controls. This carries risk of inclusion bias that makes the true incidence of PC-AKI hard to interpret. Our aim was to determine the incidence of PC-AKI in a large, randomly selected cohort, comparing the serum creatinine (Scr) changes after contrast medium exposure with the normal intraindividual fluctuation in Scr. METHODS: In this prospective study of 1009 participants (age 50-65 years, 48% females) in the Swedish CArdioPulmonary bioImage Study (SCAPIS), with estimated glomerular filtration rate (eGFR) ≥ 50 mL/min, all received standard dose intravenous iohexol at coronary CT angiography (CCTA). Two separate pre-CCTA Scr samples and a follow-up sample 2-4 days post-CCTA were obtained. Change in Scr was statistically analyzed and stratification was used in the search of possible risk factors. RESULTS: Median increase of Scr post-CCTA was 0-2 µmol/L. PC-AKI was observed in 12/1009 individuals (1.2%) according to the old ESUR criteria (> 25% or > 44 µmol/L Scr increase) and 2 individuals (0.2%) when using the updated ESUR criteria (≥ 50% or ≥ 27 µmol/L Scr increase). Possible risk factors (e.g., diabetes, age, eGFR, NSAID use) did not show increased risk of developing PC-AKI. The mean effect of contrast media on Scr did not exceed the intraindividual Scr fluctuation. CONCLUSIONS: Iohexol administration to a randomly selected cohort with mildly reduced eGFR is safe, and PC-AKI is very rare, occurring in only 0.2% when applying the updated ESUR criteria. KEY POINTS: • Iohexol administration to a randomly selected cohort, 50-65 years old with mildly reduced eGFR, is safe and PC-AKI is very rare. • Applying the updated ESUR PC-AKI criteria resulted in fewer cases, 0.2% compared to 1.2% using the old ESUR criteria in this cohort with predominantly mild reduction of renal function. • The mean effect of CM on Scr did not exceed the intraindividual background fluctuation of Scr, regardless of potential risk factors, such as diabetes or NSAID use in our cohort of 1009 individuals.

Surveillance of small, solid pulmonary nodules at digital chest tomosynthesis: data from a cohort of the pilot Swedish CArdioPulmonary bioImage Study (SCAPIS).

BACKGROUND: Digital tomosynthesis (DTS) might be a low-dose/low-cost alternative to computed tomography (CT). PURPOSE: To investigate DTS relative to CT for surveillance of incidental, solid pulmonary nodules. MATERIAL AND METHODS: Recruited from a population study, 106 participants with indeterminate solid pulmonary nodules on CT underwent surveillance with concurrently performed CT and DTS. Nodule size on DTS was assessed by manual diameter measurements and semi-automatic nodule segmentations were independently performed on CT. Measurement agreement was analyzed according to Bland-Altman with 95% limits of agreement (LoA). Detection of nodule volume change > 25% by DTS in comparison to CT was evaluated with receiver operating characteristics (ROC). RESULTS: A total of 81 nodules (76%) were assessed as measurable on DTS by two independent observers. Inter- and intra-observer LoA regarding change in average diameter were ± 2 mm. Calculation of relative volume change on DTS resulted in wide inter- and intra-observer LoA in the order of ± 100% and ± 50%. Comparing relative volume change between DTS and CT resulted in LoA of -58% to 67%. The area under the ROC curve regarding the ability of DTS to detect volumetric changes > 25% on CT was 0.58 (95% confidence interval [CI] = 0.40-0.76) and 0.50 (95% CI = 0.35-0.66) for the two observers. CONCLUSION: The results of the present study show that measurement variability limits the agreement between DTS and CT regarding nodule size change for small solid nodules.

Increased aortic wall thickness on CT as a sign of prosthetic valve endocarditis.

Background Increased wall thickness in the aortic root has been suggested as an early sign of prosthetic valve endocarditis (PVE). However, there are no previous studies on the aortic wall thickness after aortic valve replacement (AVR) or in patients with PVE. Purpose To identify a clinically useful cutoff value for aortic wall thickness to detect PVE. Material and Methods Chest computed tomography (CT) studies (n = 303) on patients with a prosthetic aortic valve were retrospectively analyzed. CT studies on patients without PVE (n = 260) were compared with CT studies on patients with definite PVE (n = 43). A receiver operator characteristic (ROC) analysis was performed. Results In non-PVE patients, the wall thickness during the first 3 months postoperatively (n = 70, 4.5 ± 1.7 mm) was increased compared to beyond 3 months postoperatively (n = 190, 3.2 ± 1.0 mm, P < 0.001). Beyond 3 months postoperatively, the wall thickness 95th percentile was 5.0 mm without signs of further decrease with time. The wall thickness in PVE patients was 6.8 ± 3.0 mm (n = 43). Beyond 3 months postoperatively, ROC analysis yielded an area under the curve of 0.89 (95% CI, 0.81-0.96). With a cutoff value of 5 mm the sensitivity was 67%, specificity 95%, positive likelihood ratio 14.1, and negative likelihood ratio 0.35 of increased wall thickness in detecting PVE. Conclusion In the early postoperative period after AVR, the aortic wall thickness is increased compared to the late postoperative period. After 3 months, the wall thickness has decreased and stabilized. Increased wall thickness (>5 mm) beyond 3 months postoperatively significantly increases the likelihood of PVE.

Bacteraemia with gram-positive bacteria-when and how do I need to look for endocarditis?

BACKGROUND: Patients with bacteraemia caused by gram-positive bacteria are at risk for infective endocarditis (IE). Because IE needs long antibiotic treatment and sometimes heart valve surgery, it is very important to identify patients with IE. OBJECTIVES: In this narrative review we present and discuss how to determine which investigations to detect IE that are needed in individual patients with gram-positive bacteraemia. SOURCES: Published original studies and previous reviews in English, within the relevant field are used. CONTENT: First, the different qualities of the bacteraemia in relation to IE risk are discussed. The risk for IE in bacteraemia is related to the species of the bacterium but also to monomicrobial bacteraemia and the number of positive cultures. Second, patient-related factors for IE risk in bacteraemia are presented. Next, the risk stratification systems to determine the risk for IE in gram-positive bacteraemia caused by Staphylococcus aureus, viridans streptococci, and Enterococcus faecalis are presented and their use is discussed. In the last part of the review, an account for the different modalities of IE-investigations is given. The main focus is on echocardiography, which is the cornerstone of IE-investigations. Furthermore, 18F-fluorodesoxyglucose positron emission tomography/computed tomography and cardiac computed tomography are presented and their use is also discussed. A brief account for investigations used to identify embolic phenomena in IE is also given. Finally, we present a flowchart suggesting which investigations to perform in relation to IE in patients with gram-positive bacteraemia. IMPLICATIONS: For the individual patient as well as the healthcare system, it is important both to diagnose IE and to decide when to stop looking for IE. This review might be helpful in finding that balance.

NoiseNet, a fully automatic noise assessment tool that can identify non-diagnostic CCTA examinations.

Image noise and vascular attenuation are important factors affecting image quality and diagnostic accuracy of coronary computed tomography angiography (CCTA). The aim of this study was to develop an algorithm that automatically performs noise and attenuation measurements in CCTA and to evaluate the ability of the algorithm to identify non-diagnostic examinations. The algorithm, "NoiseNet", was trained and tested on 244 CCTA studies from the Swedish CArdioPulmonary BioImage Study. The model is a 3D U-Net that automatically segments the aortic root and measures attenuation (Hounsfield Units, HU), noise (standard deviation of HU, HUsd) and signal-to-noise ratio (SNR, HU/HUsd) in the aortic lumen, close to the left coronary ostium. NoiseNet was then applied to 529 CCTA studies previously categorized into three subgroups: fully diagnostic, diagnostic with excluded parts and non-diagnostic. There was excellent correlation between NoiseNet and manual measurements of noise (r = 0.948; p < 0.001) and SNR (r = 0.948; <0.001). There was a significant difference in noise levels between the image quality subgroups: fully diagnostic 33.1 (29.8-37.9); diagnostic with excluded parts 36.1 (31.5-40.3) and non-diagnostic 42.1 (35.2-47.7; p < 0.001). Corresponding values for SNR were 16.1 (14.0-18.0); 14.0 (12.4-16.2) and 11.1 (9.6-14.0; p < 0.001). ROC analysis for prediction of a non-diagnostic study showed an AUC for noise of 0.73 (CI 0.64-0.83) and for SNR of 0.80 (CI 0.71-0.89). In conclusion, NoiseNet can perform noise and SNR measurements with high accuracy. Noise and SNR impact image quality and automatic measurements may be used to identify CCTA studies with low image quality.

Eveningness is associated with coronary artery calcification in a middle-aged Swedish population.

Coronary artery calcification (CAC) is an established imaging biomarker of subclinical atherosclerosis, but its relationship to diurnal preference is not well studied. We investigated the association between chronotype and CAC in the Swedish CArdioPulmonary bioImage Study (SCAPIS) pilot cohort. Participants aged 50-64 years were randomly recruited and underwent extensive examination including imaging and accelerometry-assessed physical activity. 771 participants (47.3 % male, 57.6 ± 4.4 years) were included in this cross-sectional analysis. CAC was assessed by non-contrast computed tomography, and a CAC score > 10 was considered significant calcification. Self-assessed chronotype was classified as extreme morning, moderate morning, intermediate, moderate evening, or extreme evening. 10-year risk of first-onset cardiovascular disease was estimated by the Systemic Coronary Risk Evaluation 2 (SCORE2). Significant CAC was present in 29 % of the cohort. CAC prevalence increased from extreme morning to extreme evening type (22 %, 28 %, 29 %, 27 %, 41 % respectively, p = 0.018). In a multivariate logistic regression model controlling for confounders, extreme evening chronotype was independently associated with increased CAC prevalence compared to extreme morning type (OR 1.90, [95%CI 1.04-3.46], p = 0.037). When stratified by SCORE2 risk category (low: <5 %; moderate: 5 to <10 %; high: ≥10 %), significant CAC was most prevalent among extreme evening chronotypes in the low and moderate-risk groups, while chronotype seemed less important in the high-risk group (p = 0.011, p = 0.023, p = 0.86, respectively). Our findings suggest circadian factors may play an important role in atherosclerosis and should be considered in early cardiovascular prevention.

Sex differences in prevalence and characteristics of imaging detected atherosclerosis - a population-based study.

AIMS: Men are more likely to suffer a myocardial infarction than women, but population-based studies on sex differences in imaging detected atherosclerosis are lacking. The aims were to assess sex differences in prevalence of imaging detected coronary and carotid atherosclerosis, as well as multivariable adjusted associations between sex and atherosclerosis. METHODS AND RESULTS: Participants aged 50-65, recruited from the general population to the Swedish Cardiopulmonary bioImage Study (SCAPIS), were included in this population-based cross-sectional study. Comprehensive diagnostics, including coronary computed tomography angiography and carotid ultrasound, were performed. The image findings were any coronary atherosclerosis, coronary stenosis ≥50%, segment involvement score (SIS) ≥4, coronary artery calcium score (CACS) ≥100, and any ultrasound-detected carotid plaque.In 25,580 participants (50% women), men had more hypertension (20.3% vs 17.0%), hyperlipidaemia (9.0% vs 5.5%), and diabetes (8.5% vs 4.7%). The prevalence was 56.2% vs 29.5% for any coronary atherosclerosis (p<0.01), 9.0% vs 2.3% for coronary stenosis ≥50% (p<0.01), 20.2% vs 5.3% for SIS≥4 (p<0.01), 18.2% vs 5.6% for CACS≥100 (p<0.01), and 60.9% vs 48.7% for carotid plaque (p<0.01), in men vs women, respectively. Multivariable adjustment only marginally changed these associations: odds ratios [OR] (95% confidence interval [CI]): 2.75 (2.53-2.99) for coronary atherosclerosis, 2.88 (2.40-3.45) for coronary stenosis ≥50%, 3.99 (3.50-4.55) for SIS≥4, 3.29 (2.88-3.75), for CACS≥100, and 1.57 (1.45-1.70) for carotid plaque. CONCLUSION: Men had higher prevalence of imaging detected carotid and coronary atherosclerosis with prevalence in women aged 65 corresponding to men 10-14 years younger. The associations remained after extensive multivariable adjustment.

High-quality annotations for deep learning enabled plaque analysis in SCAPIS cardiac computed tomography angiography.

Background: Plaque analysis with coronary computed tomography angiography (CCTA) is a promising tool to identify high risk of future coronary events. The analysis process is time-consuming, and requires highly trained readers. Deep learning models have proved to excel at similar tasks, however, training these models requires large sets of expert-annotated training data. The aims of this study were to generate a large, high-quality annotated CCTA dataset derived from Swedish CArdioPulmonary BioImage Study (SCAPIS), report the reproducibility of the annotation core lab and describe the plaque characteristics and their association with established risk factors. Methods and results: The coronary artery tree was manually segmented using semi-automatic software by four primary and one senior secondary reader. A randomly selected sample of 469 subjects, all with coronary plaques and stratified for cardiovascular risk using the Systematic Coronary Risk Evaluation (SCORE), were analyzed. The reproducibility study (n = 78) showed an agreement for plaque detection of 0.91 (0.84-0.97). The mean percentage difference for plaque volumes was -0.6% the mean absolute percentage difference 19.4% (CV 13.7%, ICC 0.94). There was a positive correlation between SCORE and total plaque volume (rho = 0.30, p < 0.001) and total low attenuation plaque volume (rho = 0.29, p < 0.001). Conclusions: We have generated a CCTA dataset with high-quality plaque annotations showing good reproducibility and an expected correlation between plaque features and cardiovascular risk. The stratified data sampling has enriched high-risk plaques making the data well suited as training, validation and test data for a fully automatic analysis tool based on deep learning.

Accelerometer derived physical activity and subclinical coronary and carotid atherosclerosis: cross-sectional analyses in 22 703 middle-aged men and women in the SCAPIS study.

OBJECTIVES: The aim included investigation of the associations between sedentary (SED), low-intensity physical activity (LIPA), moderate-to-vigorous intensity PA (MVPA) and the prevalence of subclinical atherosclerosis in both coronaries and carotids and the estimated difference in prevalence by theoretical reallocation of time in different PA behaviours. DESIGN: Cross-sectional. SETTING: Multisite study at university hospitals. PARTICIPANTS: A total of 22 670 participants without cardiovascular disease (51% women, 57.4 years, SD 4.3) from the population-based Swedish CArdioPulmonary bioImage study were included. SED, LIPA and MVPA were assessed by hip-worn accelerometer. PRIMARY AND SECONDARY OUTCOMES: Any and significant subclinical coronary atherosclerosis (CA), Coronary Artery Calcium Score (CACS) and carotid atherosclerosis (CarA) were derived from imaging data from coronary CT angiography and carotid ultrasound. RESULTS: High daily SED (>70% ≈10.5 hours/day) associated with a higher OR 1.44 (95% CI 1.09 to 1.91), for significant CA, and with lower OR 0.77 (95% CI 0.63 to 0.95), for significant CarA. High LIPA (>55% ≈8 hours/day) associated with lower OR for significant CA 0.70 (95% CI 0.51 to 0.96), and CACS, 0.71 (95% CI 0.51 to 0.97), but with higher OR for CarA 1.41 (95% CI 1.12 to 1.76). MVPA above reference level, >2% ≈20 min/day, associated with lower OR for significant CA (OR range 0.61-0.67), CACS (OR range 0.71-0.75) and CarA (OR range 0.72-0.79). Theoretical replacement of 30 min of SED into an equal amount of MVPA associated with lower OR for significant CA, especially in participants with high SED 0.84 (95% CI 0.76 to 0.96) or low MVPA 0.51 (0.36 to 0.73). CONCLUSIONS: MVPA was associated with a lower risk for significant atherosclerosis in both coronaries and carotids, while the association varied in strength and direction for SED and LIPA, respectively. If causal, clinical implications include avoiding high levels of daily SED and low levels of MVPA to reduce the risk of developing significant subclinical atherosclerosis.

Pulmonary nodule size evaluation with chest tomosynthesis.

PURPOSE: To evaluate intra- and interobserver variability, as well as agreement for nodule size measurements on chest tomosynthesis and computed tomographic (CT) images. MATERIALS AND METHODS: The Regional Ethical Review Board approved this study, and all participants gave written informed consent. Thirty-six segmented nodules in 20 patients were included in the study. Eight observers measured the left-to-right, inferior-to-superior, and longest nodule diameters on chest tomosynthesis and CT images. Intra- and interobserver repeatability, as well as agreement between measurements on chest tomosynthesis and CT images, were assessed as recommended by Bland and Altman. RESULTS: The difference between the mean manual and the segmented diameter was -2.2 and -2.3 mm for left-to-right and -2.6 and -2.2 mm for the inferior-to-superior diameter for measurements on chest tomosynthesis and CT images, respectively. Intraobserver 95% limits of agreement (LOA) for the longest diameter ranged from a lower limit of -1.1 mm and an upper limit of 1.0 mm to -1.8 and 1.8 mm for chest tomosynthesis and from -0.6 and 0.9 mm to -3.1 and 2.2 mm for axial CT. Interobserver 95% LOA ranged from -1.3 and 1.5 mm to -2.0 and 2.1 mm for chest tomosynthesis and from -1.8 and 1.1 mm to -2.2 and 3.1 mm for axial CT. The 95% LOA concerning the mean of the observers' measurements of the longest diameter at chest tomosynthesis and axial CT were ±2.1 mm (mean measurement error, 0 mm). For the different observers, the 95% LOA between the modalities ranged from -2.2 and 1.6 mm to -3.2 and 2.8 mm. CONCLUSION: Measurements on chest tomosynthesis and CT images are comparable, because there is no evident bias between the modalities and the repeatability is similar. The LOA between measurements for the two modalities raise concern if measurements from chest tomosynthesis and CT were to be used interchangeably.

ECG-gated computed tomography: a new role for patients with suspected aortic prosthetic valve endocarditis.

OBJECTIVES: The aim of this prospective study was to investigate the agreement in findings between ECG-gated CT and transoesophageal echocardiography (TEE) in patients with aortic prosthetic valve endocarditis (PVE). METHODS: Twenty-seven consecutive patients with PVE underwent 64-slice ECG-gated CT and TEE and the results were compared. Imaging was compared with surgical findings (surgery was performed in 16 patients). RESULTS: TEE suggested the presence of PVE in all patients [thickened aortic wall (n = 17), vegetation (n = 13), abscess (n = 16), valvular dehiscence (n = 10)]. ECG-gated CT was positive in 25 patients (93 %) [thickened aortic wall (n = 19), vegetation (n = 7), abscess (n = 18), valvular dehiscence (n = 7)]. The strength of agreement [kappa (95 % CI)] between ECG-gated CT and TEE was very good for thickened wall [0.83 (0.62-1.0)], good for abscess [0.68 (0.40-0.97)] and dehiscence [0.75 (0.48-1.0)], and moderate for vegetation [0.55 (0.26-0.88)]. The agreement was good between surgical findings (abscess, vegetation and dehiscence) and imaging for ECG-gated CT [0.66 (0.49-0.87)] and TEE [0.79 (0.62-0.96)] and very good for the combination of ECG-gated CT and TEE [0.88 (0.74-1.0)]. CONCLUSION: Our results indicate that ECG-gated CT has comparable diagnostic performance to TEE and may be a valuable complement in the preoperative evaluation of patients with aortic PVE.

Endovascular plugs to occlude proximal entries in chronic aortic dissection.

OBJECTIVES: Patients with expanding chronic aortic dissection and patent proximal entries are sometimes poor candidates for open surgery or TEVAR. Occlusion of proximal entries with endovascular plugs has previously been suggested in selected patients, but clinical results over time are unknown. This study analyses aortic remodelling and clinical outcome after proximal entry occlusion. METHODS: Between 2007 and 2016, 14 patients, with expanding chronic aortic dissection, considered poor candidates for standard treatment, were treated with endovascular plugs in proximal entries located in the arch (n = 6) or descending aorta (n = 8). The Amplatzer™ Vascular Plug II was used for entries ≤4 mm and the Amplatzer™ Septal Occluder or Amplatzer™ Muscular VSD Occluder for entries 5-16 mm. Patients were followed for 0.5-13 years (median 7.3) with clinical visits and computed tomography. Diameters and cross-sectional areas along the aorta were measured. RESULTS: Occlusion of proximal entries was achieved in 10/14 patients (71%), including 4 patients with an adjunctive reintervention needed for complete seal in the segment. Unchanged or reduced maximum thoracic aortic diameter was observed in all 10 patients with successful occlusion. In 4 patients, proximal occlusion was not achieved and early conversion to FET (n = 1), FET/TEVAR (n = 2) or TEVAR (n = 1) was performed. Two aorta-related deaths occurred during follow-up, both after early conversion. CONCLUSIONS: Endovascular occlusion of proximal dissection entries of expanding chronic aortic dissections can induce favourable aortic remodelling and may be considered in selected patients with expanding chronic aortic dissection who are poor candidates for open surgery or stent graft repair.

Calcium Load in the Aortic Valve, Aortic Root, and Left Ventricular Outflow Tract and the Risk for a Periprocedural Stroke.

Background: Periprocedural stroke during transcatheter aortic valve implantation is a rare but devastating complication. The calcified aortic valve is the most likely source of the emboli in a periprocedural stroke. The total load and distribution of calcium in the leaflets, aortic root, and left ventricular outflow tract varies from patient to patient. Consequently, there could be patterns of calcification that are associated with a higher risk of stroke. This study aimed to explore whether the pattern of calcification in the left ventricular outflow tract, annulus, aortic valve, and ascending aorta can be used to predict a periprocedural stroke. Methods: Among the 3282 consecutive patients who received a transcatheter aortic valve implantation in the native valve in Sweden from 2014 to 2018, we identified 52 who had a periprocedural stroke. From the same cohort, a control group of 52 patients was constructed by propensity score matching. Both groups had one missing cardiac computed tomography, and 51 stroke and 51 control patients were blindly reviewed by an experienced radiologist. Results: The groups were well balanced in terms of demographics and procedural data. Of the 39 metrics created to describe calcium pattern, only one differed between the groups. The length of calcium protruding above the annulus was 10.6 mm (interquartile range 7-13.6) for patients without stroke and 8 mm (interquartile range 3-10) for stroke patients. Conclusions: This study could not find any pattern of calcification that predisposes for a periprocedural stroke.

Cadmium Exposure and Coronary Artery Atherosclerosis: A Cross-Sectional Population-Based Study of Swedish Middle-Aged Adults.

BACKGROUND: The general population is ubiquitously exposed to the toxic metal cadmium through the diet and smoking. Cadmium exposure is associated with increased morbidity and mortality in myocardial infarction and stroke. Atherosclerosis is the main underlying mechanism of myocardial infarction. However, associations between cadmium and coronary artery atherosclerosis have not been examined. OBJECTIVES: Our study sought to examine the hypothesis that blood cadmium (B-Cd) is positively associated with coronary artery calcification, as a measure of coronary artery atherosclerosis in the population-based Swedish SCAPIS study. METHODS: Our analysis included 5,627 individuals (51% women), age 50-64 y, enrolled from 2013 to 2018. The coronary artery calcium score (CACS) was obtained from computed tomography. Blood cadmium was determined by inductively coupled plasma mass spectrometry (ICP-MS). Associations between B-Cd and coronary artery calcium score (CACS Agatston score) were evaluated using prevalence ratios (PRs) in models adjusted for sex, age, smoking, hypertension, diabetes, low-density cholesterol/high-density cholesterol ratio, and family history. RESULTS: The median B-Cd concentration was 0.24µg/L. The prevalence of positive coronary artery calcium (CACS>0) was 41% and the prevalence of CACS≥100 was 13%. Relative to the lowest quartile (Q) of B-Cd (<0.16µg/L), the highest quartile (median 0.63µg/L) was associated with a small but significant increase in CACS>0 (PR 1.1; 95% CI: 1.0, 1.3), and a greater relative increase in CACS≥100 (PR 1.6; 95% CI: 1.3, 2.0). When restricted to 2,446 never-smokers, corresponding PRs were 1.1 (95% CI 0.9, 1.3) for CACS>0 (63 cases in Q4) and 1.7 (95% CI 1.1, 2.7) for CACS≥100 (17 cases in Q4). DISCUSSION: Blood cadmium in the highest quartile was associated with CACS in a general population sample with low to moderate cadmium exposure. This supports the hypothesis that atherosclerosis is an important mechanism underlying the associations between cadmium and incident cardiovascular disease. The findings suggest that public health measures to reduce cadmium exposure are warranted. https://doi.org/10.1289/EHP8523.

Systematic Coronary Risk Evaluation estimated risk and prevalent subclinical atherosclerosis in coronary and carotid arteries: A population-based cohort analysis from the Swedish Cardiopulmonary Bioimage Study.

BACKGROUND: It is not clear if the European Systematic Coronary Risk Evaluation algorithm is useful for identifying prevalent subclinical atherosclerosis in a population of apparently healthy individuals. Our aim was to explore the association between the risk estimates from Systematic Coronary Risk Evaluation and prevalent subclinical atherosclerosis. DESIGN: The design of this study was as a cross-sectional analysis from a population-based study cohort. METHODS: From the general population, the Swedish Cardiopulmonary Bioimage Study randomly invited individuals aged 50-64 years and enrolled 13,411 participants mean age 57 (standard deviation 4.3) years; 46% males between November 2013-December 2016. Associations between Systematic Coronary Risk Evaluation risk estimates and coronary artery calcification and plaques in the carotid arteries by using imaging data from a computed tomography of the heart and ultrasonography of the carotid arteries were examined. RESULTS: Coronary calcification was present in 39.5% and carotid plaque in 56.0%. In men, coronary artery calcium score >0 ranged from 40.7-65.9% and presence of carotid plaques from 54.5% to 72.8% in the age group 50-54 and 60-65 years, respectively. In women, the corresponding difference was from 17.1-38.9% and from 41.0-58.4%. A doubling of Systematic Coronary Risk Evaluation was associated with an increased probability to have coronary artery calcium score >0 (odds ratio: 2.18 (95% confidence interval 2.07-2.30)) and to have >1 carotid plaques (1.67 (1.61-1.74)). CONCLUSION: Systematic Coronary Risk Evaluation estimated risk is associated with prevalent subclinical atherosclerosis in two major vascular beds in a general population sample without established cardiovascular disease or diabetes mellitus. Thus, the Systematic Coronary Risk Evaluation risk chart may be of use for estimating the risk of subclinical atherosclerosis.

Social Support and Subclinical Coronary Artery Disease in Middle-Aged Men and Women: Findings from the Pilot of Swedish CArdioPulmonary bioImage Study.

Social support has been associated with coronary artery disease (CAD), particularly in individuals who have sustained a cardiovascular event. This study investigated the relationship between social support and subclinical CAD among 1067 healthy middle-aged men and women. Social support was assessed with validated social integration and emotional attachment measures. Subclinical CAD was assessed as a coronary artery calcium score (CACS) using computed tomography. There was no association between social support and CACS in men. In women, low social support was strongly linked to cardiovascular risk factors, high levels of inflammatory markers, and CACS > 0. In a logistic regression model, after adjustment for 12 cardiovascular risk factors, the odds ratio (95% confidence intervals) for CACS > 0 in women with the lowest social integration, emotional attachment, and social support groups (reference: highest corresponding group) were 2.47 (1.23-5.12), 1.87 (0.93-3.59), and 4.28 (1.52-12.28), respectively. Using a machine learning approach (random forest), social integration was the fourth (out of 12) most important risk factor for CACS > 0 in women. Women with lower compared to higher or moderate social integration levels were about 14 years older in "vascular age". This study showed an association between lack of social support and subclinical CAD in middle-aged women, but not in men. Lack of social support may affect the atherosclerotic process and identify individuals vulnerable to CAD events.