Cardiometabolic predictors of high-risk CCTA phenotype in a diverse patient population.

Introduction: Low-attenuation non-calcified plaque (LAP) burden and vascular inflammation by pericoronary adipose tissue (PCAT) measured from coronary CT angiography (CCTA) have shown to be predictors of cardiovascular outcomes. We aimed to investigate the relationships of cardiometabolic risk factors including lipoprotein(a) and epicardial adipose tissue (EAT) with CCTA high-risk imaging biomarkers, LAP and vascular inflammation. Methods: The patient population consisted of consecutive patients who underwent CCTA for stable chest pain and had a complete cardiometabolic panel including lipoprotein(a). Plaque, PCAT and EAT were measured from CT using semiautomated software. Elevated LAP burden and PCAT attenuation were defined as ≥4% and ≥70.5 HU, respectively. The primary clinical end-point was a composite of myocardial infarction, revascularization or cardiovascular death. Results: A total of 364 consecutive patients were included (median age 56 years, 64% female); the majority of patients were of Hispanic (60%), and the rest were of non-Hispanic Black (21%), non-Hispanic White (6%) and non-Hispanic Asian (4%) race/ethnicity. The prevalence of elevated LAP burden and PCAT attenuation was 31 and 18%, respectively, while only 8% had obstructive stenosis. There were significant differences in plaque characteristics among different racial/ethnic groups (p<0.001). Lipoprotein(a) correlated with LAP burden in Hispanic patients. Patients with elevated LAP were older, more likely to be have diabetes, hypertension, hyperlipidemia and smoke with higher CAC and EAT volume (all P<0.05). Patients with elevated LAP were more likely to develop the primary clinical outcome (p<0.001) but those with elevated PCAT were not (p=0.797). Conclusion: The prevalence of LAP and PCAT attenuation were 31 and 18%, respectively. Lipoprotein(a) levels correlated with LAP burden in Hispanic patients. Age, male sex, hypertension and hyperlipidemia increased the odds of elevated LAP, which showed prognostic significance.

Interplay Between Zero CAC, Quantitative Plaque Analysis, and Adverse Events in a Diverse Patient Cohort.

BACKGROUND: Coronary artery calcium scoring (CAC) has garnered attention in the diagnostic approach to chest pain patients. However, little is known about the interplay between zero CAC, sex, race, ethnicity, and quantitative coronary plaque analysis. METHODS: We conducted a retrospective analysis from our computed tomography registry of patients with stable angina without prior myocardial infarction or revascularization undergoing coronary computed tomography angiography at Montefiore Healthcare System. Follow-up end points collected included invasive angiography, type-1 myocardial infarction, coronary revascularization, cardiovascular and all-cause death. RESULTS: A total of 2249 patients were included (66% female). The median follow-up was 5.5 years. The median age of those without CAC was 52 years (interquartile range, 44-59) and 60 years (interquartile range, 53-68) in those with CAC. Most patients were Hispanic (58%), and the rest were non-Hispanic Black (28%), non-Hispanic White (10%), and non-Hispanic Asian (5%). The majority had CAC=0 (55%). The negative predictive value of CAC=0 was 92.8%, 99.9%, and 99.9% for any plaque, obstructive coronary artery stenosis, and the composite outcome of all-cause death, myocardial infarction, or coronary revascularization, respectively. Among patients without CAC (n=1237), 89 patients (7%) had evidence of plaque on their coronary computed tomography angiography with a median low-attenuation noncalcified plaque burden of 4% (2-7). There were no significant differences in the negative predictive value for CAC=0 by sex, race, or ethnicity. Patients with ≥2 risk factors had higher odds of having plaque with zero CAC. CONCLUSIONS: In summary, no sex, race, or ethnicity differences were demonstrated in the negative predictive value of a zero CAC; however, patients with ≥2 risk factors had a higher prevalence of plaque. A small percentage (7%) of symptomatic patients undergoing coronary computed tomography angiography with zero CAC had noncalcified coronary plaque, with the implication that caution is needed for downscaling of preventive treatment in patients with zero CAC, chest pain, and multiple risk factors.

Influence of BMI on virtual coronary artery calcium scoring.

PURPOSE: Virtual non-contrast (VNC) coronary artery calcium scoring (CAC) may obviate the need for traditional non-contrast (TNC) CAC. There is no data on the influence of body mass index (BMI) on VNC reliability. We aimed to evaluate the influence of BMI on VNC CAC agreement with TNC. MATERIALS AND METHODS: All patients who underwent sequential CAC and coronary CT angiography (CCTA) using spectral CT with TNC CAC > 0 between August 2020 and December 2021 were included. Agatston CAC scores were calculated manually by 2 blinded readers from VNC scans. A correction factor was calculated from the slope of the linear regression using the method of least squares and applied to the VNC scores. Bland-Altman plots and Cohen's weighted Kappa were utilized. RESULTS: We included 174 patients (57.5% female). Mean BMI was 32.6 ± 7.02 kg/m2 [BMI < 30 (39.7%); BMI 30-40 (45.4%); and BMI > 40 kg/m2 (14.9%)]. Mean TNC CAC was 177.8 ± 316.86 and mean VNC CAC after applying the correction factor 149.34 ± 296.73. The TNC value strongly correlated with VNC (r = 0.94; p < 0.0001). As BMI increased there was a progressive reduction in signal-to-noise ratio, contrast-to-noise ratio and coronary enhancement (p < 0.05). The degree of agreement between VNC and TNC CAC decreased as BMI increased (agreement = 91.79 (weighted Kappa = 0.72), 91.14 (weighted Kappa = 0.58) and 88.46% (weighted Kappa = 0.48) (all P values < 0.001) for BMI < 30; 30-40 and > 40 kg/m2, respectively). CONCLUSION: BMI has a significant influence on the accuracy of VNC CAC. VNC CAC shows substantial agreement in non-obese patients but performs poorly in BMI > 40 kg/m2. This is the first study to evaluate the influence of body mass index (BMI) on virtual non-contrast (VNC) coronary artery calcium scoring (CAC) as compared to traditional non-contrast (TNC). We retrospectively evaluated 174 patients with TNC CAC and two blinded reviewers manually calculated the VNC CAC. All cases were included without specific selection for quality. The ratio between the two directly proportional values was determined using the slope from the linear regression through the method of least squares. This correction factor of 2.65 was applied to the calcium scores obtained from VNC images. We found that VNC CAC shows substantial risk-class agreement with TNC in non-obese patients (agreement = 91.79 and weighted Kappa = 0.72) but performs poorly in BMI > 40 kg/m2 (agreement: 88.46% and weighted Kappa = 0.48). These findings show the potential use of VNC CAC to avoid additional radiation in non-obese patients. However, further research on potential improvement strategies for VNC CAC in obese patients is needed.

The role of invasive cardiopulmonary exercise testing in patients with unexplained dyspnea: a systemic review.

BACKGROUND: Dyspnoea is a common complaint that often remains unexplained with no diagnosis and poor management despite extensive, repetitive and costly testing. Invasive cardiopulmonary testing has been used in the evaluation of dyspnoea, however, its role is not yet well defined. We sought to perform a systematic review of the literature looking at the role of invasive cardiopulmonary testing in the evaluation of chronic dyspnoea and/or exercise intolerance. METHODS AND RESULTS: We performed a literature review in accordance with PRISMA, analysing articles published in peer-reviewed journals between January 1st 1985 and January 31st 2020, available in 3 databases. The aim was to identify randomised and non-randomised clinical studies that focussed on the utility of invasive cardiopulmonary exercise test in the evaluation of dyspnoea. Emphasis was placed on studies that noted the use of exercise stress testing with the concomitant use of right heart catheterisation to evaluate hemodynamics as part of the work up for dyspnoea. We identified 6 retrospective studies that assessed the use of exercise hemodynamics to identify the aetiology of dyspnoea. CONCLUSION: Invasive cardiopulmonary exercise test is a useful tool for identifying the cause of unexplained dyspnoea. It can be helpful in early recognition and prognostication of patients with heart failure with preserved ejection fraction and pulmonary hypertension. It has also shown to be beneficial for constructing a multidisciplinary approach to chronic dyspnoea.

Management of Recurrent Pregnancy-Related Pericarditis.

The evidence on recurrent pregnancy-related pericarditis is limited, and management strategies are based on case reports and expert opinion. We describe a patient with myopericarditis complicated by cardiac tamponade presenting shortly after her first pregnancy, which was then complicated by refractory recurrent pericarditis. She was treated with standard first line therapies, such as NSAIDs, corticosteroids, and colchicine, and eventually initiated on the purine analog, azathioprine. Out of fear of teratogenicity, she self-discontinued her maintenance medications and thereafter, her course was complicated by a recurrent flare of pericarditis during a subsequent pregnancy. Our case illustrates the significant burden on our patient due to the incessant nature of her disease and on the providers due to the therapeutic dilemmas associated with family planning and pregnancy. Further data is required on this unique clinical scenario, and patient-centered management by a multidisciplinary team is critical.

The use of diflunisal for transthyretin cardiac amyloidosis: a review.

Transthyretin cardiac amyloidosis (ATTR-CM) is caused by the accumulation of misfolded transthyretin (TTR) protein in the myocardium. Diflunisal, an agent that stabilizes TTR, has been used as an off-label therapeutic for ATTR-CM. Given limited data surrounding the use of diflunisal, a systematic review of the literature is warranted. We searched the PubMed, MEDLINE, and Embase databases for studies that reported on the use of diflunisal therapy for patients with ATTR-CM. We included English language studies which assessed the effect of diflunisal in adult patients with ATTR-CM who received diflunisal as primary treatment and reported clinical outcomes with emphasis on studies that noted the safety and efficacy of diflunisal in cardiac manifestations of ATTR amyloidosis. We excluded studies which did not use diflunisal therapy or used diflunisal therapy for non-cardiac manifestations of TTR amyloidosis. We also excluded case reports, abstracts, oral presentations, and studies with fewer than 10 subjects. Our search yielded 316 records, and we included 6 studies reporting on 400 patients. Non-comparative single-arm small non-randomized trials for diflunisal comprised 4 of the included studies. The 2 studies that compared diflunisal versus no treatment found improvements in TTR concentration, left atrial volume index, cardiac troponin I, and global longitudinal strain. Overall, diflunisal use was associated with decreased mortality and number of orthotopic heart transplant in ATTR-CM patients. Although a smaller number of patients had to stop treatment due to gastrointestinal side effects and transient renal dysfunction, there were no severe reactions reported in the studies included in our review. This systematic review supports the use of diflunisal for ATTR-CM. Additional long-term analyses and randomized clinical trials are needed to confirm these results.

Association between pretreatment obesity, sarcopenia, and survival in patients with head and neck cancer.

BACKGROUND: Body mass index (BMI), sarcopenia, and obesity-related comorbidities have been associated with head and neck squamous cell carcinoma (HNSCC) progression. METHODS: We conducted a retrospective analysis of 441 normal-weight, overweight, and obese HNSCC patients treated at Montefiore Medical Center (New York). Patients were grouped by BMI prior to treatment and assessed for differences in survival adjusting for comorbid conditions (cardiovascular disease and diabetes). Evidence of sarcopenia was also assessed using pretreatment abdominal CT scans in a subset of 113 patients. RESULTS: Prior to treatment, 55% of HNSCC patients were overweight or obese. Overweight/obese patients had significantly better overall survival (hazard ratio [HR] = 0.4, 95% CI: 0.3-0.6) compared to normal-weight patients, independent of comorbid conditions. Patients with sarcopenia had significantly poorer survival (HR = 2.1, 95% CI: 1.1-3.9) compared to non-sarcopenic patients, with the strongest association seen among overweight/obese patients. CONCLUSION: Our data support the importance of sarcopenia assessment, in addition to BMI, among patients with HNSCC.