Early drop in systolic blood pressure, heart rate at admission, and their effects on worsening renal function in elderly patients with acute heart failure.

BACKGROUND: Regardless of patients' baseline renal function, worsening renal function (WRF) during hospitalization is associated with poor outcomes. In individuals with acute heart failure (AHF), one predictor of WRF is an early drop in systolic blood pressure (SBP). Few studies have investigated WRF in elderly AHF patients or the influence of these patients' heart rate (HR) at admission on the relationship between an early SBP drop SBP and the AHF. METHODS: We measured the SBP and HR of 245 elderly AHF inpatients (83 ± 6.0 years old, females 51%) at admission and another six times over the next 48 h. We defined 'WRF' as a serum creatinine increase ≥0.3 mg/dL by Day 5 post-admission. We calculated the 'early SBP drop' as the difference between the admission SBP value and the lowest value during the first 48 h of hospitalization. RESULTS: There were significant differences between the 36 patients with WRF and the 209 patients without WRF: early SBP drop (51 vs. 33 mmHg, p < 0.01) and HR at admission (79 vs. 90 bpm, p < 0.05), respectively. In the multiple logistic regression analysis adjusted for the confounders, higher early SBP drop (p < 0.04) and lower HR at admission (p < 0.01) were significantly associated with WRF. No significant association was shown for the interaction term of early SBP drop × HR at admission with WRF. CONCLUSIONS: In these elderly AHF patients, exaggerated early SBP drop and lower HR at admission were significant independent predictors of WRF, and these factors were additively associated with WRF.

Impact of the Coronary Artery Calcium Score on Mid- to Long-Term Cardiovascular Mortality and Morbidity Measured With Coronary Computed Tomography Angiography.

BACKGROUND: Although the coronary artery calcium score (CACS) is a prognostic measurement in asymptomatic individuals, it is measured in symptomatic patients using coronary computed tomography angiography (CCTA). We aimed to examine the predictive value of the CACS for mid- to long-term cardiovascular mortality and morbidity in patients who underwent CCTA. Methods and Results: We studied 736 patients with suspected coronary artery disease (CAD) who underwent CCTA. During a median follow-up period of 6.5 years, there were 39 primary outcomes (composite of cardiovascular disease death, non-fatal myocardial infarction, and non-fatal stroke). The estimated 10-year cumulative rates of the primary outcome were significantly increased across CACS classes (3.9%, 9.2%, 11.8%, and 18.2% in CACS of 0, 1-99, 100-399, and ≥400, respectively, P<0.001). These rates of cardiovascular disease death and stroke were also significantly increased across CACS classes. Multivariate Cox proportional hazard analysis showed that a CACS ≥100 was independently predictive for the primary outcome (hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.40-6.00, P=0.003), as well as the presence of ≥50% stenosis on CCTA (HR 2.27, 95% CI 1.13-4.46, P=0.022). CONCLUSIONS: An elevated CACS with the use of CCTA is an independent predictor of mid- to long-term cardiovascular mortality and morbidity in patients suspected of having CAD.

Insulin resistance and subclinical abnormalities of global and regional left ventricular function in patients with aortic valve sclerosis.

BACKGROUND: Insulin resistance, as a key mediator of metabolic syndrome, is thought to be associated with pathogenesis of calcific aortic valve disease and altered left ventricular (LV) function and structure. However, in patients with aortic valve sclerosis (AVS), the association between insulin resistance and subclinical impairment of LV function is not fully elucidated. METHODS: We studied 57 patients (mean age 70 ± 8 years, 22 women) with asymptomatic AVS but normal LV ejection fraction in echocardiography. LV longitudinal and circumferential strain and strain rate was analyzed using two-dimensional speckle tracking echocardiography. Patients with uncontrolled hypertension and diabetes mellitus, chronic kidney disease, and concomitant coronary artery disease were excluded. They were divided into the insulin-resistant group (AVS+IR; N = 28) and no insulin-resistant group (AVS-IR; N = 29) according to the median value of homeostatic model assessment index. Computed tomography scans were also performed to measure the aortic valve calcium score and the visceral adipose tissue (VAT) area. In addition, age- and sex- adjusted 28 control subjects were recruited for the comparison. RESULTS: There were no significant differences in LV ejection fraction or mass index among the groups. The AVS+IR group had a higher aortic valve calcium score (median 94 versus 21, P = 0.022) and a larger VAT area (113 ± 42 cm2 versus 77 ± 38 cm2, P = 0.001) than the AVS-IR group. Notably, LV global longitudinal strain, strain rate (SR), and early diastolic SR were significantly lower in the AVS+IR group than in the AVS-IR group and in control subjects (strain: -16.2 ± 1.6% versus -17.2 ± 1.2% and -18.9 ± 0.8%; SR: -1.18 ± 0.26 s(-1) versus -1.32 ± 0.21 s(-1) and -1.52 ± 0.08 s(-1); early diastolic SR: -1.09 ± 0.23 s(-1) versus -1.23 ± 0.18 s(-1) and -1.35 ± 0.12 s(-1); P < 0.05 for all comparison), whereas circumferential function were not significantly different. Multiple linear regression analyses revealed insulin resistance as an independent determinant of LV longitudinal strain (P = 0.017), SR (P = 0.047), and early diastolic SR (P = 0.049) regardless of LV mass index or VAT area. CONCLUSIONS: Insulin resistance is a powerful independent predictor of subclinical LV dysfunction regardless of concomitant visceral obesity and LV hypertrophy. Thus, it may be a novel therapeutic target to prevent subsequent heart failure in patients with AVS.

Predicting elevated natriuretic peptide in chest radiography: emerging utilization gap for artificial intelligence.

Aims: This study assessed an artificial intelligence (AI) model's performance in predicting elevated brain natriuretic peptide (BNP) levels from chest radiograms and its effect on diagnostic performance among healthcare professionals. Methods and results: Patients who underwent chest radiography and BNP testing on the same day were included. Data were sourced from two hospitals: one for model development, and the other for external testing. Two final ensemble models were developed to predict elevated BNP levels of ≥ 200 pg/mL and ≥ 100 pg/mL, respectively. Humans were evaluated to predict elevated BNP levels, followed by the same test, referring to the AI model's predictions. A total of 8390 images were collected for model creation, and 1713 images, for tests. The AI model achieved an accuracy of 0.855, precision of 0.873, sensitivity of 0.827, specificity of 0.882, f1 score of 0.850, and receiver-operating-characteristics area-under-curve of 0.929. The accuracy of the testing by 35 participants significantly improved from 0.708 ± 0.049 to 0.829 ± 0.069 (P < 0.001) with the AI assistance (an accuracy of 0.920). Without the AI assistance, the accuracy of the veterans in the medical career was higher than that of early-career professionals (0.728 ± 0.051 vs. 0.692 ± 0.042, P = 0.030); however, with the AI assistance, the accuracy of the early-career professionals was rather higher than that of the veterans (0.851 ± 0.074 vs. 0.803 ± 0.054, P = 0.033). Conclusion: The AI model can predict elevated BNP levels from chest radiograms and has the potential to improve human performance. The gap in utilizing new tools represents one of the emerging issues.

Heart failure is a growing medical issue, and there is a high demand for automated tools to support daily medical practice. We developed an artificial intelligence (AI) model that can predict heart failure by identifying elevated biomarkers from chest X-ray images. Our results showed that this AI model performed better than expert cardiologists in predicting these biomarkers. In this study, healthcare providers, including both those early in their careers and seasoned veterans, were assessed on their ability to detect these biomarkers from chest radiograms. The AI model significantly improved diagnostic accuracy for both groups, with early-career professionals performing as well or better than the veterans. The study highlights how the AI model enhances healthcare providers' capabilities, with varying degrees of improvement among individuals. The AI model promises to support daily medical practice and elevate the quality of heart failure management. As the adoption of innovative tools like AI becomes more crucial, addressing the gap in their utilization is an emerging issue. We must embrace and adapt to new ideas, technologies, and methods to advance medical care.

Feasibility of Simple Evaluation of Coronary Artery Calcium Using a Number of Chest Computed Tomography Slices: A Multicenter Study.

Objective: We aimed to evaluate the visual measurements of coronary artery calcium (CAC) on nonelectrocardiogram (ECG)-gated chest computed tomography (CT) using a simple scoring method that involves counting the number of CT slices containing CAC. Materials and Methods: We analyzed 163 participants who underwent both coronary and chest CT examinations at six centers within 3 months. Agatston scores were calculated on standard ECG-gated scans and classified as none (0), mild (1-99), moderate (100-400), or severe (>400). Next, chest CT images were reconstructed to standard 5.0 mm axial slices. Then, CAC on chest CT scans was measured using two methods: the Weston score (sum of the assigned score of each vessel, range: 0-12) and number of slices showing CAC (Ca-slice#). Results: When the Weston score and Ca-slice# were divided into four levels according to the optimal divisional levels corresponding to the Agatston score classes, good agreements with the 4-grade Agatston score were observed (kappa value=0.610 and 0.794, respectively). The sensitivity and specificity of Ca-slice# ≥9 to identify severe Agatston scores of >400 were 86% and 96%, respectively. Conclusion: The Ca-slice#, a simple scoring method using chest CT scans, was in good agreement with the ECG-gated Agatston score.

Association between plasma high-molecular-weight adiponectin and coronary plaque characteristics assessed by computed tomography angiography in conditions of visceral adipose accumulation.

BACKGROUND: Our group has previously reported that visceral adipose tissue (VAT) accumulation was associated with the extent and vulnerable characteristics of coronary plaques using coronary computed tomography angiography (CTA). An investigation of the associations between these coronary lesions with plasma adiponectin and leptin was performed. METHODS AND RESULTS: A total of 394 patients (220 men and 174 women) in the study were referred for CTA. Plain abdominal scanning was simultaneously performed to evaluate VAT areas. The median level of plasma high-molecular-weight (HMW) adiponectin in patients with CTA-based obstructive coronary artery disease was significantly lower than that in patients without (men: 1.45 vs. 1.88 µg/ml, P=0.002; women: 2.49 vs. 3.44 µg/ml, P<0.001). Multivariate analyses revealed that a lower HMW adiponectin concentration was significantly associated with the presence (men: P=0.019; women: P=0.018) and involved segment numbers (men: P=0.001; women: P=0.003) of coronary plaques. Furthermore, it was significantly related to coronary plaque with all 3 vulnerable characteristics of positive remodeling, low CT density (≤38 Hounsfield units), and adjacent spotty calcium (men: P=0.019; women: P=0.016). These associations were also observed with VAT areas, but not with plasma leptin concentrations, in both genders. CONCLUSIONS: Lower plasma HMW adiponectin is associated with the presence, extent, and vulnerable characteristics of coronary plaques assessed by CTA in both genders.

Coronary calcium score as a predictor for coronary artery disease and cardiac events in Japanese high-risk patients.

BACKGROUND: Although the coronary artery calcium (CAC) score as measured with computed tomography (CT) is associated with cardiovascular mortality and morbidity in Western countries, little is known in Asian populations. METHODS AND RESULTS: Three hundred and seventeen Japanese patients (205 men and 112 women) were followed in the study and they underwent both coronary angiography and CT for CAC measurements. The frequencies of angiographic coronary artery disease (CAD) were 5%, 36%, 76%, 80%, and 94% (P<0.001) and the needs for revascularization were 5%, 26%, 53%, 59%, and 69% (P<0.001) in patients with CAC scores of 0 (n=64), 1-100 (n=58), 101-400 (n=76), 401-1,000 (n=70), and >1,000 (n=49), respectively. In the average of 6.0 (range, 1-10) years follow-up period, 34 patients died including 13 from reasons of cardiac disease. In a Cox proportional hazard model after adjustment for age and sex, traditional coronary risk factors, previous myocardial infarction, and the need for revascularization, the hazard ratio for cardiac mortality in patients with a CAC score >1,000 was 2.98 (95% confidence interval: 1.15-9.40) compared with those with a CAC score=0-100. CONCLUSIONS: The CAC score has a predictive value for angiographical CAD and long-term mortality from cardiac disease in Japanese high-risk patients who undergo coronary angiography.

A mid-ventricular variant of Takotsubo syndrome: was it triggered by insular cortex damage?

Takotsubo syndrome (TTS) is a transient cardiomyopathy that is often associated with cerebrovascular diseases. Earlier studies have supported the concept that the cardiovascular system is regulated by a central autonomic network (CAN) consisting of the insular cortex (IC), anterior cingulate gyrus and amygdala. We report the case of a 79-year-old female diagnosed with a mid-ventricular variant of TTS concomitant with right IC ischaemic stroke. After 12 h of hospitalization, she experienced a sudden collapse. Rapid cardiopulmonary resuscitation resulted in a return of spontaneous circulation. Subsequent left ventriculography revealed akinesis in the mid-portion of the left ventricle with vigorous contraction of the basal and apex segment. Two weeks after admission, cardiac ultrasound showed improved left ventricular contraction. Right IC ischaemia in this patient might have been associated with a dysregulation of the CAN and subsequent increased sympathetic nervous system activity that triggered TTS.

Visit-to-visit Blood Pressure Variability and Arterial Stiffness: Which Came First: The Chicken or the Egg?

Earlier studies have shown that visit-to-visit blood pressure (BP) variability (VVV) served as a significant independent risk factor of stroke, specifically, in the high-risk elderly of cardiovascular disease (CVD). Although the mechanism is not clearly understood, arterial remodeling such as carotid artery, coronary artery and large aortic artery would be a strong moderator in the relationship between VVV and CVD incidence. Recent studies have provided evidence that VVV predicted the progression of arterial stiffness. While the class of antihypertensive agents is suggested to be an important determinant of VVV, long-acting calcium channel blockers use (CCBs) is associated with the reduction of VVV, and thus, is suggested to decrease the arterial stiffness. Specifically, the relationship between VVV and coronary arterial remodeling has never been reviewed until now. This article summarizes the recent literature on these topics. In the elderly hypertensives, strict BP control using CCBs could play a pivotal role in suppressing arterial stiffening via VVV reduction.

Coronary plaque characteristics in computed tomography and 2-year outcomes: The PREDICT study.

BACKGROUND: Coronary computed tomography angiography (CCTA) not only provides information regarding luminal stenoses but also allows for visualization of mural atheromatous changes (coronary plaques). OBJECTIVE: We sought to elucidate whether plaques seen on CCTA enable prediction of 2-year outcomes in patients with suspected and known coronary artery disease (CAD). METHODS: Of 3015 patients who underwent CCTA, the images and 2-year clinical courses of 2802 patients were independently analyzed. The primary endpoint was the composite of all-cause death and acute coronary syndrome. RESULTS: During the 2-year observation period, 49 (1.7%) patients developed the primary outcome. The 2-year rates of the primary outcome in the normal (n = 515, no mural lesions), calcium (n = 654, calcified lesion alone), and plaque groups (n = 1633, presence of noncalcified or partially calcified plaques) were 0.2%, 2.0%, and 2.1%, respectively (P = 0.0028). Adverse plaque features such as low attenuation, positive remodeling, spotty calcification, and the napkin-ring sign (low-attenuation core with a higher-attenuation rim) were assessed by an independent core laboratory. Stepwise multivariate Cox proportional hazard analysis showed that a plaque with two or more characteristics (adjusted hazard ratio, 1.98; 95% confidence interval, 1.09-3.60; P = 0.0254), age of ≥67 years (mean), statin treatment after CCTA, and obstructive stenosis remained independent predictors of the primary outcome. CONCLUSIONS: Plaque imaging in CCTA has predictive value for the 2-year outcome and is a useful identifier for high-risk patients among those with known and suspected CAD.

Noninvasive assessment of coronary stents in patients by 16-slice computed tomography.

BACKGROUND: The usefulness of thin-slice multi-detector computed tomography (MDCT) has been highly expected to assess the lumens of coronary artery stents. We evaluated the usefulness of 16-slice MDCT to assess the in-stent lumen after coronary artery stenting. METHODS: In 42 consecutive patients after coronary artery stenting, retrospective ECG-gated CT-angiography using 16-slice MDCT (0.5-s rotation time, 16x0.625-mm detector collimation) was performed. The qualitative assessability of the lumens of 61 coronary stents (14 different types) by MDCT and the reasons for non-assessability were investigated. Furthermore, the evaluation of in-stent restenosis in 21 assessable stents of 16 patients, including quantitative density analysis by MDCT, was performed and the results were compared with those of conventional coronary angiography (CAG). RESULTS: Of 61 stents, 42 (68.9%) were assessable. The assessability of diameter > or =3.5-mm stents made of stainless steel or cobalt was high (88.6%, 31/35), that of 3.0-mm stents was low (57.9%, 11/19) and all 2.5-mm stents were non-assessable due to partial volume effects and metal artifacts of stents. The lumens of stents made of tantalum were totally obscured and the metal artifacts of Bestent2 (gold markers) and S670 were severer than others. All non-assessable stents due to banding artifact and calcification were implanted in segment #1-3 and #6, respectively. In comparison to CAG, MDCT correctly detected the 5 in-stent restenoses and identified absence of restenoses was influenced strongly by the stent strut. CONCLUSION: Despite some limitations, 16-slice MSCT is sufficiently useful for assessment of various coronary stents in patients and can detect in-stent restenoses of assessable stents with high accuracy in comparison to CAG.

Ability for visualization, reasons for nonassessable image, and diagnostic accuracy of 16-slice multidetector row helical computed tomography for the assessment of the entire coronary arteries.

It was demonstrated that 16-slice multidetector row helical computed tomography may permit more accurate assessment of entire coronary arteries, with a low rate of arteries unable to be evaluated. The detection of coronary artery stenoses with this modality was applicable to assessable segments.

Prognostic value of coronary artery calcium and epicardial adipose tissue assessed by non-contrast cardiac computed tomography.

OBJECTIVE: Epicardial adipose tissue (EAT) accumulation is believed to be associated with development of coronary atherosclerosis. We investigated whether EAT volume as assessed by computed tomography (CT) has value in prediction of future cardiac events. METHODS: We studied 722 patients without proven coronary artery disease (CAD) who underwent non-contrast cardiac CT. EAT volume and coronary artery calcium (CAC) score were measured simultaneously. Patients were followed as to the occurrence of coronary events (cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and late coronary revascularization≥3 months after CT examination). RESULTS: During a 3.7±1.7 years follow-up period, 37 coronary events were documented. Annual event rates increased across CAC score categories (0.3%, 1.0%, 2.4%, and 4.3%, in 0, 1-99, 100-399, and ≥400, respectively, p<0.001); these were significantly higher in the higher EAT volume group (>median; 107.2 mL, 0.7% vs., 2.1%, adjusted hazard ratio; 2.65, p=0.0090). Cox-proportional hazard analysis demonstrated that a combination of CAC score≥100 and high EAT volume had a significantly higher event rate than CAC score<100 and low EAT volume group (adjusted hazard ratio 11.6, p<0.0001). Using Cox regression models, incremental prognostic values were identified by adding high EAT volume to clinical risks plus CAC score≥100 (global χ2, 6.7; p=0.059). CONCLUSION: We suggest that high EAT volume may be an independent predictor of future coronary events and increases predictive values of CAC score in patients without proven CAD.

Incremental prognostic value of cardiac computed tomography angiography in asymptomatic aortic stenosis: significance of aortic valve calcium score.

BACKGROUND: Cardiac computed tomography angiography (CCTA) provides the simultaneous evaluation of the aortic valve, myocardium, and coronary arteries. In particular, aortic valve calcium score (AVCS) can be accurately measured on the same scanning sequence used to measure coronary artery calcification, with no additional cost or radiation exposure. We sought to evaluate the prognostic value of CCTA measures, including AVCS, in asymptomatic aortic stenosis (AS). METHODS AND RESULTS: Sixty-four initially asymptomatic patients with AS with a normal ejection fraction were prospectively enrolled and followed for median 29 (IQR=18-50) months. During follow-up, 27 (42%) patients experienced cardiac events, including five cardiac deaths, eleven aortic valve replacements. Multivariate Cox proportional hazards analysis identified three CCTA measures as significant predictors of cardiac events: aortic valve area (per 0.1cm(2) decrease; hazard ratio [HR]: 1.19, 95% confidence interval [CI]: 1.05-1.34); multi-vessel obstructive coronary artery disease (HR: 2.84, 95% CI: 1.10-7.32); and AVCS (per 100; HR: 1.09, 95% CI: 1.04-1.15). Kaplan-Meier analysis showed that patients with AVCS greater than or equal to the median value of 723 had significantly worse outcomes than those with AVCS less than 723 (p<0.0001). The C-statistic value for cardiac events substantially increased when these CCTA measures were added to clinical characteristics plus echocardiographic peak transaortic velocity (0.913 vs. 0.702, p<0.001). CONCLUSIONS: In patients with asymptomatic AS, CCTA measures of valve area, coronary stenosis, and calcification severity provide independent and incremental prognostic value after accounting for the echocardiographic severity of stenosis.

Association between heart calcification assessed by echocardiography and future cardiovascular disease mortality and morbidity.

BACKGROUND: Echocardiography can detect calcium deposits in heart valves and aortic root, but the relationship of echocardiographic heart calcification such as aortic valve calcification (AVC), mitral annular calcification (MAC), and aortic root calcification (ARC) with future cardiovascular disease (CVD) mortality and morbidity is not fully elucidated. METHODS: We analyzed data from 943 patients with suspected coronary heart disease (mean age, 65.7 years; 36% female). Echocardiographic total heart calcification (THC) score was determined by summing up the AVC, MAC, and ARC variables; THC-0 (N = 397), THC-1 (N = 236), THC-2 (N = 224), and THC-3 (N = 86). Subjects were followed for mean 2.9 years to assess the risk of death from CVD causes. Cardiovascular morbidity was defined as new episodes of non-fatal myocardial infarction, congestive heart failure, stroke, and surgical treatment of vascular disease. RESULTS: There were 43 CVD deaths and a total of 160 CVD events. Kaplan-Meier curves showed a graded CVD mortality and morbidity across increasing THC score values. With full adjustment, Cox regression hazard ratios (95% confidence intervals) for CVD mortality and morbidity, using no calcification as reference, for THC-1, THC-2, and THC-3 were 2.21 (1.31-3.74), 2.59 (1.53-4.39) and 4.14 (2.30-7.47), respectively. When THC score was added to models with CVD risk factors, C-statistics were significantly larger for CVD mortality (p = 0.048) and for CVD mortality and morbidity (p = 0.004). CONCLUSIONS: THC score, the sum of the amounts of AVC, MAC, and ARC present as estimated by echocardiography, has an independent and incremental prognostic value in a high-risk population.