Predictors of non-calcified plaque presence and future adverse cardiovascular events in symptomatic rural Appalachian patients with a zero coronary artery calcium score.

BACKGROUND: Coronary artery calcium (CAC) scoring is a proven predictor for future adverse cardiovascular events (CVE) in asymptomatic individuals. Data is emerging regarding the usefulness of non-calcified plaque (NCP) assessment on cardiac computed tomography (CCT) angiography in symptomatic patients with a zero CAC score for further risk assessment. METHODS: A retrospective review from January 2019 to January 2022 of 696 symptomatic patients with no known CAD and a zero CAC score identified 181 patients with NCP and 515 patients without NCP by a visual assessment on CCT angiography. The primary endpoint was to identify predictors for NCP presence and adverse CVEs (death, myocardial infarction, or cerebrovascular accident) within two years. RESULTS: Based on logistic regression, age (OR 1.039, 95% CI [1.020-1.058], p â€‹< â€‹0.001), diabetes mellitus (OR 2.192, 95% CI [1.307-3.676], p â€‹< â€‹0.003), tobacco use (OR 1.748, 95% CI [1.157-2.643], p â€‹< â€‹0.008), low-density lipoprotein cholesterol level (OR 1.009, 95% CI [1.003-1.015], p â€‹< â€‹0.002), and hypertension (OR 1.613, 95% CI [1.024-2.540], p â€‹< â€‹0.039) were found to be predictors of NCP presence. NCP patients had a higher pretest probability for CAD using the Morise risk score (p â€‹< â€‹0.001∗), with NCP detection increasing as pretest probability increased from low to high (OR 55.79, 95% CI [24.26-128.26], p â€‹< â€‹0.001∗). 457 patients (66%) reached a full two-year period after CCT angiography completion, with NCP patients noted to have shorter follow-up times and higher rates of elective coronary angiography, intervention, and CVEs. The presence of NCP (aOR 2.178, 95% CI [1.025-4.627], p â€‹< â€‹0.043) was identified as an independent predictor for future adverse CVEs when adjusted for diabetes mellitus, age, and hypertension. CONCLUSION: NCP was identified at high rates (26%) in our symptomatic Appalachian population with no known CAD and a zero CAC score. NCP was identified as an independent predictor of future adverse CVEs within two years.

Quantitative single photon emission computed tomography derived standardized uptake values on 99mTc-PYP scan in patients with suspected ATTR cardiac amyloidosis.

Technetium-99 pyrophosphate scintigraphy (99mTc-PYP) provides qualitative and semiquantitative diagnosis of ATTR cardiac amyloidosis (ATTR-CA) using the Perugini scoring system and heart/contralateral heart ratio (H/CL) on planar imaging. Standardized uptake values (SUV) with quantitative single photon emission computed tomography (xSPECT/CT) can offer superior diagnostic accuracy and quantification through precise myocardial contouring that enhances assessment of ATTR-CA burden. We examined the correlation of xSPECT/CT SUVs with Perugini score and H/CL ratio. We also assessed SUV correlation with cardiac magnetic resonance (CMR), echocardiographic, and baseline clinical characteristics. Retrospective review of 78 patients with suspected ATTR-CA that underwent 99mTc-PYP scintigraphy with xSPECT/CT. Patients were grouped off Perugini score (Grade 0-1 and Grade 2-3), H/CL ratio (≥ 1.5 and < 1.5). Two cohorts were also created: myocardium SUVmax > 1.88 and ≤ 1.88 at 1-hour based off an AUC curve with 1.88 showing the greatest sensitivity and specificity. Cardiac SUV retention index was calculated as [SUVmax myocardium/SUVmax vertebrae] × SUVmax paraspinal muscle. Primary outcome was myocardium SUVmax at 1-hour correlation with Perugini grades, H/CL ratio, CMR, and echocardiographic data. Higher Perugini Grades corresponded with higher myocardium SUVmax values, especially when comparing Perugini Grade 3 to Grade 2 and 1 (3.03 ± 2.1 vs 0.59 ± 0.97 and 0.09 ± 0.2, P < 0.001). Additionally, patients with H/CL ≥ 1.5 had significantly higher myocardium SUVmax compared to patients with H/CL ≤ 1.5 (2.92 ± 2.18 vs 0.35 ± 0.60, P < 0.01). Myocardium SUVmax at 1-hour strongly correlated with ECV (r = 0.91, P = 0.001), pre-contrast T1 map values (r = 0.66, P = 0.037), and left ventricle mass index (r = 0.80, P = 0.002) on CMR. SUVs derived from 99mTc-PYP scintigraphy with xSPECT/CT provides a discriminatory and quantitative method to diagnose and assess ATTR-CA burden. These findings strongly correlate with CMR.

Evaluating Gender-based Differences in Clinical Outcomes for Patients Undergoing Left Atrial Appendage Occlusion: A Single Centre Experience.

There is emerging recent data that has shown women to be more prone to in-hospital major adverse events after trans catheter left atrial appendage occlusion. Institutional LAAO registry at West Virginia University (WVU) was reviewed from January 2016 to October 2021 to identify 271 women and 293 men who underwent successful LAAO device implantation. Patients were evaluated for gender-based differences in baseline characteristics, CHA2DS2-VASc Score, HAS-BLED score, procedural data, in-hospital, and follow-up outcomes. Compared to men, women had lower baseline comorbidities including coronary artery disease (135 (49.6%) vs 172 (58.7%), P = 0.03), myocardial infarction (MI) (56 (20.5%) vs 85 (29%), P = 0.02) and coronary artery bypass surgery (10 (3.6%) vs 27 (9.2%), P = 0.008). Women were noted to have a higher CHA2DS2-VASc Score (5.3 ± 1.4 vs 4.4 ± 1.4, P < 0.001), and left ventricular ejection fraction (57.9 ± 7.7 vs 52.7 ± 12.4, P < 0.001). Women were noted to have a significantly higher rate of in-hospital composite adverse events (74 (27.2%) vs 58 (19.8%), P = 0.03); bleeding events (38 (10.2%) vs 19 (6.4%), P = 0.003) and associated blood transfusion (6 vs 0, P = 0.001) compared with men. No statistically significant differences were noted between both genders regarding the follow-up outcome. Our single center study shows women to have higher in-hospital composite adverse events as well as higher bleeding events during the index hospital admission.

Large serpiginous thrombus straddling the patent foramen ovale and traversing through mitral and tricuspid valves into both ventricles: a therapeutic dilemma of impending paradoxical embolism and recurrent pulmonary embolism.

A 51-year-old male with history of resected renal cell carcinoma and prior pulmonary embolism presented with tachypnea, tachycardia and progressive dyspnea on exertion. Chest computed tomography revealed bilateral acute pulmonary embolism. Transthoracic echocardiogram showed severe pulmonary hypertension with severe cor-pulmonale and presence of a large worm-like thrombus extending across the foramen ovale, entering both ventricles through the mitral and tricuspid valves. The risks of anti-coagulation, pharmacologic thrombolysis, and surgical thrombectomy, in a hemodynamically stable patient, posed a significant therapeutic dilemma. Ultimately, a collective decision was made to start anticoagulation, without incident. At 1 month follow up, complete resolution of the intracardiac thrombus, pulmonary hypertension, and cor-pulmonale were observed with full clinical recovery of the patient.

Relation of mitral annular calcium and coronary calcium (from the Multi-Ethnic Study of Atherosclerosis [MESA]).

Atherosclerosis is a complex diffuse disorder. The close correlation between coronary artery calcium (CAC) score on computed tomogram and extent and severity of coronary atherosclerosis is well established. It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. The MESA population included a population-based sample of 4 ethnic groups (12% Chinese, 38% white, 22% Hispanic, and 28% black) of 6,814 women and men 45 to 84 years of age. Computed tomographic scans were performed for all participants. The calcium score of each lesion was calculated by multiplying lesion area by a density factor derived from maximal Hounsfield units. A total calcium score was determined by summing individual lesion scores at each anatomic site. Relative risk regression was used to model the probability of MAC as a function of CAC >0 and CAC categories (0, 1 to 99, 100 to 399, and ≥400) with the referent group being CAC 0. The final study population consisted of 6,814 subjects (mean age 62 ± 10 years, 47% men). Overall 9% and 50% had detectable MAC and CAC, respectively. Of those with absent CAC, only 4% had MAC, whereas 9%, 19%, and 15% had MAC scores with increasing CAC scores of 1 to 99, 100 to 399, and ≥400, respectively (p<0.0001 for trend). After taking into account demographics and other risk factors, the prevalence ratio of MAC in those with mild CAC (1 to 99) was 2.13 (95% confidence interval 1.69 to 2.69) and increased to 7.57 (95% confidence interval 5.95 to 9.62) for CAC ≥400. Similar statistically significant increased risk of MAC was found when CAC was assessed as a continuous variable. In conclusion, we observed a strong association between MAC and increasing burden of CAC. This association weakened but persisted after adjustment for age, gender, and other traditional cardiovascular risk factors. These findings suggest that presence of MAC is an indicator of atherosclerotic burden rather than just a degenerative change of the mitral valve.

Coronary artery calcium and plaque association with left ventricular mass, assessed by multi-row detector computed tomography.

INTRODUCTION: Few studies have been published describing the association of coronary plaques and coronary artery calcium (CAC) to left ventricular (LV) mass and LV function using multi-detector computed tomography (MDCT). Coronary plaques can potentially influence the LV function. We sought to evaluate LV mass and function on MDCT and its correlation with CAC and plaque burden in the coronary arteries. METHODS: We included 197 symptomatic patients from the multicenter ACCURACY Study. The LV mass was measured manually using Advantage 4.4 workstation. Interobserver variability of LV mass was assessed using 34 randomly selected studies. LV mass was indexed to the body surface area. The coronary plaque severity was assessed in each segment using MDCT, following the 15 segment American Heart Association model. Plaque and segment scores were calculated accordingly. Statistical analysis using multiple logistic regression analysis was performed. RESULTS: We divided the cohort into those with CAC=0 [n=67 (34%)] and those with CAC greater than 0 [n=130 (66%)]. A significant correlation was found between indexed LV mass and CAC, plaque, and segment scores in both adjusted and unadjusted models. A significant association was observed between nonindexed LV mass with CAC, MDCT plaque score and segment score upon adjusting for various cardiovascular risk factors. A significant correlation was found between hyperlipidemia, hypertension, family history of CAD, and greater than 50% and greater than 70% stenosis on invasive cardiac catheterization with LV mass (all P<0.05). CONCLUSION: To our knowledge, this is the first study evaluating coronary plaque on computed tomographic angiography with LV mass. We were able to show a significant correlation of LV mass with CAC score, and with total plaque and total segment scores. The poor prognosis associated with increased CAC scores may be partially explained by this association with increased LV mass.

Atherosclerotic plaque composition among patients with stenotic coronary artery disease on noninvasive CT angiography.

INTRODUCTION: Multidetector computed tomographic angiography (MDCTA) has emerged as a promising noninvasive tool to rule out significant coronary artery disease (CAD). In addition, MDCTA also provides additional information about atherosclerotic plaque composition. In this study, we aim to assess whether differences in plaque composition exist across patients with varying degree of stenotic CAD disease. METHODS: Four hundred and sixteen patients with chest pain or shortness of breath thought to be related to CAD (64% males, mean age: 61+/-13 years), with 61 (15%) reporting type 2 diabetes mellitus, who underwent contrast-enhanced MDCTA were studied. Enrolled patients had an intermediate pretest probability of obstructive disease. RESULTS: Overall 51 patients (12%) had normal coronaries without evidence of plaque. In the remaining 365 patients, 45 (12%) and 83 (23%) were found to have stenosis 50-70% and at least 70% in at-least one coronary artery segment, respectively. Those with a higher degree of stenotic CAD showed significantly more coronary segments with exclusively calcified and mixed plaques. With increasing severity of CAD (<50 vs. 50-70% vs. >70% stenosis), the overall proportion of plaque burden was more likely to be mixed (18 vs. 38% vs. 44%) in nature as well less likely to be exclusively noncalcified (39 vs. 20 vs. 16%). Only two of 108 (2%) patients without any underlying calcification had significant CAD (stenosis> or =50%). CONCLUSION: Significant differences in plaque composition according to severity of CAD were observed in our study. Individuals with a higher likelihood of stenotic CAD were more likely to have higher underlying burden of exclusively calcified and mixed plaque. These findings should stimulate further investigations to assess the prognostic value of plaque according to their underlying composition.

Association of plaque in the carotid and coronary arteries, using MDCT angiography.

OBJECTIVE: Associations between various plaque types in coronary and carotid arteries using multidetector row computed tomography (MDCT) have not yet been reported. We evaluated MDCT correlation of total plaque and various plaque subtypes in carotid and coronary arteries. METHODS: We studied 62 patients who had both carotid and cardiac computed tomography angiography (CTA). The plaque in each vascular segment was classified as non-calcified, calcified or mixed. RESULTS: The average age of this population was 68+/-22 years, 63% males. Total plaque in the carotid artery correlated with total, calcified and mixed plaque in the coronary artery (all P<0.001). Calcified plaque in the carotid artery was associated with total and calcified plaque in the coronary bed (P<0.001). Non-calcified coronary plaque was not associated with carotid plaque. CONCLUSION: Total plaque in coronary and carotid arteries are highly correlated.

Determinants of left main calcifications in a cohort of 2136 diabetes patients.

INTRODUCTION: Left main (LM) calcification has been shown to be an independent predictor of mortality. Diabetes accelerates atherosclerosis and coronary artery calcification (CAC). In this study we aimed to describe the predictors of LM calcification in diabetes patients. METHODS: From a database of >25,000 patients who have undergone CAC scanning at our institution, consecutive diabetic patients (n=2136) were evaluated for demographic data, CAC scores and coronary risk factors. RESULTS: In our cohort 29.1% of patients had LM CAC. Of the classical atherosclerosis risk factors, in binary regression analysis, only age (OR 1.03 [1.017-1.043]), male gender (OR 1.59; p<0.05), hypertension (OR 1.73; p<0.05), and CAC score (OR 1.001; p<0.05) were found to be independently associated with LM disease. CONCLUSION: The prevalence of LM CAC is high amongst diabetics (29.1%); associated with increased age, HTN and male sex.

Effect of obesity on coronary artery plaque using 64 slice multidetector cardiac computed tomography angiography.

Patients with a coronary artery calcification score (CACS) of zero and an intermediate risk of coronary artery disease have been shown to have a low prevalence of non-calcified coronary artery plaque (NCP). 181 consecutive patients with CAC 'zero', undergoing cardiac computed tomography angiography (CCTA) angiography at our center were evaluated. Presence of detectable NCP on CCTA in these patients was 13.8%. Mild non-obstructive disease (<30% and limited to one segment) was present in 76% of patients while only one patient (0.6%) had significant stenosis (>50%). Traditional risk factors were not found to be associated with the presence of NCP. However higher body mass index (BMI) was strongly found to be associated with NCP (31.6 in patients with NCP vs. 27.6 kg/m(2) in patients without NCP, p<.05). Obesity was 2.76 times more likely to be associated with NCP as compared to normal BMI (p<0.05).

Markers of inflammation and coronary artery calcification: a systematic review.

OBJECTIVES: The goal of this systematic review is to assess the cross-sectional relationship of inflammatory markers with the presence and extent of coronary artery calcium (CAC) to identify asymptomatic individuals with a higher risk of coronary heart disease (CHD). BACKGROUND: Markers of subclinical inflammation and subclinical atherosclerosis have both been used to improve detection of individuals at high risk of developing cardiovascular disease. CAC has emerged as a surrogate maker for underlying coronary atherosclerosis, and has been shown to predict future CHD events. Although inflammation is intimately associated with atherosclerosis, and levels of inflammatory markers predict cardiovascular risk, the relationship of subclinical inflammatory markers with the burden of coronary atherosclerosis is not clear. METHODS: Medline and Pub Med databases were searched for all studies assessing the relationship of inflammatory markers with CAC published till July 2007. RESULTS: We found 12 studies that met our criteria. CRP, fibrinogen, metallic metalloproteinase-9 (MMP-9), monocyte chemotactic protein 1 (MCP-1), resistin, lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), IL-6, tumor necrosis factor alpha (TNF-alpha) and beta-fibroblast growth factor (bFGF) were used as inflammatory markers. There was a wide variation among studies with regards to population size, inclusion criterias, age range and techniques. It was observed that in almost all studies the relationship between inflammatory markers and CAC was weak, and was mostly found upon univariate analysis in women. However, this association was lost after correction for obesity and BMI. The data on the relationship of inflammation and CAC with progression of atherosclerosis is scarce and did not show any predictive benefits for future CHD. CONCLUSION: Variable associations between CAC and inflammatory markers were identified. In most studies where a positive relationship was found, this relationship disappeared after appropriate correction for the presence of traditional risk factors. Our data suggests that an approach in which inflammatory markers are used to further characterize risk in individuals with an established coronary artery disease burden is more warranted than using biomarkers as sole risk predictors of future CHD events. Large, well-planned comprehensive studies are required to identify the combined role of measuring inflammatory markers in assessment of atherosclerotic disease.