A peripheral blood gene expression score is associated with atherosclerotic Plaque Burden and Stenosis by cardiovascular CT-angiography: results from the PREDICT and COMPASS studies.

OBJECTIVE: We previously validated a gene expression score (GES) based on age, sex and peripheral blood cell expression levels of 23 genes measured by quantitative real-time PCR (qRT-PCR) for diagnosis of obstructive coronary artery disease (CAD) (≥ 50% luminal diameter stenosis). In this study we sought to determine the association between the GES and coronary arterial Plaque Burden and Stenosis by CT-angiography. METHODS: A total of 610 patients (mean age: 57 ± 11; 50% male) from the PREDICT and COMPASS studies from 59 centers were analyzed. Coronary artery calcium (CAC) scoring, CT angiography (CTA)-based plaque and stenosis and GES measurements were performed. CAC was expressed as Agatston score and CTA evaluated for stenosis severity: 0. None; 1. Minimal, 2. Mild, 3. Moderate, 4. Severe and 5. Occluded. Correlation analysis, one-way analysis of variance (ANOVA) and receiver operating characteristics (ROC) analyses were performed. RESULTS: GES was significantly associated with plaque burden by CAC (r = 0.50; p < 0.001) and CTA (segment involvement score index: r = 0.37, p < 0.001); a low score (≤ 15) had sensitivity of 0.71 and a high score (≥ 28) a specificity of 0.97 for the prediction of zero vs. non-zero CAC. Increasing GES was associated with a greater degree of categorical stenosis by ANOVA (p < 0.001); GES significantly correlated with maximum luminal stenosis (r = 0.41; p < 0.01) and segment stenosis score index (r = 0.38; p < 0.01). A low score had sensitivity of 0.90 and a high score a specificity of 0.87 for ≥ 70% stenosis. CONCLUSIONS: A previously validated GES is significantly associated with Plaque Burden and Stenosis by CT. CLINICAL TRIAL REGISTRATION: (PREDICT [NCT00500617] and COMPASS [NCT01117506]), www.clinicaltrials.gov.

Funerary artifacts, social status, and atherosclerosis in ancient peruvian mummy bundles.

BACKGROUND: Evidence of atherosclerotic plaques in ancient populations has led to the reconsideration of risk factors for heart disease and of the common belief that it is a disease of modern times. METHODS: Fifty-one wrapped mummy bundles excavated from the sites of Huallamarca, Pedreros, and Rinconada La Molina from the Puruchuco Museum collection in Lima, Peru, were scanned using computed tomography to investigate the presence of atherosclerosis. Funerary artifacts contained within the undisturbed mummy bundles were analyzed as an attempt to infer the social status of the individuals to correlate social status with evidence of heart disease in this ancient Peruvian group. This work also provides an inventory of the museum mummy collection to guide and facilitate future research. RESULTS: Statistical analysis concluded that there is little association between the types of grave goods contained within the bundles when the groups are pooled together. However, some patterns of artifact type, material, atherosclerosis, and sex emerge when the 3 excavation sites are analyzed separately. CONCLUSIONS: From the current sample, it would seem that social class is difficult to discern, but those from Huallamarca have the most markers of elite status. We had hypothesized that higher-status individuals may have had lifestyles that would place them at a higher risk for atherogenesis. There seems to be some indication of this within the site of Huallamarca, but it is inconclusive in the other 2 archeological sites. It is possible that a larger sample size in the future could reveal more statistically significant results.

Assessing the need for nuclear cardiology and other advanced cardiac imaging modalities in the developing world.

BACKGROUND: In 2005, 80% of cardiovascular disease (CVD) deaths occurred in low- to middle-income countries (i.e., developing nations). Cardiovascular imaging, such as myocardial perfusion SPECT, is one method that may be applied to detect and foster improved detection of at-risk patients. This document will review the availability and utilization for nuclear cardiology procedures worldwide and propose strategies to devise regional centers of excellence to achieve quality imaging around the world. METHODS: As a means to establish the current state of nuclear cardiology, International Atomic Energy Agency member and non-member states were queried as to annual utilization of nuclear cardiology procedures. Other sources for imaging statistics included data from medical societies (American Society of Nuclear Cardiology, European Society of Cardiology, and the European Association of Nuclear Medicine) and nuclear cardiology working groups within several nations. Utilization was calculated by dividing annual procedural volume by 2007 population statistics (/100,000) and categorized as high (>1,000/100,000), moderate-high (250-999/100,000), moderate (100-249/100,000), low-moderate (50-99/100,000) and low (<50/100,000). RESULTS: High nuclear cardiology utilization was reported in the United States, Canada, and Israel. Most Western European countries, Australia, and Japan reported moderate-high utilization. With the exception of Argentina, Brazil, Colombia and Uruguay, South America had low usage. This was also noted across Eastern Europe, Russia, and Asia. Utilization patterns generally mirrored each country's gross domestic product. However, nuclear cardiology utilization was higher for developing countries neighboring moderate-high "user" countries (e.g., Algeria and Egypt); perhaps the result of accessible high-quality training programs. CONCLUSIONS: Worldwide utilization patterns for nuclear cardiology vary substantially and may be influenced by physician access to training and education programs. Development of regional training centers of excellence can guide utilization of nuclear cardiology through the application of guideline- and appropriateness-driven testing, training, continuing education, and quality assurance programs aiding developing nations to confront the epidemics of CVD.

Indications and reimbursement of cardiac computed tomography angiography: history, present and future perspectives.

To comment that cardiac computed tomography angiography (CCTA) is an exciting tool in the evaluation of coronary artery disease (CAD) is an understatement. As a new method, however, differing clinical and reimbursement guidelines exist to guide the use of the method, resulting in confusion among referring and interpreting physicians in whether CCTA is reasonably indicated and covered by an individual patient's payer. Such confusion has slowed the acceptance of CCTA within the medical community. Clinical and reimbursement guidelines related to CCTA indications, including those from public and private payers, are reviewed, summarized, and compared in text and table formats. The commonalities extant within medical society guidelines and gradually within the payer community allow the increasingly frequent use of CCTA for certain indications. Challenges to full-fledged acceptance of the technique based on guideline and payer policies are reviewed and are increasingly being overcome.

Should we screen asymptomatic individuals for coronary artery disease or implement universal lipid-lowering therapy?

The lifetime risk of developing coronary heart disease after age 40 has been estimated to be 49% and 32% in men and women, respectively. Including other diseases secondary to atherosclerosis makes the likelihood of developing cardiovascular disease even greater. Lacking an adequate screening test for subclinical cardiovascular disease, or for those in whom it will develop, our current national prevention and treatment strategy is to screen for risk factors of coronary artery disease (CAD), treating only those at greatest risk. Although pharmacologic lipid-lowering therapy has proven to be effective at reducing the development and manifestations of CAD, as well as remarkably safe, our current strategy withholds treatment of many in whom cardiovascular disease will ultimately develop. An alternate strategy is to implement universal lipid-lowering therapy, initiated in men at age 30 and at the time of menopause in women. Such a policy would not limit effective treatment to only those at greatest risk. While the cost of such a program would be substantial, although decreasing with the increasing availability of generic agents, this must be weighed against the direct and indirect costs of cardiovascular disease, estimated to be $368 billion in 2004. If such a strategy were implemented, the goal of screening would shift from CAD detection to detection of a disease burden such that therapies shown to decrease events among those with manifest CAD would be expected to benefit. Such treatments currently include aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and revascularization.