Detection of subclinical atherosclerosis using vascular ultrasound as a vascular risk assessment method. Simplified protocol. / Detección de aterosclerosis subclínica mediante ecografía vascular como método de evaluación de riesgo vascular. Protocolo simplificado.

Cardiovascular disease secondary to atherosclerosis is the main cause of morbidity and mortality in the world. Cardiovascular risk stratification has proven to be an insufficient approach to detect those subjects who are going to suffer a cardiovascular event, which is why for years other markers have been sought to help stratify each individual with greater precision. Two-dimensional vascular ultrasound is a excellent method for vascular risk assessment.

Recent advances in cardiovascular risk assessment: The added value of non-invasive anatomic imaging.

In 2022, multiple original research studies were conducted highlighting the utility of coronary artery calcium (CAC) imaging in young individuals and provided further evidence for the role of CAC to improve atherosclerotic cardiovascular disease (ASCVD) risk assessment. Mean calcium density was shown to be a more reliable predictor than peak density in risk assessment. Additionally, in light of the ACC/AHA/Multispecialty Chest Pain Guideline's recent elevation of coronary computed tomography angiography (CCTA) to a Class I (level of evidence A) recommendation as an index diagnostic test for acute or stable chest pain, several studies support the utility of CCTA and guided future directions. This review summarizes recent studies that highlight the role of non-invasive imaging in enhancing ASCVD risk assessment across different populations.

Incidental Coronary Arterial Calcification for Cardiovascular Risk Assessment in Men With Prostate Cancer Undergoing PET/CT Imaging.

BACKGROUND: Cardiovascular (CV) disease is common among men with prostate cancer and the leading cause of death in this population. There is a need for CV risk assessment tools that can be easily implemented in the prostate cancer treatment setting. METHODS: Consecutive patients who underwent positron emission tomography/computed tomography (PET/CT) for recurrent prostate cancer at a single institution from 2012 to 2017 were identified retrospectively. Clinical data and coronary calcification on nongated CT imaging were obtained. The primary outcome was major adverse CV event (MACE; myocardial infarction, coronary or peripheral revascularization, stroke, heart failure hospitalization, or all-cause mortality) occurring within 5 years of PET/CT. RESULTS: Among 354 patients included in the study, there were 98 MACE events that occurred in 74 patients (21%). All-cause mortality was the most common MACE event (35%), followed by coronary revascularization/myocardial infarction (26%) and stroke (19%). Coronary calcification was predictive of MACE (HR = 1.9, 95% CI: 1.1-3.4, P = .03) using adjusted Kaplan-Meier analysis. As a comparator, the Framingham risk score was calculated for 198 patients (56%) with complete clinical and laboratory data available. In this subgroup, high baseline Framingham risk (corresponding to 10-year risk of CV disease > 20%) was not predictive of MACE. CONCLUSIONS: MACE was common (21%) in men with recurrent prostate cancer undergoing PET/CT over 5 years of follow-up. Incidental coronary calcification on PET/CT was associated with increased risk of MACE and may have utility as a CV risk predictor that is feasible to implement among all prostate cancer providers.

Use of coronarycomputed tomography for cardiovascular risk assessment in immune-mediated inflammatory diseases.

Immune-mediated inflammatory diseases (IMIDs) are recognised risk factors for accelerated atherosclerotic cardiovascular disease (CVD), particularly in younger individuals and women who lack traditional CVD risk factors. Reflective of the critical role that inflammation plays in the formation, progression and rupture of atherosclerotic plaques, research into immune mechanisms of CVD has led to the identification of a range of therapeutic targets that are the subject of ongoing clinical trials. Several key inflammatory pathways implicated in the pathogenesis of atherosclerosis are targeted in people with IMIDs. However, cardiovascular risk continues to be systematically underestimated by conventional risk assessment tools in the IMID population, resulting in considerable excess CVD burden and mortality. Hence, there is a pressing need to improve methods for CVD risk-stratification among patients with IMIDs, to better guide the use of statins and other prognostic interventions. CT coronary angiography (CTCA) is the current first-line investigation for diagnosing and assessing the severity of coronary atherosclerosis in many individuals with suspected angina. Whether CTCA is also useful in the general population for reclassifying asymptomatic individuals and improving long-term prognosis remains unknown. However, in the context of IMIDs, it is conceivable that the information provided by CTCA, including state-of-the-art assessments of coronary plaque, could be an important clinical adjunct in this high-risk patient population. This narrative review discusses the current literature about the use of coronary CT for CVD risk-stratification in three of the most common IMIDs including rheumatoid arthritis, psoriasis and systemic lupus erythematosus.

Myocardial perfusion scintigraphy in the assessment of cardiovascular risk in adult liver transplantation.

INTRODUCTION: The non-invasive diagnostic study of cardiovascular risk in patients who are going to undergo liver transplantation is not clear, especially in asymptomatic patients. Regarding myocardial perfusion scintigraphy (MPS), it has been thought that the impaired vasodilator reserve in these patients may reduce its performance. The objective is to assess the role of the MPS in the pre-surgical evaluation of patients who are going to undergo liver transplantation. MATERIAL AND METHODS: Retrospective, descriptive and observational study was designed. All adult patients undergoing liver transplantation between 2017 and 2021 who had previous MPS were included. The findings of MPS were described and correlated with the findings of invasive angiography and with the appearance or not of peri- and post-transplant cardiovascular events. RESULTS: There were a total of 188 transplanted patients (mean age: 57 years, SD: 12), 178 had previous myocardial perfusion, 82 (46%) patients had no cardiovascular risk factors, and 5 (2.8%) had a history of coronary disease. Of the MPS, 177 were with dipyridamole stress performed on average 10 months before transplantation. Only 17/178 (9.5%) studies were abnormal. The mean follow-up was 38 months (SD: 10). Of the patients with normal MPS, only 2 (1.2%) presented cardiovascular events, both with studies performed more than 2 years before the procedure. There were no deaths of cardiovascular origin. CONCLUSIONS: MPS is a safe and reliable technique for cardiovascular assessment of patients who are candidates for liver transplantation, given the low rate of false negatives during follow-up.

Unsupervised Time-Series Clustering of Left Atrial Strain for Cardiovascular Risk Assessment.

BACKGROUND: Early identification of individuals at high risk for developing cardiovascular (CV) events is of paramount importance for efficient risk management. Here, the authors investigated whether using unsupervised machine learning methods on time-series data of left atrial (LA) strain could distinguish clinically meaningful phenogroups associated with the risk for developing adverse events. METHODS: In 929 community-dwelling individuals (mean age, 51.6 years; 52.9% women), clinical and echocardiographic data were acquired, including LA strain traces, at baseline, and cardiac events were collected on average 6.3 years later. Two unsupervised learning techniques were used: (1) an ensemble of a deep convolutional neural network autoencoder with k-medoids and (2) a self-organizing map to cluster spatiotemporal patterns within LA strain curves. Clinical characteristics and cardiac outcome were used to evaluate the validity of the k clusters using the original cohort, while an external population cohort (n = 378) was used to validate the trained models. RESULTS: In both approaches, the optimal number of clusters was five. The first three clusters had differences in sex distribution and heart rate but had a similar low CV risk profile. On the other hand, cluster 5 had the worst CV profile and a higher prevalence of left ventricular remodeling and diastolic dysfunction compared with the other clusters. The respective indexes of cluster 4 were between those of clusters 1 to 3 and 5. After adjustment for traditional risk factors, cluster 5 had the highest risk for cardiac events compared with clusters 1, 2, and 3 (hazard ratio, 1.36; 95% CI, 1.09-1.70; P = .0063). Similar LA strain patterns were obtained when the models were applied to the external validation cohort, and clinical characteristics revealed similar CV risk profiles across all clusters. CONCLUSION: Unsupervised machine learning algorithms used in time-series LA strain curves identified clinically meaningful clusters of LA deformation and provide incremental prognostic information over traditional risk factors.

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation.

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

Echocardiographic assessment of COVID19 sequelae in survivors with elevated cardiac biomarkers.

AIMS: We sought to determine, using advanced echocardiography, the prevalence and type of cardiovascular sequelae after COVID19 infection with marked elevation of cardiovascular biomarkers (CVB), and their prognostic implications. METHODS: All patients admitted from March 1st to May 25th, 2020 to a tertiary referral hospital were included. Those with cardiovascular diseases or dead during admission were excluded. Patients with hs-TnI > 45 ng/L, NT-proBNP>300 pg/mL, and D-dimer >8000 ng/mL were matched with COVID controls (three biomarkers within the normal range) based on intensive care requirements and age, and separately analyzed. RESULTS: From 2025 patients, 80 patients with significantly elevated CVB and 29 controls were finally included. No differences in baseline characteristics were observed among groups, but elevated CVB patients were sicker. Follow-up echocardiograms showed no differences among groups regarding LVEF and only slight differences between groups within the normal range. Hs-TnI patients had lower myocardial work and longitudinal strain. The presence of an abnormal echocardiogram was more frequent in the elevated CVB group compared to controls (23.8 vs 10.3%, P = 0.123) but mainly associated with mild abnormalities in deformation parameters. Management did not change in any case and no major cardiovascular events except deep vein thrombosis occurred after a median follow-up of 7 months. CONCLUSION: Minimal abnormalities in cardiac structure and function are observed in COVID19 survivors without previous cardiovascular diseases who presented a significant CVB rise at admission, with no impact on patient management or short-term prognosis. These results do not support a routine screening program after discharge in this population.

Cardiovascular risk assessment with carotid ultrasound in rheumatoid arthritis.

BACKGROUND/OBJECTIVE: To assess the Cardiovascular Risk (CV) in Rheumatoid Arthritis (RA) patients using carotid ultrasound additionally to the traditional CV risk factors. METHODS: A cross-sectional case control study was performed including RA patients and matched controls. This study was performed from July-2019 to January-2020. Population over 75 years old, established CV disease and/or chronic kidney disease (from III Stage) were excluded. Statistical analysis included a multivariate variance analysis (Manova) and a negative binomial regression adjusted by confounding factors. RESULTS: Overall, a total of 200 cases and 111 controls were included in the study. Demographical and clinical variables were comparable between groups. A relationship between age, BMI and high blood pressure was detected in both groups. RA patients showed higher intima-media thickness and higher plaque account compared to controls and it was related to the disease duration and DAS28 score. CONCLUSION: RA leads to a higher intima-media thickness, and this is related to the disease duration and DAS28 score. These findings support that RA acts as an independent cardiovascular risk factor.

Can we increase efficiency of CT lung cancer screening by combining with CVD and COPD screening? Results of an early economic evaluation.

OBJECTIVES: Estimating the maximum acceptable cost (MAC) per screened individual for low-dose computed tomography (LDCT) lung cancer (LC) screening, and determining the effect of additionally screening for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), or both on the MAC. METHODS: A model-based early health technology assessment (HTA) was conducted to estimate whether a new intervention could be cost-effective by calculating the MAC at a willingness-to-pay (WTP) of €20k/quality-adjusted life-year (QALY) and €80k/QALY, for a population of current and former smokers, aged 50-75 years in The Netherlands. The MAC was estimated based on incremental QALYs gained from a stage shift assuming screened individuals are detected in earlier disease stages. Data were obtained from literature and publicly available statistics and validated with experts. RESULTS: The MAC per individual for implementing LC screening at a WTP of €20k/QALY was €113. If COPD, CVD, or both were included in screening, the MAC increased to €230, €895, or €971 respectively. Scenario analyses assessed whether screening-specific disease high-risk populations would improve cost-effectiveness, showing that high-risk CVD populations were more likely to improve economic viability compared to COPD. CONCLUSIONS: The economic viability of combined screening is substantially larger than for LC screening alone, primarily due to benefits from CVD screening, and is dependent on the target screening population, which is key to optimise the screening program. The total cost of breast and cervical cancer screening is lower (€420) than the MAC of Big-3, indicating that Big-3 screening may be acceptable from a health economic perspective. KEY POINTS: • Once-off combined low-dose CT screening for lung cancer, COPD, and CVD in individuals aged 50-75 years is potentially cost-effective if screening would cost less than €971 per screened individual. • Multi-disease screening requires detailed insight into the co-occurrence of these diseases to identify the optimal target screening population. • With the same target screening population and WTP, lung cancer-only screening should cost less than €113 per screened individual to be cost-effective.

Cardiac microcalcification burden: Global assessment in high cardiovascular risk subjects with Na[18F]F PET-CT.

BACKGROUND: Fluorine-18 sodium fluoride (Na[18F]F) atherosclerotic plaque uptake in positron emission tomography with computed tomography (PET-CT) identifies active microcalcification. We aim to evaluate global cardiac microcalcification activity with Na[18F]F, as a measure of unstable microcalcification burden, in high cardiovascular (CV) risk patients. METHODS AND RESULTS: Thirty-four high CV risk individuals without previous CV events were scanned with Na[18F]F PET-CT. Cardiac Na[18F]F uptake was assessed through the global molecular calcium score (GMCS), which was calculated by summing the product of the mean standardized uptake value times the area of the cardiac regions of interest times the slice thickness for all cardiac transaxial slices, divided by the total number of slices. Mean age is 63.5 ± 7.8 years and 62% male. Median GMCS is 320.9 (240.8-402.8). Individuals with more than five CV risk factors (50%) have increased GMCS [356.7 (321.0-409.6) vs. 261.1 (225.6-342.1), P = 0.01], which is positively correlated with predicted fatal CV risk by SCORE (rs = 0.32, P = 0.04). There is a positive correlation between GMCS and weight (rs = 0.61), body mass index (rs = 0.66), abdominal perimeter (rs = 0.74), thoracic fat volume (rs = 0.47), and epicardial adipose tissue (rs = 0.41), all with P ≤ 0.01. There is no correlation between GMCS and coronary calcium score nor coronary artery wall Na[18F]F uptake. CONCLUSIONS: In a high CV risk group, the global cardiac microcalcification burden is related to CV risk factors, metabolic syndrome variables and cardiac fat. Cardiac GMCS is a promising risk stratification tool, combining a straightforward and objective methodology with a comprehensive analysis of both coronary and valvular microcalcification.

Cardiovascular Risk Assessment in Women With Rheumatoid Arthritis Through Carotid and Femoral Artery Doppler Ultrasound.

OBJECTIVE: The aims of this study were to assess cardiovascular risk in patients with rheumatoid arthritis (RA) classified as low-risk by the Framingham score, before and after the multiplication by 1.5 recommended by the European League Against Rheumatism (EULAR), and to stratify them using carotid and femoral Doppler ultrasound (DUS) in order to optimize the assessment of the asymptomatic cardiovascular disease incidence. METHODS: Thirty-five female patients with RA and 35 healthy women (control group), both with low cardiovascular risk by Framingham score, were enrolled in the study (randomized). All of them underwent carotid and femoral DUS studies. RESULTS: The mean age at diagnosis was 44.57 years, the mean disease duration was 12.11 years and the mean disease activity score according to the Disease Activity Score 28 was 1.91, whereas according to the Clinical Disease Activity Index, it was 6.176. The sample was homogeneous. Within the RA group, 46% showed changes in the carotid and/or femoral DUS, compared with 14% in the control group (p = 0.004). Of the DUS with abnormalities, in the RA group, 31% of the carotid DUS and 81% of the femoral DUS (p = 0.005) showed intima-media thickness and/or atherosclerotic plaques. After EULAR 1.5 multiplication factor, 66% remained low cardiovascular risk. Of these, 35% of the patients showed changes in the carotid and/or femoral DUS, compared with 14% of the control group (p = 0.07). CONCLUSIONS: The EULAR criteria are effective at identifying patients with high cardiovascular risk. Carotid DUS and, especially, femoral DUS are tools that can be used in clinical practice as ways to detect CVD even in its asymptomatic form.

Cardiovascular risk assessment and coronary artery calcification burden in asymptomatic patients in the initial years of hemodialysis.

The specific tool for cardiovascular risk assessment in hemodialysis population has not yet been proposed, despite high prevalence of cardiovascular morbidity, and mortality in clinically asymptomatic patients. Coronary artery calcium score (CACS), as a reliable predictor of future cardiovascular events, might be a valuable approach. We sought to evaluate coronary artery calcification burden and its association with clinical and laboratory parameters in asymptomatic patients who recently initiated hemodialysis. The cross-sectional study included 60 asymptomatic patients receiving chronic hemodialysis for no longer than 48 months. CACS was assessed by cardiac computed tomography. Intima-media thickness (IMT) of both common carotid and femoral arteries were measured using ultrasonography. The mean total CACS was 160.50 (443). Patients' age correlated significantly with CACS (σ = 0.367; P = 0.004), carotid (σ = 0.375; P = 0.004) and femoral IMT (σ = 0.323; P = 0.013). Patients with CACS = 0 were significantly younger than patients with CACS >400: 52.4 ± 7.91 vs. 63.88 ± 8.37 years old, respectively (P = 0.034). In patients receiving dialysis for longer than 24 months CACS, femoral and carotid IMT were higher than in those dialyzed for less than 24 months; however, none has reached significance. There was a significant positive correlation between CACS and right (σ = 0.312; P = 0.018) and left (σ = 0.521; P < 0.001) femoral IMT, while not with carotid. CACS showed significant negative correlation with the serum iron (σ = -0.351; P = 0.007). Calcification burden varies significantly in asymptomatic patients in early years of dialysis. It correlates with patients' age and tends to increase with dialysis vintage. Femoral IMT might be useful for cardiovascular risk stratification in asymptomatic patients who recently initiated hemodialysis.

Ultrasound-Based Assessment of Preperitoneal Fat as a Surrogate Marker of Cardiovascular Risk: Comparative Study Between People Living with HIV and Controls.

Optimal management of cardiovascular disease should start with the identification of subjects at subclinical stages. However, available tools are not always accurate or affordable. We assess the usefulness of ultrasound-guided measurement of abdominal fat layers as a surrogate marker of cardiovascular risk. We performed a cross-sectional, case-control, exploratory, pilot study in 10 people living with HIV (PLWH) and 10 HIV-uninfected subjects (control group) matched for age, sex, and body mass index. All participants were men 45-60 years of age, with no active disease or previous abdominal surgery; the PLWH group had been virologically suppressed for ≥2 years under stable antiretroviral therapy. The thickness of abdominal superficial and deep subcutaneous fat, preperitoneal fat, omental (periaortic) fat, and retroperitoneal (perirenal) fat was compared between both groups. Correlations between fat layers and traditional markers of cardiovascular risk were assessed. The thickness of most layers was always higher among PLWH. The differences were statistically significant for the preperitoneal fat layer (p = .04). The presence of atherosclerotic plaque was correlated with the preperitoneal fat layer in the PLWH group (odds ratio = 1.49, p = .02), and metabolic syndrome was correlated with superficial subcutaneous fat, although this was low (odds ratio = 0.54, p = .02). In the control group, several associations were found between carotid intima media thickness and abdominal fat layers. All abdominal fat layers were thicker in the PLWH group, especially preperitoneal fat, and several associations were found between specific fat layers and traditional cardiovascular risk markers. Our results suggest that the thickness of abdominal fat layers, assessed by ultrasound, could be a marker of cardiovascular risk. However, further studies with larger populations are required to confirm these findings.

Cardiovascular Risk Assessment in COVID-19.

COVID-19 bezeichnet eine der schlimmsten Krisen unserer Generation und stellt (nicht nur) für das Gesundheitssystem eine schwer bewältigbare Herausforderung dar. Mortalität und Morbidität sind im Vergleich zu anderen saisonalen Erkrankungen wie der Influenza deutlich erhöht. COVID-19 bedroht allerdings nicht die gesamte Bevölkerung in gleichem Maße. Hochrisikopatienten sind älter und leiden an kardiovaskulären Erkrankungen wie Bluthochdruck, Diabetes mellitus oder einer koronaren Herzerkrankung. Um das Risiko für einen schweren Erkrankungsverlaufs zu quantifizieren bedarf es einer multimodalen Herangehensweise. Verschiedene Risikostratifizierungssysteme stehen zu Verfügung um ungünstige Verläufe wie Intensivbehandlung oder Gesamtmortalität vorauszusagen. Biomarker wie Troponin-I, D-Dimere und NT pro-BNP kombiniert mit echokardiographischen Parametern wie links- und rechtsventrikulärer Pumpfunktion sowie pulmonalarteriellem Druck können hilfreich sein um Hochrisikopatienten zu identifizieren, die ein intensiviertes Monitoring und eine stringentere Behandlung benötigen. Da kardiovaskuläre Risikofaktoren und Komorbiditäten von großer Bedeutung zur Abschätzung des Verlaufs einer SARS-CoV-2 Infektion sind, könnten alle hospitalisierten COVID-19 Patienten von einer routinemäßigen kardiologischen Betreuung durch ein COVID-19-Heart-Team profitieren. Ein frühzeitiges Erkennen von (kardiovaskulären) Hochrisikopatienten könnte das Management erleichtern sowie die Prognose einer schweren SARS-CoV-2 Infektion verbessern.

Significance of serum FGF-23 for risk assessment of contrast-associated acute kidney injury and clinical outcomes in patients undergoing coronary angiography.

BACKGROUND: Fibroblast growth factor (FGF)-23 levels rise as kidney function declines. Whether elevated FGF-23 levels are associated with an increased risk for contrast-associated acute kidney injury (CA-AKI) and major adverse cardiovascular events (MACE) in patients undergoing coronary angiography remain uncertain. METHODS: In total, 492 patients receiving coronary angiography were enrolled. Their serum FGF-23 levels were measured before administration of contrast media. The occurrence of CA-AKI was defined as a rise in serum creatinine of 0.5 mg/dL or a 25% increase from the baseline value within 48 h after the procedure. All patients were followed up for at least 1 year or until the occurrence of MACE including death, nonfatal myocardial infarction (MI), and ischemic stroke. RESULTS: Overall, CA-AKI occurred in 41 (8.3%) patients. During a median follow-up of 2.6 years, there were 24 deaths, 3 nonfatal MIs, and 7 ischemic strokes. Compared with those in the lowest FGF-23 tertile, individuals in the highest FGF-23 tertile had a significantly higher incidence of CA-AKI (P < 0.001) and lower incidence of MACE-free survival (P = 0.001). In multivariate regression analysis, higher FGF-23 level was found to be independently associated with a graded risk for CA-AKI (OR per doubling, 1.90; 95% CI 1.48-2.44) and MACE (HR per doubling, 1.25; 95% CI 1.02-1.52). CONCLUSIONS: Elevated FGF-23 levels were associated with an increased risk for CA-AKI and future MACE among patients undergoing coronary angiography. FGF-23 may play a role in early diagnosis of CA-AKI and predicting clinical outcomes after coronary angiography.