Measurement and Application of Incidentally Detected Coronary Calcium: JACC Review Topic of the Week.

Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease risk stratification. The nongated, noncontrast chest computed tomography scan (NCCT) has emerged as a source of CAC characterization with tremendous potential due to the high volume of NCCT scans. Application of incidental CAC characterization from NCCT has raised questions around score accuracy, standardization of methodology including the possibility of deep learning to automate the process, and the risk stratification potential of an NCCT-derived score. In this review, the authors aim to summarize the role of NCCT-derived CAC in preventive cardiovascular health today as well as explore future avenues for eventual clinical applicability in specific patient populations and broader health systems.

Accuracy of incidental visual coronary artery calcium assessment compared with dedicated coronary artery calcium scoring.

INTRODUCTION: CAC can be detected on routine chest computed tomography (CT) scans and may contribute to CVD risk estimation, but the accuracy of visual CAC scoring may be affected by the specialty of the interpreting radiologist and/or the use of contrast. METHODS: The accuracy of visual CAC estimation on non-gated CT scans was evaluated at UT Southwestern Medical Center (UTSW) and Parkland Health and Hospital System (PHHS). All adults who underwent CAC scanning and a non-gated CT scan within 6 months were identified and the scores from the two CTs were compared overall and stratified by type of reader and whether contrast was used. Visual CAC categories of none, small, moderate, and large were compared to CAC â€‹= â€‹0, 1-99, 100-399, and ≥400, respectively. RESULTS: From 2016 to 2021, 934 patients (mean age 60 â€‹± â€‹12 â€‹y, 43% male, 61% White, 34% Black, 24% Hispanic, 54% from PHHS) had both CT scans. Of these, 441 (47%) had no CAC, 278 (30%) small, 147 (16%) moderate, and 66 (7%) large CAC on non-gated CT. Visual CAC estimates were highly correlated with CAC scores (Kendalls tau-b â€‹= â€‹0.76, p â€‹< â€‹0.0001). Among those with no visual CAC, 76% had CAC â€‹= â€‹0 (72% of contrast-enhanced vs 85% of non-contrast scans, 88% of scans interpreted by CT radiologist vs 78% of those interpreted by other radiologist). In those with moderate-to-large visual CAC, 99% had CAC >0 and 88% had CAC ≥100, including 89% of those with contrast, 90% of those without contrast, 80% of those read by a CT radiologist, and 88% of those read by a non-CT radiologist. DISCUSSION: Visual CAC estimates on non-gated CT scans are concordant with Agatston score categories from cardiac CT scans. A lack of visual CAC on non-gated CT scans may not be sufficient to "de-risk" patients, particularly for contrast-enhanced scans and those read by non-CT radiologists. However, the presence of moderate-to-large CAC, including on contrasted scans and regardless of radiologist type, is highly predictive of CAC and may be used to identify high-risk patients for prevention interventions.

New Recommendations and Revised Concepts in Recent Guidelines on the Management of Dyslipidemias to Prevent Cardiovascular Disease: the 2018 ACC/AHA and 2019 ESC/EAS Guidelines.

PURPOSE OF REVIEW: The purpose of this review is to discuss the updated guideline recommendations on management of dyslipidemia for prevention and treatment of cardiovascular disease. RECENT FINDINGS: The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) published revised cholesterol management guidelines in 2018 and 2019, respectively, to reflect new evidence in the field. Broadly speaking, both emphasize refining cardiovascular disease risk estimation and aggressively lowering low-density lipoprotein-cholesterol (LDL-C) with statin and non-statin agents to curb cardiovascular risk. While they share the same guiding principles, there are important differences in the recommendations from both societies including how they define risk categories and goals for LDL-C lowering. This review summarizes current methods of managing dyslipidemia with a focus on the common themes and notable differences between the 2018 ACC/AHA and 2019 ESC/EAS cholesterol management guidelines.

The Comparative Effect of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on 10-Year and Lifetime Atherosclerotic Cardiovascular Disease Risk.

BACKGROUND: Bariatric surgery reduces atherosclerotic cardiovascular disease (ASCVD) risk. However, the comparative effect of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on 10-year and lifetime ASCVD risk, as defined by the American College of Cardiology/American Heart Association (ACC/AHA), remains unknown. METHODS: Using the ACC/AHA ASCVD risk estimator, 10-year and lifetime ASCVD risks were calculated before and 1 year after bariatric surgery for patients aged 40-78 who underwent RYGB or SG at an academic medical center in California between 2003 and 2015. Change in risk was calculated by taking the difference between 1-year and baseline risk. Statistical analyses included the Wilcoxon signed rank test, Mann-Whitney U test, Quade's test, and multiple logistic regression. RESULTS: There were 536 patients (mean age 52 ± 10 years, 20% male), of whom 438 underwent RYGB and 98 underwent SG. Patients undergoing RYGB were predominately female (82% vs 71%, p = 0.021) and had higher baseline BMIs (44.4 ± 8.4 vs 41.9 ± 8.0, p < 0.001) than patients undergoing SG. Compared with baseline, 10-year and lifetime ASCVD risks were significantly lower 1 year after surgery (aggregate of RYGB and SG, 4.2 ± 6.0% vs. 2.2 ± 3.5%, p < 0.001; 50 ± 11% vs. 39 ± 12%, p < 0.001, respectively). Patients who underwent RYGB had greater reductions in 10-year and lifetime ASCVD risks from baseline to 1 year after surgery than patients who underwent SG (1.7 ± 3.5% vs. 0.8 ± 2.4%, p < 0.001; 11 ± 23% vs. 0 ± 12%, p < 0.001, respectively). CONCLUSIONS: Although RYGB and SG significantly lower 10-year and lifetime cardiovascular disease risks by 1 year after surgery, patients who undergo RYGB may experience greater cardiovascular risk reduction relative to counterparts who undergo SG.

Impact of race/ethnicity on insulin resistance and hypertriglyceridaemia.

OBJECTIVE: Insulin sensitivity affects plasma triglyceride concentration and both differ by race/ethnicity. The purpose of this study was to provide a comprehensive assessment of the variation in insulin sensitivity and its relationship to hypertriglyceridaemia between five race/ethnic groups. RESEARCH DESIGN AND METHODS: In this cross-sectional study, clinical data for 1025 healthy non-Hispanic White, Hispanic White, East Asian, South Asian and African American individuals were analysed. Insulin-mediated glucose disposal (a direct measure of peripheral insulin sensitivity) was measured using the modified insulin suppression test. Statistical analysis was performed using analysis of co-variance. RESULTS: Of the study participants, 63% were non-Hispanic White, 9% were Hispanic White, 11% were East Asian, 11% were South Asian and 6% were African American. Overall, non-Hispanic Whites and African Americans displayed greater insulin sensitivity than East Asians and South Asians. Triglyceride concentration was positively associated with insulin resistance in all groups, including African Americans. Nevertheless, for any given level of insulin sensitivity, African Americans had the lowest triglyceride concentrations. CONCLUSION: Insulin sensitivity, as assessed by a direct measure of insulin-mediated glucose disposal, and its relationship to triglyceride concentration vary across five race/ethnic groups. Understanding these relationships is crucial for accurate cardiovascular risk stratification and prevention.

Surface ECG f Wave Analysis of Dofetilide Drug Effect in the Atrium.

INTRODUCTION: The electrocardiogram (ECG) fibrillatory (f) wave characteristics in atrial fibrillation (AF) could provide important information regarding the efficacy of antiarrhythmic drug therapy. METHODS AND RESULTS: To measure the effects of dofetilide on the surface ECG f wave characteristics in patients with persistent AF, baseline and post-drug (2 hours after first dose and after multiple doses) ECGs in 31 patients with persistent AF admitted for dofetilide loading were evaluated. A QRST template subtraction algorithm was used to yield an atrial ECG. Fast Fourier transform analysis was performed to evaluate the maximum organizational index (OI), the dominant frequency (DF) in the lead with max OI, the median DF for all leads, and the vector magnitude f wave amplitude. Dofetilide reduced DF in the lead with the max OI (6.32 ± 0.98 Hz at baseline vs. 4.83 ± 0.63 Hz after final dose, P < 0.0001) and median DF (6.46 ± 0.87 Hz vs. 4.92 ± 0.62 Hz, P < 0.0001). Dofetilide also increased the maximum OI from 0.52 ± 0.11 at baseline to 0.59 ± 0.11 after final dose (P = 0.02). Of the 29 patients with long-term follow-up, the 22 (76%) with recurrent AF on dofetilide had a lower baseline DF in the lead with the max OI (6.01 ± 1.08 vs. 6.89 ± 0.46; P = 0.05). The change in DF after dofetilide did not correlate with the change in QTc interval. CONCLUSIONS: The standard ECG can be used to assess atrial rate in AF. This may be useful to assess antiarrhythmic drug effects for treatment of AF.