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1.
HIV Res Clin Pract ; 21(1): 11-23, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32160827

RESUMO

Background: The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) is a multicenter, randomized, placebo-controlled trial, designed to test whether a statin medication can prevent cardiovascular disease in people with HIV. REPRIEVE recently completed enrollment of 7557 participants at over 100 clinical sites globally. Participant groups of focus were women, and racial and ethnic minorities.Objective: To describe recruitment methods and strategies developed by the REPRIEVE Clinical Coordinating Center (CCC) and share best practices learned from the recruitment process.Methods: Enrollment targets were agreed upon with the primary funder, the National Heart, Lung, and Blood Institute (NHLBI) and were milestone driven. Milestones included number of sites activated, number of participants enrolled within specific time frames, and proportion of women and minorities enrolled. Strategies to achieve these milestones included structured interviews with site-designated REPRIEVE Recruitment Champions to develop best practices, development of a multimedia campaign, and site level recruitment support.Results: Recruitment initiated March, 2015 and completed March, 2019. The final accrual target was 7500 participants over 48 months. The trial met this target within the time specified. Overall, 10,613 screens were completed, 48% of participants enrolled from sites outside of North America, 32% were female, 44% were Black or African American, and 25% were Hispanic or Latino.Conclusions: REPRIEVE met its overall projected recruitment goal by using multiple, simultaneous strategies to specifically target a diverse population including minority subgroups. REPRIEVE benefited from the development of recruitment strategies with clear targets and communication of accrual targets to study teams.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32076919

RESUMO

Change in coronary artery plaque on serial catheter intravascular ultrasound (IVUS) is an established technique to monitor the therapeutic effect of drugs on coronary atherosclerosis. Recent advances in coronary computed tomography angiography (CTA) now allow for non-invasive assessment of change in coronary plaque. Because coronary CTA is noninvasive, it enables clinical trials with lower-risk populations, higher retention rates, and lower costs. This review presents an overview of serial coronary CTA as a noninvasive imaging technique to gauge the therapeutic effect of anti-atherosclerotic therapies. Furthermore, it reviews the increasing use of serial CTA as an imaging endpoint in completed and ongoing clinical trials.

4.
Heart ; 106(4): 273-279, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31601728

RESUMO

OBJECTIVES: To test the relationship between increasing severity of obesity, calculated risk and observed outcomes. METHODS: Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians' perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction). RESULTS: BMI was ≥30 kg/m2 in 48% of patients and ≥35 in 20%. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians' estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10% increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95% CI 1.4 to 1.5) in patients with BMI <35, but only 1.2 (95% CI 1.1 to 1.3) in those with BMI ≥35 (interaction p<0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up. CONCLUSIONS: Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity. TRIAL REGISTRATION NUMBER: NCT01174550.

5.
JACC Cardiovasc Imaging ; 13(2 Pt 1): 462-464, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31542535
6.
JACC Cardiovasc Imaging ; 13(2 Pt 1): 437-448, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31326481

RESUMO

OBJECTIVES: This study sought to assess medical management of patients found to have nonobstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) performed in the emergency department (ED). BACKGROUND: Contemporary recognition and management of nonobstructive CAD discovered on CCTA performed in the ED is unknown. METHODS: Patients undergoing CCTA in the authors' hospital's ED between November 2013 and March 2018 who also received primary care within the authors' health system were studied. All patients with nonobstructive CAD, defined as 1% to 49% maximum luminal stenosis on CCTA, were included, along with a control group without CAD in a 1 case:1 control fashion. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk prior to CCTA was estimated using the Pooled Cohort Equations. Management changes were recorded until 6 months after CCTA. Multivariate logistic regression tested the association between CCTA result and follow-up statin prescription, adjusting for cardiovascular risk factors and baseline statin use. RESULTS: The cohort included 510 patients with nonobstructive CAD and 510 controls. Prevalence of statin prescription increased from 38.8% to 56.1% among patients with nonobstructive CAD (p < 0.001) and 18.0% to 20.4% among controls (p = 0.01), representing a 7.1-fold relative difference (95% confidence interval [CI]: 4.4 to 23.0; p < 0.001) in multivariate analysis. However, 30.0% of patients with nonobstructive CAD and ≥20% 10-year ASCVD risk were not prescribed a statin at the end of follow-up. Cardiologist evaluation was independently associated with statin prescription after adjustment for ASCVD risk factors (odds ratio [OR] 4.4; 95% CI: 2.4 to 8.5; p < 0.001). A Coronary Artery Disease Reporting and Data System class 1 to 2 result was associated with lower low-density lipoprotein cholesterol by 12.1 mg/dl at mean 1.9-year follow-up (p < 0.001). CONCLUSIONS: Incidental subclinical atherosclerosis on CCTA performed in the ED increases the likelihood of statin prescription, but opportunities to improve allocation of indicated preventive therapies remain.

7.
J Infect Dis ; 221(4): 510-515, 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-31077265

RESUMO

Interleukin 10 (IL-10) is an anti-inflammatory cytokine that may be protective against coronary atherosclerosis. In an observational study of persons with human immunodeficiency virus (PWH) and uninfected controls, IL-10 was measured in serum samples by means of enzyme-linked immunosorbent assay, and coronary atherosclerosis was assessed using computed tomographic angiography. Among PWH, a 10-fold decrease in IL-10 was associated with a 2.6-fold increase in the odds of coronary plaque (P = .01), after controlling for traditional and nontraditional cardiovascular risk factors. IL-10 was also inversely associated with total coronary plaque (ρ = -0.19; P = .02) and noncalcified coronary plaque (ρ = -0.24; P = .004). Our findings suggest a role for IL-10 in mitigating atherosclerosis in PWH. Clinical Trials Registration. NCT00455793.

8.
JAMA Cardiol ; 2019 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-31738382

RESUMO

Importance: Although cardiovascular (CV) disease represents the leading cause of morbidity and mortality that increases with age, the best noninvasive test to identify older patients at risk for CV events remains unknown. Objective: To determine whether the prognostic utility of anatomic vs functional testing varies based on patient age. Design, Setting, and Participants: Prespecified analysis of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) study, which used a pragmatic comparative effectiveness design. Participants were enrolled from 193 sites across North America and comprised outpatients without known coronary artery disease (CAD) but with symptoms suggestive of CAD. Data were analyzed between October 2018 and April 2019. Interventions: Randomization to noninvasive testing with coronary computed tomographic angiography or functional testing. Main Outcomes and Measures: The composite of CV death/myocardial infarction (MI) over a median follow-up of 25 months. Results: Among 10 003 PROMISE patients, we included the 8966 who received the noninvasive test to which they were randomized and had interpretable results; 6378 (71.1%) were younger than 65 years, 2062 (23.0%) were between ages 65 and 74 years, and 526 (5.9%) were 75 years and older. More than half of participants were women (4720 of 8966 [52.6%]). Only a minority of patients were of nonwhite race/ethnicity, a proportion that was lower among the older age groups (1071 of 6378 [16.8%] for <65 years; 258 of 2062 [12.5%] for age 65-74 years; 41 of 526 [7.8%] for ≥75 years). Compared with patients younger than 65 years, older patients were more likely to have a positive test result (age 65-74 years: odds ratio, 1.65; 95% CI, 1.42-1.91; age ≥75 years: odds ratio, 2.32; 95% CI, 1.83-2.95), regardless of noninvasive test completed. A positive functional test result was not associated with CV death/MI in patients younger than 65 years (hazard ratio [HR], 1.09; 95% CI, 0.43-2.82) but it was among older patients (age 65-74 years: HR, 3.18; 95% CI, 1.44-7.01; age ≥75 years: HR, 6.55; 95% CI, 1.46-29.35). Conversely, a positive anatomic test result was associated with CV death/MI among patients younger than 65 years (HR, 3.04; 95% CI, 1.46-6.34) but not among older patients (age, 65-74 years: HR, 0.67; 95% CI, 0.15-2.94; age ≥75 years: HR, 1.07; 95% CI, 0.22-5.34; P for interaction = .01). An elevated coronary artery calcium score was predictive of events in patients younger than 65 years (HR, 2.73; 95% CI, 1.31-5.69) but not for older patients (age 65-74 years: HR, 0.44; 95% CI, 0.14-1.42; age ≥75 years: HR, 1.31; 95% CI, 0.25-6.88). Conclusions and Relevance: Older patients with stable symptoms suggestive of CAD are more likely to have a positive noninvasive test result and more coronary artery calcium. However, only a positive functional test result was associated with risk of CV death/MI. Age-specific approaches to noninvasive evaluation of CAD should be further examined. Trial Registration: ClinicalTrials.gov identifier: NCT01174550.

9.
Antivir Ther ; 24(7): 505-512, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31742564

RESUMO

BACKGROUND: Vitamin D deficiency is underdiagnosed and undertreated, especially among people living with HIV (PLWH). Recently, there has been an increased interest in the role of vitamin D in cardiovascular disease (CVD). While vitamin D deficiency has been associated with CVD in observational studies in the general population, there are limited data in PLWH. We therefore performed an analysis to assess the relationship of vitamin D and coronary atherosclerosis using coronary CT angiography (CCTA). METHODS: Women living with HIV (WLWH) without known CVD were included. Based on the median value of serum vitamin D levels, participants were dichotomized to either the <25 ng/ml (lower vitamin D group) or ≥25 ng/ml (higher vitamin D group). CCTA was used to assess plaque characteristics. RESULTS: Forty-three WLWH were included in the analyses (mean age 46 ±8 years, 56% African American, duration of HIV 15 ±6 years, 83% undetectable HIV viral load). WLWH in the lower vitamin D group (n=22) had significantly higher numbers of segments with any coronary plaque (2.27 ±3.01 versus 0.38 ±0.97; P=0.02) and segments with non-calcified coronary plaque (1.41 ±1.82 versus 0.29 ±0.64; P=0.03) compared with WLWH in the higher vitamin D group (n=21). After adjusting for Framingham CHD risk point score, body mass index, diabetes and race, the relationship remained significant. CONCLUSIONS: Our study demonstrates a significant, independent relationship between lower vitamin D status and higher numbers of noncalcified coronary plaque segments in WLWH. Further studies are warranted to evaluate the effect of vitamin D on CVD in PLWH. Trial Registration Identifier: NCT00455793.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31734213

RESUMO

OBJECTIVES: The purpose of this study was to compare Coronary Artery Disease Reporting and Data System (CAD-RADS) to traditional stenosis categories and the coronary artery calcium score (CACS) for predicting cardiovascular events in patients with stable chest pain and suspected coronary artery disease (CAD). BACKGROUND: The 2016 CAD-RADS has been established to standardize the reporting of CAD on coronary CT angiography (CTA). METHODS: PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial participants' CTAs were assessed by a central CT core laboratory for CACS, traditional stenosis-based categories, and modified CAD-RADS grade including high-risk coronary plaque (HRP) features. Traditional stenosis categories and CAD-RADS grade were compared for the prediction of the composite endpoint of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 25 months. Incremental prognostic value over traditional risk factors and CACS was assessed. RESULTS: In 3,840 eligible patients (mean age: 60.4 ± 8.2 years; 49% men), 3.0% (115) experienced events. CAD-RADS (concordance statistic [C-statistic] 0.747) had significantly higher discriminatory value than traditional stenosis-based asessments (C-statistic 0.698 to 0.717; all p for comparison ≤0.001). With no plaque (CAD-RADS 0) as the baseline, the hazard ratio (HR) for an event increased from 2.43 (95% confidence interval [CI]: 1.16 to 5.08) for CAD-RADS 1 to 21.84 (95% CI: 8.63 to 55.26) for CAD-RADS 4b and 5. In stepwise nested models, CAD-RADS added incremental prognostic value beyond ASCVD risk score and CACS (C-statistic 0.776 vs. 0.682; p < 0.001), and added incremental value persisted in all CACS strata. CONCLUSIONS: These data from a large representative contemporary cohort of patients undergoing coronary CTA for stable chest pain support the prognostic value of CAD-RADS as a standard reporting system for coronary CTA.

11.
Artigo em Inglês | MEDLINE | ID: mdl-31734449

RESUMO

BACKGROUND & AIMS: Many individuals presumed to have nonalcoholic fatty liver disease (NAFLD) consume moderate amounts of alcohol. Little is known about patterns of alcohol use in patients with NAFLD or how drinking behaviors affect liver fat. METHODS: We conducted a cross-sectional study of 2475 participants of the Framingham Heart Study with hepatic steatosis, as determined by computed tomography. We performed multivariable-adjusted logistic regression models to evaluate the association between alcohol drinking patterns and hepatic steatosis. Models were adjusted for sociodemographic factors, diet, and the components of the metabolic syndrome. We excluded heavy alcohol users, defined as women who consume more than 14 alcohol drinks per week and men who consume more than 21 alcohol drinks per week. RESULTS: In our sample (mean age, 49.8 ± 10.2 y; 50.3% women), the prevalence of hepatic steatosis was 17.5%. The total number of alcohol drinks per week and the maximum drinks consumed per drinking day each were associated with hepatic steatosis (adjusted odds ratio [aOR], 1.15; 95% CI, 1.02-1.29 and aOR 1.15; 95% CI, 1.02-1.30). Binge drinking occurred in 25.4% of individuals with presumed NAFLD and was associated with an increased odds of hepatic steatosis (aOR, 1.45; 95% CI, 1.06-1.98) among alcohol users. In a beverage-specific analysis, alcohol use patterns were associated with hepatic steatosis among beer drinkers, but not among wine drinkers. CONCLUSIONS: In a cross-sectional study of participants of the Framingham Heart Study with hepatic steatosis, we observed an association between alcohol use and liver fat, even after excluding heavy alcohol users from our analysis. Alcohol use therefore appears to be a risk factor for NAFLD. Prospective studies are needed to validate these findings and determine if alcohol use should be a focus for research, prevention, and treatment of presumed NAFLD.

12.
Nat Genet ; 51(11): 1580-1587, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31659325

RESUMO

Aortic calcification is an important independent predictor of future cardiovascular events. We performed a genome-wide association meta-analysis to determine SNPs associated with the extent of abdominal aortic calcification (n = 9,417) or descending thoracic aortic calcification (n = 8,422). Two genetic loci, HDAC9 and RAP1GAP, were associated with abdominal aortic calcification at a genome-wide level (P < 5.0 × 10-8). No SNPs were associated with thoracic aortic calcification at the genome-wide threshold. Increased expression of HDAC9 in human aortic smooth muscle cells promoted calcification and reduced contractility, while inhibition of HDAC9 in human aortic smooth muscle cells inhibited calcification and enhanced cell contractility. In matrix Gla protein-deficient mice, a model of human vascular calcification, mice lacking HDAC9 had a 40% reduction in aortic calcification and improved survival. This translational genomic study identifies the first genetic risk locus associated with calcification of the abdominal aorta and describes a previously unknown role for HDAC9 in the development of vascular calcification.


Assuntos
Aterosclerose/patologia , Predisposição Genética para Doença , Histona Desacetilases/metabolismo , Histona Desacetilases/fisiologia , Contração Muscular , Músculo Liso Vascular/patologia , Proteínas Repressoras/metabolismo , Proteínas Repressoras/fisiologia , Calcificação Vascular/patologia , Idoso , Animais , Aorta/metabolismo , Aorta/patologia , Aterosclerose/genética , Aterosclerose/metabolismo , Estudos de Coortes , Feminino , Proteínas Ativadoras de GTPase/genética , Proteínas Ativadoras de GTPase/metabolismo , Estudo de Associação Genômica Ampla , Histona Desacetilases/genética , Humanos , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Pessoa de Meia-Idade , Músculo Liso Vascular/metabolismo , Fenótipo , Polimorfismo de Nucleotídeo Único , Proteínas Repressoras/genética , Calcificação Vascular/genética , Calcificação Vascular/metabolismo
13.
Artigo em Inglês | MEDLINE | ID: mdl-31451438

RESUMO

BACKGROUND: It is not known how the volume and composition of individual coronary plaques change over time in HIV-infected people and whether statins influence these changes. METHODS: We included forty adults with HIV and subclinical coronary atherosclerosis who participated in a randomized controlled trial of placebo vs. atorvastatin. All participants underwent serial coronary computed tomography angiography at baseline and after one year. Individual coronary plaques were measured to assess the within-patient variability of plaque volume and composition changes. Left-main, proximal-right, proximal-left-anterior descending, and proximal-circumflex coronary segments were considered proximal. Plaque voxels with attenuation ≤130 Hounsfield Units (HU) were defined as noncalcified and further divided into fatty (<40HU) and fibrotic (40-130HU) components. RESULTS: In 37 patients who completed the trial, there were 92 coronary plaques. Individual plaque changes varied highly, with some plaques increasing while others decreased in the same patient. Overall, 77% vs. 51% of individual plaques progressed, while 24% vs. 49% regressed in placebo and statin, respectively (p = 0.016). Substantial increases in proximal plaques drove the progression in placebo. Statins suppressed these large increases, resulting in a 3-fold lower variance in plaque volume change compared to placebo (p = 0.025). Statins suppressed progression of fibrotic (p = 0.015) plaque, with a trend towards reducing fatty (p = 0.075) plaque and no significant effect on the calcified portion (p = 0.203). CONCLUSION: In persons with HIV, a population with increased atherosclerosis burden and cardiovascular risk, individual coronary plaque changes vary within a given individual. Large increases in proximal plaques characterize progression, and statins act in part by stabilizing progressing plaques by reducing fatty and fibrotic plaque components, without influencing the calcified portion.

14.
Artigo em Inglês | MEDLINE | ID: mdl-31404666

RESUMO

Nonalcoholic fatty liver disease (NAFLD) is associated with increased liver- and cardiovascular disease (CVD)-related morbidity and mortality. In cross-sectional analyses, NAFLD clusters with several cardiometabolic traits including obesity,1,2 hypertension,3 diabetes,1 and dyslipidemia.3 However, liver fat is dynamic and changes over time. Aside from limited prior studies evaluating diet or exercise interventions, little is known about the association between changes in liver fat and the incidence of CVD risk factors. Additionally, previous studies often have limited follow-up; evaluate only select populations, such as individuals with obesity4,5 or diabetes6-8; and may not account for changes in weight or body mass index (BMI). The aim of the present study was to examine, in a longitudinal cohort, the natural history of liver fat change and the association with the incidence of multiple CVD risk factors.

15.
Radiology ; 293(1): 89-96, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31385755

RESUMO

Background Visual and histogram-based assessments of coronary CT angiography have limited accuracy in the identification of advanced lesions. Radiomics-based machine learning (ML) could provide a more accurate tool. Purpose To compare the diagnostic performance of radiomics-based ML with that of visual and histogram-based assessment of ex vivo coronary CT angiography cross sections to identify advanced atherosclerotic lesions defined with histologic examination. Materials and Methods In this prospective study, 21 coronary arteries from seven hearts obtained from male donors (mean age, 52.3 years ± 5.3) were imaged ex vivo with coronary CT angiography between February 23, 2009, and July 31, 2010. From 95 coronary plaques, 611 histologic cross sections were coregistered with coronary CT cross sections. Lesions were considered advanced if early fibroatheroma, late fibroatheroma, or thin-cap atheroma was present. CT cross sections were classified as showing homogeneous, heterogeneous, or napkin-ring sign plaques on the basis of visual assessment. The area of low attenuation (<30 HU) and the average Hounsfield unit were quantified. Radiomic parameters were extracted and used as inputs to ML algorithms. Eight radiomics-based ML models were trained on randomly selected cross sections (training set, 75% of the cross sections) to identify advanced lesions. Visual assessment, histogram-based assessment, and the best ML model were compared on the remaining 25% of the data (validation set) by using the area under the receiver operating characteristic curve (AUC) to identify advanced lesions. Results After excluding sections with no visible plaque (n = 134) and with heavy calcium (n = 32), 445 cross sections were analyzed. Of those 445 cross sections, 134 (30.1%) were advanced lesions. Visual assessment of the 445 cross sections indicated that 207 (46.5%) were homogeneous, 200 (44.9%) were heterogeneous, and 38 (8.5%) demonstrated the napkin-ring sign. A radiomics-based ML model incorporating 13 parameters outperformed visual assessment (AUC = 0.73 with 95% confidence interval [CI] of 0.63, 0.84 vs 0.65 with 95% CI of 0.56, 0.73, respectively; P = .04), area of low attenuation (AUC = 0.55 with 95% CI of 0.42, 0.68; P = .01), and average Hounsfield unit (AUC = 0.53 with 95% CI of 0.42, 0.65; P = .004) in the identification of advanced atheromatous lesions. Conclusion Radiomics-based machine learning analysis improves the discriminatory power of coronary CT angiography in the identification of advanced atherosclerotic lesions. Published under a CC BY 4.0 license.

16.
JAMA Netw Open ; 2(7): e197416, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31322692

RESUMO

Importance: Chest radiography is the most common diagnostic imaging test in medicine and may also provide information about longevity and prognosis. Objective: To develop and test a convolutional neural network (CNN) (named CXR-risk) to predict long-term mortality, including noncancer death, from chest radiographs. Design, Setting, and Participants: In this prognostic study, CXR-risk CNN development (n = 41 856) and testing (n = 10 464) used data from the screening radiography arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) (n = 52 320), a community cohort of asymptomatic nonsmokers and smokers (aged 55-74 years) enrolled at 10 US sites from November 8, 1993, through July 2, 2001. External testing used data from the screening radiography arm of the National Lung Screening Trial (NLST) (n = 5493), a community cohort of heavy smokers (aged 55-74 years) enrolled at 21 US sites from August 2002, through April 2004. Data analysis was performed from January 1, 2018, to May 23, 2019. Exposure: Deep learning CXR-risk score (very low, low, moderate, high, and very high) based on CNN analysis of the enrollment radiograph. Main Outcomes and Measures: All-cause mortality. Prognostic value was assessed in the context of radiologists' diagnostic findings (eg, lung nodule) and standard risk factors (eg, age, sex, and diabetes) and for cause-specific mortality. Results: Among 10 464 PLCO participants (mean [SD] age, 62.4 [5.4] years; 5405 men [51.6%]; median follow-up, 12.2 years [interquartile range, 10.5-12.9 years]) and 5493 NLST test participants (mean [SD] age, 61.7 [5.0] years; 3037 men [55.3%]; median follow-up, 6.3 years [interquartile range, 6.0-6.7 years]), there was a graded association between CXR-risk score and mortality. The very high-risk group had mortality of 53.0% (PLCO) and 33.9% (NLST), which was higher compared with the very low-risk group (PLCO: unadjusted hazard ratio [HR], 18.3 [95% CI, 14.5-23.2]; NLST: unadjusted HR, 15.2 [95% CI, 9.2-25.3]; both P < .001). This association was robust to adjustment for radiologists' findings and risk factors (PLCO: adjusted HR [aHR], 4.8 [95% CI, 3.6-6.4]; NLST: aHR, 7.0 [95% CI, 4.0-12.1]; both P < .001). Comparable results were seen for lung cancer death (PLCO: aHR, 11.1 [95% CI, 4.4-27.8]; NLST: aHR, 8.4 [95% CI, 2.5-28.0]; both P ≤ .001) and for noncancer cardiovascular death (PLCO: aHR, 3.6 [95% CI, 2.1-6.2]; NLST: aHR, 47.8 [95% CI, 6.1-374.9]; both P < .001) and respiratory death (PLCO: aHR, 27.5 [95% CI, 7.7-97.8]; NLST: aHR, 31.9 [95% CI, 3.9-263.5]; both P ≤ .001). Conclusions and Relevance: In this study, the deep learning CXR-risk score stratified the risk of long-term mortality based on a single chest radiograph. Individuals at high risk of mortality may benefit from prevention, screening, and lifestyle interventions.

17.
Artigo em Inglês | MEDLINE | ID: mdl-31303580

RESUMO

BACKGROUND: Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime. METHODS: Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model. RESULTS: Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively). CONCLUSION: Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.

18.
J Am Coll Cardiol ; 73(23): 2976-2987, 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31196455

RESUMO

BACKGROUND: Radiotherapy-associated cardiac toxicity studies in patients with locally advanced non-small cell lung cancer (NSCLC) have been limited by small sample size and nonvalidated cardiac endpoints. OBJECTIVES: The purpose of this analysis was to ascertain whether cardiac radiation dose is a predictor of major adverse cardiac events (MACE) and all-cause mortality (ACM). METHODS: This retrospective analysis included 748 consecutive locally advanced NSCLC patients treated with thoracic radiotherapy. Fine and Gray and Cox regressions were used to identify predictors for MACE and ACM, adjusting for lung cancer and cardiovascular prognostic factors, including pre-existing coronary heart disease (CHD). RESULTS: After a median follow-up of 20.4 months, 77 patients developed ≥1 MACE (2-year cumulative incidence, 5.8%; 95% confidence interval [CI]: 4.3% to 7.7%), and 533 died. Mean radiation dose delivered to the heart (mean heart dose) was associated with a significantly increased risk of MACE (adjusted hazard ratio [HR]: 1.05/Gy; 95% CI: 1.02 to 1.08/Gy; p < 0.001) and ACM (adjusted HR: 1.02/Gy; 95% CI: 1.00 to 1.03/Gy; p = 0.007). Mean heart dose (≥10 Gy vs. <10 Gy) was associated with a significantly increased risk of ACM in CHD-negative patients (178 vs. 118 deaths; HR: 1.34; 95% CI: 1.06 to 1.69; p = 0.014) with 2-year estimates of 52.2% (95% CI: 46.1% to 58.5%) versus 40.0% (95% CI: 33.5% to 47.4%); but not among CHD-positive patients (112 vs. 82 deaths; HR: 0.94; 95% CI: 0.70 to 1.25; p = 0.66) with 2-year estimates of 54.6% (95% CI: 46.8% to 62.7%) versus 50.8% (95% CI: 41.5% to 60.9%), respectively (p for interaction = 0.028). CONCLUSIONS: Despite the competing risk of cancer-specific death in locally advanced NSCLC patients, cardiac radiation dose exposure is a modifiable cardiac risk factor for MACE and ACM, supporting the need for early recognition and treatment of cardiovascular events and more stringent avoidance of high cardiac radiotherapy dose.

19.
Rofo ; 191(9): 817-826, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31250415

RESUMO

BACKGROUND: Rapid improvement of scanner and postprocessing technology as well as the introduction of minimally invasive procedures requiring preoperative imaging have led to the broad utilization of cardiac computed tomography (CT) beyond coronary CT angiography (CTA). METHOD: This review article presents an overview of recent literature on cardiac CT. The goal is to summarize the current guidelines on performing cardiac CT and to list established as well as emerging techniques with a special focus on extracoronary applications. RESULTS AND CONCLUSION: Most recent guidelines for the appropriate use of cardiac CT include the evaluation of coronary artery disease, cardiac morphology, intra- and extracardiac structures, and functional and structural assessment of the myocardium under certain conditions. Besides coronary CTA, novel applications such as the calculation of a CT-derived fractional flow reserve (CT-FFR), assessment of myocardial function and perfusion imaging, as well as pre-interventional planning in valvular heart disease or prior pulmonary vein ablation in atrial fibrillation are becoming increasingly important. Especially these extracoronary applications are of growing interest in the field of cardiac CT and are expected to be gradually implemented in the daily clinical routine. KEY POINTS: · Coronary artery imaging remains the main indication for cardiac CT. · Novel computational fluid dynamics allow the calculation of a CT-derived fractional flow reserve in patients with known or suspected coronary artery disease. · Cardiac CT delivers information on left ventricular volume as well as myocardial function and perfusion. · CT is the cardinal element for pre-interventional planning in transcatheter valve implantation and pulmonary vein isolation. CITATION FORMAT: · Taron J, Foldyna B, Eslami P et al. Cardiac Computed Tomography - More Than Coronary Arteries? A Clinical Update. Fortschr Röntgenstr 2019; 191: 817 - 826.

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