Impact of coronary artery calcification on all-cause mortality in individuals with and without hypertension

Coronary artery calcium and all-cause mortality in the Multicenter AIDS Cohort Study

BACKGROUND AND AIMS

People with HIV (PWH) have greater risk of subclinical cardiovascular disease than people without HIV, but few studies have evaluated risk for mortality based on coronary artery calcium (CAC) among PWH. We aimed to determine the association between CAC and all-cause mortality among men with (MWH) and without HIV (MWOH) and if it differs by HIV serostatus.

METHODS

We performed a longitudinal analysis in the Multicenter AIDS Cohort Study. We included men who underwent non-contrast cardiac computed tomography. Cox regression analyses were used to examine the associations between CAC presence (Agatston score>0), and with extent of CAC (log (CAC+1)), and subsequent mortality to calculate adjusted hazard ratios [aHR]. We evaluated differences by HIV serostatus using multiplicative CAC × HIV interaction terms.

RESULTS

Among 1344 men (mean age 50 years, CAC prevalence 45.7 %, 821 [61.1 %] MWH), we observed 108 deaths (13.2 %) among MWH and 43 deaths (8.2 %) among MWOH during follow-up (median:13.4 years). CAC presence was positively associated with mortality among all participants (aHR:1.46, 95 %CI:1.02-2.10, p = 0.04) and MWH (aHR:1.62, 1.05-2.49, p = 0.03). Among MWOH, we found no significant association (aHR:1.28, 0.63-2.58, p = 0.50). The extent of CAC was associated with mortality among all participants (aHR:1.37 per SD, 1.15-1.63, p < 0.001) and MWH (aHR:1.41,1.14-1.74, p = 0.002). Among MWOH, we found no significant association (aHR:1.35, 0.98-1.85, p = 0.07). There were no significant interactions by HIV serostatus for mortality for either the presence (p = 0.35) or extent of CAC (p = 0.51).

CONCLUSIONS

CAC was positively associated with mortality in a large cohort of MWH, and the overall cohort including MWH and MWOH.

Updates on CAD risk assessment: using the coronary artery calcium score in combination with traditional risk factors

BACKGROUND

Coronary artery disease (CAD) is the third leading cause of death worldwide, so prevention and early diagnosis play important roles to reduce mortality and morbidity. Traditional risk-score assessments were used to find the at-risk patients in order to prevent or early treatment of CAD. Adding imaging data to traditional risk-score systems will able us to find these patients more confidently and reduce the probable mismanagements.

MAIN TEXT

Measuring the vascular calcification by coronary artery calcium (CAC) score can prepare valuable data for this purpose. Using CAC became more popular in recent years. The most applicable method to evaluate CAC is Agatston scoring using computed tomography (CT) scanning. Patients are classified into several subgroups: no evidence of CAD (score 0), mild CAD (score 1-10), minimal CAD (score 11-100), moderate CAD (score 101-400), and severe CAD (score > 400) and higher than1000 as the extreme risk of CVD events.

CONCLUSIONS

CAC assessment was recommended in the patients older than 40 years old with CAD risk factors, the ones with stable angina, borderline-to-intermediate-risk group, etc. According to the results of the CAC the patients may be candidate for further evaluation for needing revascularization, medical treatment, or routine follow-up. Adding artificial intelligence (AI) to CAC will prepare more data and can increase the reliability of our approach to the patients promising a bright future to improve this technology.

Prognostic Value of Coronary Calcium Score in Asymptomatic Individuals: A Systematic Review

Despite updated guidelines and technological developments that allow for an accurate diagnosis, many asymptomatic individuals have a high risk of developing CAD or cardiac events. The CAC score can estimate a correct risk level for these subjects, which is clinically significant for adequate management of risk factors and obtaining personalized preventive therapy. This systematic review aims to assess the prognostic value of CAC score in asymptomatic individuals. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a systematic literature search was performed to identify original articles since 2010 that evaluated the prognostic value of CAC score in asymptomatic individuals. The quality of the included studies was assessed by the QUIPS tool. A total of 45 articles were selected. Many of these (25 studies) evaluated the prognostic value of CAC score in asymptomatic subjects. In comparison, others (20 studies) evaluated the association of CAC score with other clinical parameters and imaging modalities or the comparison with computed tomography coronary angiography (CTCA). Our findings showed that the CAC score provides valuable prognostic information for predicting CAD risk in asymptomatic individuals.

Associations of the Mediterranean-Style Dietary Pattern Score with Coronary Artery Calcification and Pericardial Adiposity in a Sample of US Adults

Several studies have identified improvements in the risks of cardiovascular disease in adults following a Mediterranean dietary pattern. However, data are scarce on its association with coronary artery calcification (CAC) and pericardial adiposity (PAT) in US adults with and without diabetes. To address this gap, we conducted a case-control study using baseline data from the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study [n = 1255; Type 1 Diabetes (T1D): n = 563; non-Diabetes Mellitus (non-DM): n = 692]. Participants completed a validated food frequency questionnaire, fasting (12 h overnight fast) biochemical analyses, and a physical examination including anthropometric measures. CAC and PAT were measured using electron beam-computed tomography. Logistic regression models were used to examine the associations of the Mediterranean-Style Dietary Pattern Score (MSDPS) with CAC (presence or absence), and linear regression models were applied to PAT analyses. In all of the adjusted models, no significant associations with CAC were found. For PAT, an increasing MSDPS was consistently associated with its lower volume in models adjusted for age, sex, diabetes status, total calories, and body mass index (all p < 0.05). The association between MSDPS and PAT was attenuated after adjusting for serum lipids and physical activity. In conclusion, the baseline data from the CACTI study show that a greater adherence to MSDPS is associated with a lower PAT volume and provide evidence that the Mediterranean dietary pattern is associated with lower cardiovascular risk markers.

Hypertension-mediated organ damage in masked hypertension

OBJECTIVES

Masked hypertension - a blood pressure (BP) phenotype characterized by a clinic BP in the normal range but elevated BP outside the office - is associated with early hypertension-mediated organ damage. This study examined early target organ manifestations of masked hypertension diagnosed by home (HBPM) and ambulatory (ABPM) BP monitoring.

METHODS

Left ventricular (LV) structure and diastolic function measured by echocardiography, microalbuminuria, and coronary artery calcification were evaluated in 420 patients with high clinic BP (SBP 120-150 mmHg or DBP 80-95 mmHg). Evidence of hypertension-mediated organ damage was compared in patients with sustained normotension, masked hypertension, and sustained hypertension based on measurements by HBPM, daytime ABPM, and 24-h ABPM.

RESULTS

The 420 participants averaged 48 (12) [mean (SD)] years of age; the average clinic BP was 130 (13)/81 (8) mmHg. In individuals with masked hypertension diagnosed by HBPM, indexed LV mass, relative wall thickness, and e' and E/e' (indices of LV relaxation), were generally intermediate between values observed in normotensives and sustained hypertensive patients, and were significantly greater in masked hypertension than normotensives. Similar trends were observed when masked hypertension was diagnosed by ABPM but a diagnosis of masked hypertension was not as reliably associated with LV remodeling or impaired LV relaxation in comparison to normotensives. There were trends towards greater likelihoods of detectable urinary microalbumin and coronary calcification in masked hypertension than in normotensives.

CONCLUSION

These results support previous studies demonstrating early hypertension-mediated organ damage in patients with masked hypertension, and suggest that HBPM may be superior to ABPM in identifying patients with masked hypertension who have early LV remodeling and diastolic LV dysfunction.

Associations between untraditional risk factors, pneumonia/lung cancer, and hospital fatality among hypertensive men in Guangzhou downtown

Mortality of primary hypertension is high worldwide. Whether untraditional factors exist in modern life and affect the mortality is not well studied. The aim of the study was to evaluate the risk factors for fatality rate of hypertensive men in downtown area. A cross-sectional study was performed on hypertensive men, who were hospitalized into our hospital and lived in eligible urban areas. The characteristics of the patients and factors for the fatality were analyzed and of the risks or the contributors on the status were investigated. 14354 patients were identified. Mean age was 68.9 ± 12.4 year old (y) and dead ones was 75.9 ± 9.5 y. The overall hospitalized fatality was 5.9%, which was increased with age: fatality with 0.7%, 2.2%, 2.9%, 7.1%, 11.1% and 16.6% was for age group ≦ 49 y, 50-59 y, 60-69 y, 70-79 y, 80-89 y and ≧ 90 y respectively. The increased fatality was significantly positively correlated with the incidence of pneumonia, P < 0.05, r = 0.99. Pneumonia was prone to involve in men with older age and severer organ damage by hypertension. Similar to traditional risks such as coronary heart disease and stroke, pneumonia and lung cancer were also significantly associated with the fatality. Odds ratio (95% CI) for pneumonia and lung cancer were 6.18 (4.35-8.78) and 1.55 (1.14-2.11). The study provides evidence that pneumonia and lung cancer are highly associated with fatality of hypertensive men in downtown area, indicating that in order to reduce the fatality of hypertension, these lung diseases should be prevented and treated intensively in modern life.

Novel assessments of systemic calcification propensity

PURPOSE OF REVIEW

Blood is a biological fluid, which controls the precipitation of calcium and phosphate and transports mineral debris. This review presents and discusses the current concepts and novel assessment methods of systemic calcification propensity in blood.

RECENT FINDINGS

Calcium and phosphate combine with calcification-inhibiting proteins, mainly fetuin-A, to form amorphous calcium phosphate-containing primary calciprotein particles (CPPs). These nanosized mineral-protein clusters undergo spontaneous transformation to secondary CPP, which contain crystalline calcium phosphate. Two recently developed methods assess complementary aspects of the calcification propensity of serum. The CPP-fetuin-A method determines the amount of sedimentable fetuin-A, whereas the T50-Test determines the transformation time point T50 from amorphous to crystalline CPPs in artificially supersaturated serum.Clinical studies in renal patients have already demonstrated close associations of the CPP-fetuin-A method with all-cause mortality, severity of coronary calcification and aortic stiffness, and of the T50-Test with cardiovascular and all-cause mortality, renal graft failure and aortic stiffening.

SUMMARY

Systemic calcification propensity can be assessed by two novel methods providing complementary information about the status and performance of the humoral calcification-regulating system in serum. These tests may help guide better patient care in the future with the use of more individualized therapies.

Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography

This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.

Impact of pneumonia and lung cancer on mortality of women with hypertension

Essential hypertension is one of the most severe women's health problems. Modern life brings more chances of pulmonary diseases to human. The purpose of the study is to investigate weather pneumonia and lung cancer are associated with the mortality of women with hypertension in different age. A cross-sectional retrospective study was conducted in women with hypertension, who were admitted into our hospital in 2004-2013. 14219 women were enrolled and 68.8 ± 12.2 year old (y). Isolated hypertension was 14.7%. The age of death was 78.1 ± 9.8 y. The mortality was 4.4% for average and 0.2%, 1.1%, 2.4%, 4.8%, 10.4% and 15.8% in group age ≦49, 50-59, 60-69, 70-79, 80-89 and ≧90 y separately. This mortality increased with age was positively significantly correlated with the increased incidences of pneumonia (P < 0.05, r = 0.77). Pneumonia was a significant risk associated with the mortality in age 55-89 y (OR = 6.4-22.5; 95% CI = 3.06-51.12). While, lung cancer was the significant risk in 70-79 y. These observations indicate that pneumonia and lung cancer are significant risk factors associated with the mortality of certain age women with hypertension, and bring an alert that pneumonia and lung cancer should be prevented and treated intensively in modern life in order to reduce the mortality.

Characteristics of coronary arterial lesions in patients with coronary heart disease and hypertension

Objective

The aim of this study was to investigate the correlations between risk factors such as hypertension and the complex degrees of coronary arterial lesions (CAL).

Methods

We selected 462 patients with coronary heart disease (CHD) with confirmed the stenosis (≥50 %) in at least one major coronary artery on coronary angiography and divided them into the “CHD with hypertension” group (CHD-HT, n = 306) and the CHD group (n = 156). The characteristics of CAL and the occurrence of 2-year postoperative major adverse cardiac cerebrovascular events (MACCE) in the two groups were observed.

Results

The mean SYNTAX scores (SS) was higher in the CHD-HT group than in the CHD group (P < 0.05). The proportions of complex, calcified, and diffused long lesions in the PCI patients’ target vascular lesions, as well as the total MACCE incidence, were significantly higher in the CHD-HT group than in the CHD group (P < 0.05). Logistic multifactor regression analysis showed that age, male sex, hypertension, diabetes, hyperlipidemia, and previous history of myocardial infarction were positively correlated with the SS (P < 0.05).

Conclusions

The patients with CHD-HT exhibited complicated and diffused CAL, and arterial hypertension can be considered as a risk factor for the complexity of coronary lesions in patients with ischemic heart disease.

Low serum testosterone level was associated with extensive coronary artery calcification in elderly male patients with stable coronary artery disease

BACKGROUND

Coronary artery calcification (CAC) is a pandemic condition in elderly patients with coronary artery disease (CAD) and associated with a worse prognosis. Although available data have shown an association between testosterone levels in men and CAD, the association between testosterone and CAC in elderly male patients with CAD remains unknown.

METHODS

A total of 211 consecutive male patients (age ≥ 65 years) who underwent first multidetector computed tomography and following angiography were enrolled from our institution between March 2009 and September 2014. CAD was angiographically documented as significant stenoses (reduction ≥ 50% of the lumen diameter) on any major coronary vessel. The standard Agatston calcium score was calculated. The relationship of serum testosterone level with the CAC score measured by multidetector computed tomography in elderly male patients with stable CAD was evaluated. For data analyses, the CAC score was divided into four categories: ≤ 10, 11-99, 100-399, and ≥ 400, corresponding to minimal, moderate, increased, and extensive calcification.

RESULTS

Patients with higher CAC scores had significantly lower testosterone levels than patients with lower CAC scores (P = 0.048). In logistic regression analysis, testosterone level remained an independent predictor of extensive CAC (odds ratio 0.997, 95% confidence interval 0.994-0.999, P = 0.043).

CONCLUSION

Our findings indicate an inverse association between testosterone level and the susceptibility to extensive CAC in elderly men with stable CAD.

Fibroblast growth factor signaling in the vasculature

Despite their discovery as angiogenic factors and mitogens for endothelial cells more than 30 years ago, much remains to be determined about the role of fibroblast growth factors (FGFs) and their receptors in vascular development, homeostasis, and disease. In vitro studies show that members of the FGF family stimulate growth, migration, and sprouting of endothelial cells, and growth, migration, and phenotypic plasticity of vascular smooth muscle cells. Recent studies have revealed important roles for FGFs and their receptors in the regulation of endothelial cell sprouting and vascular homeostasis in vivo. Furthermore, recent work has revealed roles for FGFs in atherosclerosis, vascular calcification, and vascular dysfunction. The large number of FGFs and their receptors expressed in endothelial and vascular smooth muscle cells complicates these studies. In this review, we summarize recent studies in which new and unanticipated roles for FGFs and their receptors in the vasculature have been revealed.

The Addition of Vascular Calcification Scores to Traditional Risk Factors Improves Cardiovascular Risk Assessment in Patients with Chronic Kidney Disease

Background

Although a variety of non-invasive methods for measuring cardiovascular (CV) risk (such as carotid intima media thickness, pulse wave velocity (PWV), coronary artery and aortic calcification scores (measured either by CT scan or X-ray) and the ankle brachial index (ABI)) have been evaluated separately in chronic kidney disease (CKD) cohorts, few studies have evaluated these methods simultaneously. Here, we looked at whether the addition of non-invasive methods to traditional risk factors (TRFs) improves prediction of the CV risk in patients at different CKD stages.

Methods

We performed a prospective, observational study of the relationship between the outputs of non-invasive measurement methods on one hand and mortality and CV outcomes in 143 patients at different CKD stages on the other. During the follow-up period, 44 patients died and 30 CV events were recorded. We used Cox models to calculate the relative risk for outcomes. To assess the putative clinical value of each method, we also determined the categorical net reclassification improvement (NRI) and the integrated discrimination improvement.

Results

Vascular calcification, PWV and ABI predicted all-cause mortality and CV events in univariate analyses. However, after adjustment for TRFs, only aortic and coronary artery calcification scores were found to be significant, independent variables. Moreover, the addition of coronary artery calcification scores to TRFs improved the specificity of prediction by 20%.

Conclusion

The addition of vascular calcification scores (especially the coronary artery calcification score) to TRFs appears to improve CV risk assessment in a CKD population.

Mitral Annular and Coronary Artery Calcification Are Associated with Mortality in HIV-Infected Individuals

BACKGROUND

HIV infection increases cardiovascular risk. Coronary artery calcification (CAC) and mitral annular calcification (MAC) identify patients at risk for cardiovascular disease (CVD). The purpose of this study was to examine the association between MAC, CAC and mortality in HIV-infected individuals.

METHODS AND RESULTS

We studied 152 asymptomatic HIV-infected individuals with transthoracic echocardiography (TTE) and computed tomography (CT). MAC was identified on TTE using standardized criteria. Presence of CAC, CAC score and CAC percentiles were determined using the modified Agatston criteria. Mortality data was obtained from the Social Security and National Death Indices (SSDI/NDI). The median age was 49 years; 87% were male. The median duration of HIV was 16 years; 84% took antiretroviral therapy; 64% had an undetectable viral load. CVD risk factors included hypertension (35%), smoking (62%) and dyslipidemia (35%). Twenty-five percent of individuals had MAC, and 42% had CAC. Over a median follow-up of 8 years, 11 subjects died. Subjects with CAC had significantly higher mortality compared to those with MAC only or no MAC. The Harrell's C-statistic of CAC was 0.66 and increased to 0.75 when MAC was added (p = 0.05). MAC, prior CVD, age and HIV viral load were independently associated with higher age- and gender-adjusted CAC percentiles in an adjusted model (p < 0.05 for all).

CONCLUSION

In HIV patients, the presence of MAC, traditional risk factors and HIV viral load were independently associated with CAC. Presence of CAC and MAC may be useful in identifying HIV-infected individuals at higher risk for death.

Lipoprotein metabolism in familial hypercholesterolemia: Serial assessment using a one-step ultracentrifugation method

Objectives

It is well known that familial hypercholesterolemia (FH) is a common inherited disorder that can markedly elevate the level of plasma LDL cholesterol. However, little data exists regarding the clinical impact of the plasma triglyceride (TG)-rich lipoprotein fraction, including VLDL and IDL, in FH. Thus, we assessed the hypothesis that the mutations in the LDL receptor modulate lipoprotein metabolism other than the LDL fraction.

Design and methods

We investigated plasma lipoprotein with a one-step ultracentrifugation method for 146 controls (mean age=61.4±17.1 yr, mean LDL cholesterol=92.7±61.2 mg/dl), 213 heterozygous mutation-determined FH subjects (mean age=46.0±18.0 yr, mean LDL cholesterol=225.1±61.2 mg/dl), and 16 homozygous/compound heterozygous mutation-determined FH subjects (mean age=26.9±17.1 yr, mean LDL cholesterol=428.6±86.1 mg/dl). In addition, we evaluated cholesterol/TG ratio in each lipoprotein fraction separated by ultracentrifugation.

Results

In addition to total cholesterol and LDL cholesterol levels, VLDL cholesterol (19.5±10.4, 25.2±19.3, 29.5±21.4 mg/dl, respectively) and IDL cholesterol (8.3±3.7, 16.8±11.5, 40.0±37.3 mg/dl, respectively) exhibited a tri-model distribution according to their status in LDL receptor mutation(s). Moreover, the ratios of cholesterol/TG of each lipoprotein fraction increased significantly in heterozygous FH and homozygous/compound heterozygous FH groups, compared with that of controls, suggesting that the abnormality in LDL receptor modulates the quality as well as the quantity of each lipoprotein fraction.

Conclusions

Our results indicate that cholesterol in TG-rich lipoproteins, including VLDL and IDL, are significantly higher in FH subjects, revealing a tri-modal distribution according to the number of LDL receptor mutations.

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TG-rich lipoproteins are elevated in FH subjects.

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Such lipoproteins reveal tri-modal distribution according to the number of mutations.

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One-step ultracentrifugation is useful to assess lipoprotein abnormalities in FH.

Long-term prognosis for individuals with hypertension undergoing coronary artery calcium scoring

BACKGROUND

To examine the performance of coronary artery calcification (CAC) for stratifying long-term risk of death in asymptomatic hypertensive patients.

METHODS AND RESULTS

8905 consecutive asymptomatic individuals without cardiovascular disease or diabetes who underwent CAC testing (mean age 53.3 ± 10.5, 59.3% male) were followed for a mean of 14 years and categorized on the background of hypertension as well as age above or below 60 years (in accordance with the 2014 Guidelines from the Joint National Committee 8). The prevalence and severity of CAC were higher for those with hypertension versus without hypertension (P<0.001), and the extent increased proportionally with advancing age (P<0.001). Following adjustment, the presence of CAC in hypertensive with respect to normotensive, was associated with worse prognosis for individuals above the age of 60 years (HR 7.74 [95% CI: 5.15-11.63] vs. HR 4.83 [95% CI: 3.18-7.33]) than individuals below the age of 60 (HR 3.18 [95% CI: 2.42-4.19] vs. HR 2.14 [95% CI: 1.61-2.85]), respectively. A zero CAC score in hypertensive over the age of 60 years was associated with a lower but persisting risk of mortality for (HR 2.48 [95% CI: 1.50-4.08]) that was attenuated non-significant for those below the age of 60 years (P=0.09). In a "low risk" hypertensive population, the presence any CAC was associated with an almost five-fold (HR 4.68 [95% CI: 2.22-9.87]) increased risk of death.

CONCLUSION

The presence and extent of CAC effectively may help the clinicians to further discriminate the long-term risk of mortality among asymptomatic hypertensive individuals, beyond conventional cardiovascular risk and current guidelines.

Apolipoprotein L1 gene variants associate with prevalent kidney but not prevalent cardiovascular disease in the Systolic Blood Pressure Intervention Trial

Apolipoprotein L1 gene (APOL1) G1 and G2 coding variants are strongly associated with chronic kidney disease (CKD) in African Americans (AAs). Here APOL1 association was tested with baseline estimated glomerular filtration rate (eGFR), urine albumin:creatinine ratio (UACR), and prevalent cardiovascular disease (CVD) in 2571 AAs from the Systolic Blood Pressure Intervention Trial (SPRINT), a trial assessing effects of systolic blood pressure reduction on renal and CVD outcomes. Logistic regression models that adjusted for potentially important confounders tested for association between APOL1 risk variants and baseline clinical CVD (myocardial infarction, coronary, or carotid artery revascularization) and CKD (eGFR under 60 ml/min per 1.73 m(2) and/or UACR over 30 mg/g). AA SPRINT participants were 45.3% female with a mean (median) age of 64.3 (63) years, mean arterial pressure 100.7 (100) mm Hg, eGFR 76.3 (77.1) ml/min per 1.73 m(2), and UACR 49.9 (9.2) mg/g, and 8.2% had clinical CVD. APOL1 (recessive inheritance) was positively associated with CKD (odds ratio 1.37, 95% confidence interval 1.08-1.73) and log UACR estimated slope (β) 0.33) and negatively associated with eGFR (β -3.58), all significant. APOL1 risk variants were not significantly associated with prevalent CVD (1.02, 0.82-1.27). Thus, SPRINT data show that APOL1 risk variants are associated with mild CKD but not with prevalent CVD in AAs with a UACR under 1000 mg/g.

Association of fat density with subclinical atherosclerosis

Background

Ectopic fat density is associated with cardiovascular disease (CVD) risk factors above and beyond fat volume. Volumetric measures of ectopic fat have been associated with CVD risk factors and subclinical atherosclerosis. The aim of this study was to investigate the association between fat density and subclinical atherosclerosis.

Methods and Results

Participants were drawn from the Multi‐Detector Computed Tomography (MDCT) substudy of the Framingham Heart Study (n=3079; mean age, 50.1 years; 49.2% women). Fat density was indirectly estimated by computed tomography attenuation (Hounsfield Units [HU]) on abdominal scan slices. Visceral fat (VAT), subcutaneous fat (SAT), and pericardial fat HU and volumes were quantified using standard protocols; coronary and abdominal aortic calcium (CAC and AAC, respectively) were measured radiographically. Multivariable‐adjusted logistic regression models were used to evaluate the association between adipose tissue HU and the presence of CAC and AAC. Overall, 17.1% of the participants had elevated CAC (Agatston score [AS]>100), and 23.3% had elevated AAC (AS>age‐/sex‐specific cutoffs). Per 5‐unit decrement in VAT HU, the odds ratio (OR) for elevated CAC was 0.76 (95% confidence interval [CI], 0.65 to 0.89; P=0.0005), even after adjustment for body mass index or VAT volume. Results were similar for SAT HU. With decreasing VAT HU, we also observed an OR of 0.79 (95% CI, 0.67 to 0.92; P=0.004) for elevated AAC after multivariable adjustment. We found no significant associations between SAT HU and AAC. There was no significant association between pericardial fat HU and either CAC or AAC.

Conclusions

Lower VAT and SAT HU, indirect estimates of fat quality, are associated with a lower risk of subclinical atherosclerosis.

The relationship between serum hypoxia-inducible factor 1α and coronary artery calcification in asymptomatic type 2 diabetic patients

Background

Hypoxia-inducible factor 1 (HIF-1), a master regulator of oxygen homeostasis, is a heterodimer consisting of HIF-1α and HIF-1β subunits, and is implicated in calcification of cartilage and vasculature. The goal of this study was to determine the relationship between serum HIF-1α with coronary artery calcification (CAC) in patients with type 2 diabetes.

Methods

The subjects were 405 (262 males, 143 females, age 51.3 ± 6.4 years) asymptomatic patients with type 2 diabetes mellitus. Serum HIF-1α and interleukin-6 (IL-6) levels were measured by ELISA. CAC scores were assessed by a 320-slice CT scanner. The subjects were divided into 4 quartiles depending on serum HIF-1α levels.

Results

Average serum HIF-1α was 184.4 ± 66.7 pg/ml. Among patients with higher CAC scores, HIF-1α levels were also significantly increased (p <0.001). HIF-1α levels positively correlated with CRP, IL-6, UKPDS risk score, HbA1c, FBG, and CACS, but did not correlate with diabetes duration, age, and LDL. According to the multivariate analysis, HIF-1α levels significantly and independently predict the presence of CAC. ROC curve analysis showed that the serum HIF-1α level can predict the extent of CAC, but the specificity was lower than the traditional risk factors UKPDS and HbA1c.

Conclusion

As a marker of hypoxia, serum HIF-1α level may be an independent risk factor for the presence of CAC. These findings indicate that elevated serum HIF-1α may be involved in vascular calcification in patients with type 2 diabetes mellitus.

The predictive value of arterial and valvular calcification for mortality and cardiovascular events

A review of the predictive ability of arterial and valvular calcification has shown an additive effect of calcification in more than 1 location in predicting mortality and coronary heart disease, with mitral annual calcification being a particularly strong predictor. In individual arteries and valves there is a clear association between calcification presence, extent and progression and future cardiovascular events and mortality in asymptomatic, symptomatic and high risk patients, although adjustment for calcification in other arterial beds generally renders associations non-significant. Furthermore, in acute coronary syndrome, culprit plaque is normally not calcified. This would tend to reduce the validity of calcification as a predictor and suggest that the association with cardiovascular events and mortality may not be causal. The association with stroke is less clear; carotid and intracranial artery calcification show little predictive ability, with symptomatic plaques tending to be uncalcified.

Vascular calcification

PURPOSE OF REVIEW

This review presents new evidence related to molecular mechanisms involved in the process of cardiovascular calcification, as well as to discuss new biomarkers and novel therapeutic strategies related to vascular calcification in chronic kidney disease (CKD) patients.

RECENT FINDINGS

microRNAs have emerged as potential players in the genesis of osteo-chondrogenic transformation, depending on the stimulus and the localization of vascular calcification. The disturbances of the fibroblast growth factor-23 (FGF23)/alpha-Klotho (Klotho) axis observed in CKD appear to play an important role in CKD-associated vascular calcification. Numerous studies have identified circulating biomarkers potentially responsible for vascular calcification and have evaluated their link with this process. The respective role of these biomarkers is not yet elucidated. Beyond phosphate binders, modulation of calcium-sensing receptor and vitamin K supplementation come into sight as new potential strategies to prevent cardiovascular calcification.

CONCLUSION

A better understanding of the molecular mechanisms which are responsible for cardiovascular calcification have led to a better detection and more adequate follow-up of this pathologic process, as well as the identification of novel therapeutic targets. Whether these new insights will lead to improved care and better survival of CKD patients with cardiovascular calcification remains to be demonstrated.

Famine in childhood and postmenopausal coronary artery calcification: a cohort study

OBJECTIVE

To assess the effects of famine exposure during childhood on coronary calcium deposition and, secondarily, on cardiac valve and aortic calcifications.

DESIGN

Retrospective cohort.

SETTING

Community.

PATIENTS

286 postmenopausal women with individual measurements of famine exposure during childhood in the Netherlands during World War II.

INTERVENTION/EXPOSURE

Famine exposure during childhood.

MAIN OUTCOME MEASURES

Coronary artery calcifications measured by CT scan and scored using the Agatston method; calcifications of the aorta and cardiac valves (mitral and/or aortic) measured semiquantitatively. Logistic regression was used for coronary Agatston score of >100 or ≤100, valve or aortic calcifications as the dependent variable and an indicator for famine exposure as the independent variable. These models were also used for confounder adjustment and stratification based on age groups of 0-9 and 10-17 years.

RESULTS

In the overall analysis, no statistically significant association was found between severe famine exposure in childhood and a high coronary calcium score (OR 1.80, 95% CI 0.87 to 3.78). However, when looking at specific risk periods, severe famine exposure during adolescence was related to a higher risk for a high coronary calcium score than non-exposure to famine, both in crude (OR 3.47, 95% CI 1.00 to 12.07) and adjusted analyses (OR 4.62, 95% CI 1.16 to 18.43). No statistically significant association was found between childhood famine exposure and valve or aortic calcification (OR 1.66, 95% CI 0.69 to 4.10).

CONCLUSIONS

Famine exposure in childhood, especially during adolescence, seems to be associated with a higher risk of coronary artery calcification in late adulthood. However, the association between childhood famine exposure and cardiac valve/aortic calcification is less clear.