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Lu KC, Hung KC, Liao MT, Shih LJ, Chao CT. Vascular Calcification Heterogeneity from Bench to Bedside: Implications for Manifestations, Pathogenesis, and Treatment Considerations. Aging Dis 2024:AD.2024.0289. [PMID: 38739930 DOI: 10.14336/ad.2024.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/20/2024] [Indexed: 05/16/2024] Open
Abstract
Vascular calcification (VC) is the ectopic deposition of calcium-containing apatite within vascular walls, exhibiting a high prevalence in older adults, and those with diabetes or chronic kidney disease. VC is a subclinical cardiovascular risk trait that increases mortality and functional deterioration. However, effective treatments for VC remain largely unavailable despite multiple attempts. Part of this therapeutic nihilism results from the failure to appreciate the diversity of VC as a pathological complex, with unforeseeable variations in morphology, risk associates, and anatomical and molecular pathogenesis, affecting clinical management strategies. VC should not be considered a homogeneous pathology because accumulating evidence refutes its conceptual and content uniformity. Here, we summarize the pathophysiological sources of VC heterogeneity from the intersecting pathways and networks of cellular, subcellular, and molecular crosstalk. Part of these pathological connections are synergistic or mutually antagonistic. We then introduce clinical implications related to the VC heterogeneity concept. Even within the same individual, a specific artery may exhibit the strongest tendency for calcification compared with other arteries. The prognostic value of VC may only be detectable with a detailed characterization of calcification morphology and features. VC heterogeneity is also evident, as VC risk factors vary between different arterial segments and layers. Therefore, diagnostic and screening strategies for VC may be improved based on VC heterogeneity, including the use of radiomics. Finally, pursuing a homogeneous treatment strategy is discouraged and we suggest a more rational approach by diversifying the treatment spectrum. This may greatly benefit subsequent efforts to identify effective VC therapeutics.
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Affiliation(s)
- Kuo-Cheng Lu
- Division of Nephrology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Kuo-Chin Hung
- Division of Nephrology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- Department of Pharmacy, Tajen University, Pingtung, Taiwan
| | - Min-Tser Liao
- Department of Pediatrics, Taoyuan Armed Forces General Hospital, Hsinchu Branch, Hsinchu, Taiwan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Li-Jane Shih
- Department of Medical Laboratory, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ter Chao
- Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
- Center of Faculty Development, National Taiwan University College of Medicine, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Selvam PV, Grandhi GR, Leucker TM, Arbab-Zadeh A, Gulati M, Blumenthal RS, Whelton SP. Recent advances in cardiovascular risk assessment: The added value of non-invasive anatomic imaging. J Cardiovasc Comput Tomogr 2024; 18:113-119. [PMID: 38326189 DOI: 10.1016/j.jcct.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
Abstract
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.
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Affiliation(s)
- Pooja V Selvam
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Gowtham R Grandhi
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thorsten M Leucker
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Armin Arbab-Zadeh
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seamus P Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Garg PK, Bhatia HS, Allen TS, Grainger T, Pouncey AL, Dichek D, Virmani R, Golledge J, Allison MA, Powell JT. Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies. Arterioscler Thromb Vasc Biol 2024; 44:24-47. [PMID: 38150519 PMCID: PMC10753091 DOI: 10.1161/atvbaha.123.320138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
BACKGROUND One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease. METHODS We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries. RESULTS In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures. CONCLUSIONS The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressures seems to be a valid indicator of the presence of subclinical atherosclerosis and may be considered for use in biomarker, Mendelian randomization and similar studies.
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Affiliation(s)
- Parveen K Garg
- Division of Cardiology, University of Southern California, Keck School of Medicine, Los Angeles (G.P.)
| | - Harpreet S Bhatia
- Division of Cardiovascular Medicine, University of California San Diego (B.H., A.T., A.M.A.)
| | - Tara S Allen
- Division of Cardiovascular Medicine, University of California San Diego (B.H., A.T., A.M.A.)
| | - Tabitha Grainger
- Department of Surgery & Cancer, Imperial College London (G.T., P.A.-L., P.J.T.)
| | - Anna L Pouncey
- Department of Surgery & Cancer, Imperial College London (G.T., P.A.-L., P.J.T.)
| | - David Dichek
- Division of Cardiology, Department of Medicine, University of Washington, Seattle (D.D.)
| | | | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Australia (G.J.)
| | - Matthew A Allison
- Division of Cardiovascular Medicine, University of California San Diego (B.H., A.T., A.M.A.)
| | - Janet T Powell
- Department of Surgery & Cancer, Imperial College London (G.T., P.A.-L., P.J.T.)
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van der Werf NR, Dobrolinska MM, Greuter MJW, Willemink MJ, Fleischmann D, Bos D, Slart RHJA, Budoff M, Leiner T. Vendor Independent Coronary Calcium Scoring Improves Individual Risk Assessment: MESA (Multi-Ethnic Study of Atherosclerosis). JACC Cardiovasc Imaging 2023; 16:1552-1564. [PMID: 37318394 DOI: 10.1016/j.jcmg.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Substantial variation in Agatston scores (AS) acquired with different computed tomography (CT) scanners may influence patient risk classification. OBJECTIVES This study sought to develop a calibration tool for state-of-the-art CT systems resulting in vendor-neutral AS (vnAS), and to assess the impact of vnAS on coronary heart disease (CHD) event prediction. METHODS The vnAS calibration tool was derived by imaging 2 anthropomorphic calcium containing phantoms on 7 different CT and 1 electron beam tomography system, which was used as the reference system. The effect of vnAS on CHD event prediction was analyzed with data from 3,181 participants from MESA (Multi-Ethnic Study on Atherosclerosis). Chi-square analysis was used to compare CHD event rates between low (vnAS <100) and high calcium groups (vnAS ≥100). Multivariable Cox proportional hazard regression models were used to assess the incremental value of vnAS. RESULTS For all CT systems, a strong correlation with electron beam tomography-AS was found (R2 >0.932). Of the MESA participants originally in the low calcium group (n = 781), 85 (11%) participants were reclassified to a higher risk category based on the recalculated vnAS. For reclassified participants, the CHD event rate of 15% was significantly higher compared with participants in the low calcium group (7%; P = 0.008) with a CHD HR of 3.39 (95% CI: 1.82-6.35; P = 0.001). CONCLUSIONS The authors developed a calibration tool that enables calculation of a vnAS. MESA participants who were reclassified to a higher calcium category by means of the vnAS experienced more CHD events, indicating improved risk categorization.
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Affiliation(s)
- Niels R van der Werf
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Magdalena M Dobrolinska
- Department of Radiology, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands; Department Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands
| | - Marcel J W Greuter
- Department of Radiology, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands; Department Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Riemer H J A Slart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands; Department Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, the Netherlands
| | - Matthew Budoff
- Los Angeles Biomedical Research Institute, Torrance, California, USA
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.
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Ding H, Zhu J, Tian Y, Xu L, Song L, Shi Y, Mu D, Chen R, Liu H, Liu B. Relationship between the triglyceride-glucose index and coronary artery calcification in asymptomatic, non-diabetic patients undergoing maintenance hemodialysis. Ren Fail 2023; 45:2200849. [PMID: 37133817 PMCID: PMC10158539 DOI: 10.1080/0886022x.2023.2200849] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVE Coronary artery calcification (CAC) is positively and independently associated with cardiovascular disease (CVD) in patients undergoing maintenance hemodialysis (MHD). Insulin resistance is independently associated with CAC and is an important risk factor for CVD. The triglyceride-glucose (TyG) index is a reliable biomarker of insulin resistance. This cross-sectional, observational study aimed to investigate the relationship between the TyG index and CAC in asymptomatic non-diabetic patients undergoing MHD. METHODS The quantitative coronary artery calcification score (CACS) was calculated and expressed using the Agatston score. The TyG index was calculated as ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. Multiple Poisson regression analysis, Spearman correlation analysis, and receiver operating characteristic (ROC) curves were used to investigate the relationship between the TyG index and CAC. RESULTS The 151 patients were divided into three groups according to the tertiles of the TyG index. With an increase in the TyG index, the CACS significantly increased (Spearman's rho = 0.414, p < 0.001). Poisson regression analysis indicated that the TyG index was independently related to the presence of CAC (prevalence ratio, 1.281 [95% confidence interval, 1.121-1.465], p < 0.001). Furthermore, ROC curve analysis showed that the TyG index was of value in predicting the CAC in asymptomatic non-diabetic patients undergoing MHD, with an area under the curve of 0.667 (p = 0.010). CONCLUSION The TyG index is independently related to the presence of CAC in asymptomatic, non-diabetic patients undergoing MHD.
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Affiliation(s)
- Hong Ding
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Jinhua Zhu
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Ying Tian
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Li Xu
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Lei Song
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Ying Shi
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Dongxing Mu
- Institute of Nephrology, People's Hospital of Yangzhong city, Zhenjiang, Jiangsu Province, China
| | - Ruoxin Chen
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu Province, China
| | - Hong Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu Province, China
| | - Bicheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu Province, China
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Hussain B, Mahmood A, Flynn MG, Alexander T. Coronary Artery Calcium Scoring in Asymptomatic Patients. HCA HEALTHCARE JOURNAL OF MEDICINE 2023; 4:341-352. [PMID: 37969852 PMCID: PMC10635695 DOI: 10.36518/2689-0216.1565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Coronary artery calcium (CAC) scoring is an important prognostic tool for personalized cardiovascular preventive care and has recently been incorporated into American College of Cardiology/American Heart Association guidelines. CAC provides direct visualization and quantification of CAC burden for risk stratification and primary prevention of cardiovascular events in an asymptomatic population. CAC scoring is recommended for individuals with intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk and selective populations with borderline ASCVD risk. In this review, we outline the interpretation of CAC scores for predicting the risk of cardiovascular events, and we highlight the guidelines for starting statin and potentially starting aspirin therapy. A CAC score of 0 is the strongest negative predictive factor for cardiovascular disease (CVD), and a 0 score can successfully de-risk a patient. On the contrary, higher CAC scores correlate with worse cardiovascular prognostic outcomes. The CAC scan is a widely available and reproducible means for an early look at the atherosclerotic burden, and it can help strategize early interventions. The CAC interpretation and the decision to start treatment need to be personalized based on individual risk factors. We believe the emerging literature supports our contention that the CAC score can be used more broadly to improve the prophylaxis and treatment of a wider range of apparently healthy patients.
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Jackson CL, Garg PK, Guan W, Tsai MY, Criqui MH, Tsimikas S, Bhatia HS. Lipoprotein(a) and coronary artery calcium in comparison with other lipid biomarkers: The multi-ethnic study of atherosclerosis. J Clin Lipidol 2023; 17:538-548. [PMID: 37357049 PMCID: PMC10691212 DOI: 10.1016/j.jacl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Coronary artery calcium (CAC) scoring is often used for atherosclerotic cardiovascular disease (ASCVD) risk stratification in individuals with elevated lipoprotein(a) [Lp(a)]. OBJECTIVE To evaluate associations between Lp(a) and baseline CAC (volume/density) and CAC progression compared to other lipid biomarkers. METHODS We utilized data from the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort study of individuals without clinical ASCVD, excluding statin users. We evaluated the associations between Lp(a), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), triglycerides, total cholesterol, apolipoprotein B, and non-HDL-C with baseline CAC and annual CAC progression using multivariable ordinal regression with adjustment for ASCVD risk factors. Analyses were also stratified by median age. RESULTS In 5,597 participants (2,726 at median 9.5-year follow-up), Lp(a) was not associated with baseline CAC volume or density and was modestly associated with volume progression (OR 1.11, 95% CI 1.03-1.21). However, other biomarkers were positively associated with baseline volume and volume progression (LDL-C: OR 1.26, 95% CI: 1.19-1.33 and OR 1.22, 95% CI: 1.15-1.30, respectively), except HDL-C which was inversely associated. LDL-C, total cholesterol and non-HDL-C were inversely associated with baseline density. In participants <62 years of age, Lp(a) was modestly associated with baseline CAC volume (OR 1.10, 95% CI: 1.00-1.20) and volume progression (OR 1.16 95% CI: 1.04-1.30). CONCLUSIONS In contrast to other lipid biomarkers, Lp(a) was not associated with baseline CAC volume or density and was only modestly associated with volume progression. Our findings suggest that Lp(a) is not as robustly associated with CAC as other lipid biomarkers.
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Affiliation(s)
- Candace L Jackson
- Division of Cardiovascular Medicine, UC San Diego Health, San Diego, CA
| | - Parveen K Garg
- Division of Cardiology, Department of Medicine, University of Southern California, Los Angeles, CA
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michael Y Tsai
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Michael H Criqui
- Division of Cardiovascular Medicine, UC San Diego Health, San Diego, CA; Division of Preventive Medicine, Department of Family Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, UC San Diego Health, San Diego, CA
| | - Harpreet S Bhatia
- Division of Cardiovascular Medicine, UC San Diego Health, San Diego, CA.
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Huang EPY, Lin HS, Chen YC, Li YH, Huang YL, Ju YJ, Yu HC, Kicska GA, Wu MT. Lower attenuation and higher kurtosis of coronary artery calcification associated with vulnerable plaque - an agatston score propensity-matched CT radiomics study. BMC Cardiovasc Disord 2023; 23:158. [PMID: 36973668 PMCID: PMC10045966 DOI: 10.1186/s12872-023-03162-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Coronary artery calcification (CAC) burden assessed by Agatston score (AS) is currently recommended to stratify patients at risk for future acute coronary syndrome (ACS). Besides the CAC burden, the biostructure of CAC may also play a vital role in the vulnerability of CAC, which CT radiomics could reveal. Propensity-score matching of the traditional risk factors and CAC burden between the ACS and asymptomatic groups could radically remove biases and allow the exploration of characteristic features of CAC in ACS. METHODS We retrospectively identified 77 patients with ACS who had a CAC scan before percutaneous coronary intervention between 2016 and 2019. These 77 patients were one-to-two propensity-score matched for traditional risk factors of ACS and AS ranks to select 154 subjects from 2890 asymptomatic subjects. A validation cohort of 30 subjects was also enrolled. Radiomics features of each plaque were extracted and averaged in each person. Conditional logistic regression and area-under-curve analysis were used for statistical analysis. RESULTS A higher number of coronary segments involved, lower mean, median, first quartile, and standard deviation of attenuation, and increased kurtosis of attenuation of CAC were associated with the ACS group compared to the control group (p < 0.05 for all). Multivariable analysis showed that the lower median attenuation (OR = 0.969, p < 0.001) and higher Kurtosis (OR = 18.7, p < 0.001) were associated with the ACS group. The median attenuation and kurtosis significantly increase across AS ranks 1 to 4 (p = 0.001). The AUC of kurtosis (0.727) and median attenuation (0.66) were both significantly higher than that of the standard AS (AUC = 0.502) and the number of TRF (AUC = 0.537). The best cut-off of kurtosis at 2.74 yielded an accuracy of 74%, and the cut-off of median attenuation at 196 yielded an accuracy of 68%. The accuracy of kurtosis was 64%, and the accuracy of median attenuation was 55% in the validation cohort. CONCLUSION After propensity-matching traditional risk factors and CAC burden, CT radiomics highlighted that lower median attenuation and higher kurtosis were the CAC characteristics of vulnerable plaques. These features improve the understanding of the biomechanics of CAC evolution and enhance the value of CAC scan in ACS risk assessment.
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Affiliation(s)
- Eric Po-Yu Huang
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
- Department of Radiology, New Taipei City Hospital, No. 3, Sec. 1, New Taipei Blvd., Sanchong Dist., New Taipei City, 241204, Taiwan
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, 151 Chin-Hsueh Rd., Ta-Liao District, Kaohsiung, 831301, Taiwan
| | - Yi-Chun Chen
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
| | - Yi-He Li
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
| | - Yi-Luan Huang
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
| | - Yu-Jeng Ju
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan
- Department of Psychology, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd, Taipei, 10617, Taiwan
| | - Hsien-Chung Yu
- Health Management Center, Kaohsiung Veterans General Hospital, No. 386, Ta- Chung 1st Road, Kaohsiung, 813414, Taiwan
| | - Gregory A Kicska
- Section Chief of Thoracic Imaging, Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States of America
| | - Ming-Ting Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung Dazhong 1st Road, Kaohsiung City, 813414, Taiwan.
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
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9
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Dudum R, Dardari ZA, Feldman DI, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rozanski A, Rumberger JA, Shaw L, Dzaye O, Caínzos-Achirica M, Patel J, Blaha MJ. Coronary Artery Calcium Dispersion and Cause-Specific Mortality. Am J Cardiol 2023; 191:76-83. [PMID: 36645939 PMCID: PMC9928903 DOI: 10.1016/j.amjcard.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/11/2022] [Accepted: 12/18/2022] [Indexed: 01/15/2023]
Abstract
Coronary artery calcium (CAC) measures subclinical atherosclerosis and improves risk stratification. CAC characteristics-including vessel(s) involved, number of vessels, volume, and density-have been shown to differentially impact risk. We assessed how dispersion-either the number of calcified vessels or CAC phenotype (diffuse, normal, and concentrated)-impacted cause-specific mortality. The CAC Consortium is a retrospective cohort of 66,636 participants without coronary heart disease (CHD) who underwent CAC scoring. This study included patients with CAC >0 (n = 28,147). CAC area, CAC density, and CAC phenotypes (derived from the index of diffusion = 1 - [CAC in most concentrated vessel/total Agatston score]) were calculated. The associations between CAC characteristics and cause-specific mortality were assessed. The participant details included (n = 28,147): mean age 58.3 years, 25% female, 89.6% White, and 66% had 2+ calcified vessels. Diabetes, hypertension, and hyperlipidemia were predictors of multivessel involvement (p <0.001). After controlling for the overall CAC score, those with 4-vessel CAC involvement had more CAC area and less dense calcifications than those with 1-vessel. There was a graded increase in all-cause and cardiovascular disease (CVD)- and CHD-specific mortality as the number of calcified vessels increased. Among those with ≥2 vessels involved (n = 18,516), a diffuse phenotype was associated with a higher CVD-specific mortality and had a trend toward higher all-cause and CHD-specific mortality than a concentrated CAC phenotype. Diffuse CAC involvement was characterized by less dense calcification, more CAC area, multiple coronary vessel involvement, and presence of certain traditional risk factors. There is a graded increase in all-cause and CVD- and CHD-specific mortality with increasing CAC dispersion.
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Affiliation(s)
- Ramzi Dudum
- Department of Cardiovascular Medicine, Stanford University, Stanford, California; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - David I Feldman
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel S Berman
- Department of Nuclear Cardiology/Cardiac Imaging, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew J Budoff
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Michael D Miedema
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Alan Rozanski
- Department of Medicine, St. Luke's Roosevelt Hospital Center, New York, New York
| | - John A Rumberger
- Department of Cardiovascular Imaging, Princeton Longevity Center, Princeton, New Jersey
| | - Leslee Shaw
- Department of Radiology and Medicine, Weill Cornell Medical College, New York, New York
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Miguel Caínzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Jaideep Patel
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Johns Hopkins Heart and Vascular Institute at Greater Baltimore Medical Center, Baltimore, Maryland
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Department of Cardiology, the Johns Hopkins Hospital, Baltimore, Maryland.
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10
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Bhatia HS, McClelland RL, Denenberg J, Budoff MJ, Allison MA, Criqui MH. Coronary Artery Calcium Density and Cardiovascular Events by Volume Level: The MESA. Circ Cardiovasc Imaging 2023; 16:e014788. [PMID: 36802448 PMCID: PMC10191167 DOI: 10.1161/circimaging.122.014788] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/06/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The Agatston coronary artery calcium (CAC) score provides robust cardiovascular disease risk prediction but upweights plaque area by a density factor. Density, however, has been shown to be inversely associated with events. Using CAC volume and density separately improves risk prediction, but it is unclear how to apply this method clinically. We aimed to evaluate the association between CAC density and cardiovascular disease across the spectrum of CAC volume to better understand how to incorporate these metrics into a single score. METHODS We performed an analysis of MESA (Multi-Ethnic Study of Atherosclerosis) participants with detectable CAC to evaluate the association between CAC density and events by level of CAC volume using multivariable Cox regression models. RESULTS In a cohort of 3316 participants, there was a significant interaction (P<0.001) between CAC volume and density for coronary heart disease (CHD) risk (myocardial infarction, CHD death, resuscitated cardiac arrest). Models using CAC volume and density resulted in improvement in the C-index (0.703, SE 0.012 versus 0.687, SE 0.013) and a significant net reclassification improvement (0.208 [95% CI, 0.102-0.306]) compared with the Agatston score for CHD risk prediction. Density was significantly associated with lower CHD risk at volumes ≤130 mm3 (hazard ratio, 0.57 per unit of density [95% CI, 0.43-0.75]), but the inverse association at volumes >130 mm3 was not significant (hazard ratio, 0.82 per unit of density [95% CI, 0.55-1.22]). CONCLUSIONS The lower risk for CHD associated with higher CAC density varied by level of volume, and volume ≤130 mm3 is a potentially clinically useful cut point. Further study is needed to integrate these findings into a unified CAC scoring method.
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Affiliation(s)
- Harpreet S. Bhatia
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, USA
| | | | - Julie Denenberg
- Division of Preventive Medicine, Department of Family Medicine, University of California, San Diego, La Jolla, USA
| | - Matthew J. Budoff
- Division of Cardiology, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, USA
| | - Matthew A. Allison
- Division of Preventive Medicine, Department of Family Medicine, University of California, San Diego, La Jolla, USA
| | - Michael H. Criqui
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, USA
- Division of Preventive Medicine, Department of Family Medicine, University of California, San Diego, La Jolla, USA
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11
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Nasir K, Razavi AC, Dzaye O. Coronary Artery Calcium Density in Clinical Risk Prediction: Ready for Primetime? Circ Cardiovasc Imaging 2023; 16:e015150. [PMID: 36802446 DOI: 10.1161/circimaging.123.015150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX (K.N.)
| | - Alexander C Razavi
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA (A.C.R.).,Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (A.C.R., O.D.)
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (A.C.R., O.D.)
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12
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Lin FY, Goebel BP, Lee BC, Lu Y, Baskaran L, Yoon YE, Maliakal GT, Gianni U, Bax AM, Sengupta PP, Slomka PJ, Dey DS, Rozanski A, Han D, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rumberger J, Whelton SP, Blaha MJ, Shaw LJ. Mortality impact of low CAC density predominantly occurs in early atherosclerosis: explainable ML in the CAC consortium. J Cardiovasc Comput Tomogr 2023; 17:28-33. [PMID: 36376147 DOI: 10.1016/j.jcct.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/15/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Machine learning (ML) models of risk prediction with coronary artery calcium (CAC) and CAC characteristics exhibit high performance, but are not inherently interpretable. OBJECTIVES To determine the direction and magnitude of impact of CAC characteristics on 10-year all-cause mortality (ACM) with explainable ML. METHODS We analyzed asymptomatic subjects in the CAC consortium. We trained ML models on 80% and tested on 20% of the data with XGBoost, using clinical characteristics + CAC (ML 1) and additional CAC characteristics of CAC density and number of calcified vessels (ML 2). We applied SHAP, an explainable ML tool, to explore the relationship of CAC and CAC characteristics with 10-year all-cause and CV mortality. RESULTS 2376 deaths occurred among 63,215 patients [68% male, median age 54 (IQR 47-61), CAC 3 (IQR 0-94.3)]. ML2 was similar to ML1 to predict all-cause mortality (Area Under the Curve (AUC) 0.819 vs 0.821, p = 0.23), but superior for CV mortality (0.847 vs 0.845, p = 0.03). Low CAC density increased mortality impact, particularly ≤0.75. Very low CAC density ≤0.75 was present in only 4.3% of the patients with measurable density, and 75% occurred in CAC1-100. The number of diseased vessels did not increase mortality overall when simultaneously accounting for CAC and CAC density. CONCLUSION CAC density contributes to mortality risk primarily when it is very low ≤0.75, which is primarily observed in CAC 1-100. CAC and CAC density are more important for mortality prediction than the number of diseased vessels, and improve prediction of CV but not all-cause mortality. Explainable ML techniques are useful to describe granular relationships in otherwise opaque prediction models.
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Affiliation(s)
- Fay Y Lin
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Benjamin P Goebel
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Benjamin C Lee
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Yao Lu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Lohendran Baskaran
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yeonyee E Yoon
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Gabriel Thomas Maliakal
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; Department of Computer Science, Michigan State University, East Lansing, MI, USA
| | - Umberto Gianni
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - A Maxim Bax
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Partho P Sengupta
- Division of Cardiology, Rutgers Robert Wood Medical School and University Hospital, New Brunswick, NJ, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini S Dey
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alan Rozanski
- Department of Cardiology, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Donghee Han
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA, USA
| | - Michael D Miedema
- Cardiovascular Prevention, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | - John Rumberger
- Princeton Longevity Center, Princeton Forrestal Village, Princeton, NJ, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Leslee J Shaw
- Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Villines TC, Javaid A. CAC Density and Cardiovascular Risk: Is Less Really More? JACC. CARDIOVASCULAR IMAGING 2022; 15:1941-1943. [PMID: 36357135 DOI: 10.1016/j.jcmg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Todd C Villines
- Division of Cardiology, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA.
| | - Aamir Javaid
- Division of Cardiology, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
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14
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Razavi AC, van Assen M, De Cecco CN, Dardari ZA, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Sperling LS, Whelton SP, Mortensen MB, Blaha MJ, Dzaye O. Discordance Between Coronary Artery Calcium Area and Density Predicts Long-Term Atherosclerotic Cardiovascular Disease Risk. JACC Cardiovasc Imaging 2022; 15:1929-1940. [PMID: 35850937 PMCID: PMC9883836 DOI: 10.1016/j.jcmg.2022.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Coronary artery calcium (CAC) is commonly quantified as the product of 2 generally correlated measures: plaque area and calcium density. OBJECTIVES The authors sought to determine whether discordance between calcium area and density has long-term prognostic importance in atherosclerotic cardiovascular disease (ASCVD) risk. METHODS The authors studied 10,373 primary prevention participants from the CAC Consortium with CAC >0. Based on their median values, calcium area and mean calcium density were divided into 4 mutually exclusive concordant/discordant groups. Cox proportional hazards regression assessed the association of calcium area/density groups with ASCVD mortality over a median of 11.7 years, adjusting for traditional risk factors and the Agatston CAC score. RESULTS The mean age was 56.7 years, and 24% were female. The prevalence of plaque discordance was 19% (9% low calcium area/high calcium density, 10% high calcium area/low calcium density). Female sex (odds ratio [OR]: 1.48 [95% CI: 1.27-1.74]) and body mass index (OR: 0.81 [95% CI: 0.76-0.87], per 5 kg/m2 higher) were significantly associated with high calcium density discordance, whereas diabetes (OR: 2.23 [95% CI: 1.85-3.19]) was most strongly associated with discordantly low calcium density. Compared to those with low calcium area/low calcium density, individuals with low calcium area/high calcium density had a 71% lower risk of ASCVD death (HR: 0.29 [95% CI: 0.09-0.95]). CONCLUSIONS For a given CAC score, high calcium density relative to plaque area confers lower long-term ASCVD risk, likely serving as an imaging marker of biological resilience for lesion vulnerability. Additional research is needed to define a robust definition of calcium area/density discordance for routine clinical risk prediction.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Miedema
- Nolan Family Center for Cardiovascular Health, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, New Jersey, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Laurence S Sperling
- Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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15
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Razavi AC, Agatston AS, Shaw LJ, De Cecco CN, van Assen M, Sperling LS, Bittencourt MS, Daubert MA, Nasir K, Blumenthal RS, Mortensen MB, Whelton SP, Blaha MJ, Dzaye O. Evolving Role of Calcium Density in Coronary Artery Calcium Scoring and Atherosclerotic Cardiovascular Disease Risk. JACC Cardiovasc Imaging 2022; 15:1648-1662. [PMID: 35861969 PMCID: PMC9908416 DOI: 10.1016/j.jcmg.2022.02.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arthur S Agatston
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Leslee J Shaw
- Blavatnik Family Women's Health Research Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcio S Bittencourt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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16
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Okamura Y, Nakanishi R, Hashimoto H, Mizumura S, Homma S, Ikeda T. Relationship Between 18F-fluorodeoxyglucose Uptake on Positron Emission Tomography and Aortic Calcification. ANNALS OF NUCLEAR CARDIOLOGY 2022; 8:57-66. [PMID: 36540185 PMCID: PMC9749753 DOI: 10.17996/anc.22-00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/12/2022] [Accepted: 07/26/2022] [Indexed: 06/17/2023]
Abstract
Introduction: Although 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has been widely utilized to assess the extent of inflammation, the association between the extent and severity of atherosclerosis and 18F-FDG uptake on PET remains unexamined. The current study aimed to investigate whether aortic calcium (AC) scores were associated with increased aortic uptake of 18F-FDG on PET. Methods: A total of 167 consecutive patients with suspected lung cancer but unproven malignancy who underwent non-contrast-enhanced computed tomography (CT) and 18F-FDG PET/CT were enrolled. The average standardized uptake values in the ascending aorta were used to calculate the target-to-background ratio (Mean TBR). The total (thoracic and abdominal) AC scores were measured on non-contrast-enhanced chest and abdominal CT using the Agatston method, and were categorized into three groups (0, 1-399, and ≥400). The relationship between total AC scores and 18F-FDG uptake in the ascending aorta was assessed using multivariate linear regression analysis. Results: In total, 68.26% were male, and a mean age was 67.10±14.70 years. Mean TBR values increased progressively with total AC score 0, 1-399, and ≥400 (1.01±0.07, 1.08±0.09, and 1.11±0.11, respectively; p<0.00001). Multivariate linear regression analysis revealed that increased total AC scores of 1-399 (β=0.06, 95% CI: 0.01-0.11, p=0.02) and ≥400 (β=0.11, 95% CI: 0.06-0.16, p<0.001) were significantly associated with higher Mean TBR. Conclusions: The current study demonstrated that total AC scores were associated with Mean TBR. Patients with a greater extent and severity of aortic calcifications may possess increased atherosclerotic inflammatory activity as measured by 18F-FDG PET/CT.
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Affiliation(s)
- Yuriko Okamura
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Rine Nakanishi
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Hidenobu Hashimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Sunao Mizumura
- Department of Radiology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Sakae Homma
- Department of Respiratory Medicine, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
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17
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Verma KP, Inouye M, Meikle PJ, Nicholls SJ, Carrington MJ, Marwick TH. New Cardiovascular Risk Assessment Techniques for Primary Prevention: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 80:373-387. [PMID: 35863853 DOI: 10.1016/j.jacc.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
Risk factor-based models fail to accurately estimate risk in select populations, in particular younger individuals. A sizable number of people are also classified as being at intermediate risk, for whom the optimal preventive strategy could be more precise. Several personalized risk prediction tools, including coronary artery calcium scoring, polygenic risk scores, and metabolic risk scores may be able to improve risk assessment, pending supportive outcome data from clinical trials. Other tools may well emerge in the near future. A multidimensional approach to risk prediction holds the promise of precise risk prediction. This could allow for targeted prevention minimizing unnecessary costs and risks while maximizing benefits. High-risk individuals could also be identified early in life, creating opportunities to arrest the development of nascent coronary atherosclerosis and prevent future clinical events.
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Affiliation(s)
- Kunal P Verma
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; Baker Department of Cardio-Metabolic Health, University of Melbourne, Melbourne, Victoria, Australia; Monash Heart, Melbourne, Victoria, Australia
| | - Michael Inouye
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Meikle
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; Baker Department of Cardiovascular Research, Translation and Implementation, La Trobe University, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; Monash Heart, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia
| | | | - Thomas H Marwick
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; Baker Department of Cardio-Metabolic Health, University of Melbourne, Melbourne, Victoria, Australia; Baker Department of Cardiovascular Research, Translation and Implementation, La Trobe University, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia.
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18
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Criqui MH, Bhatia HS. How Should We Measure and Score Coronary Artery Calcium? JACC Cardiovasc Imaging 2021; 15:501-503. [PMID: 34922868 DOI: 10.1016/j.jcmg.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Michael H Criqui
- University of California, San Diego, San Diego, California, USA.
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19
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Blaha MJ, Dzaye O. Subthreshold coronary artery calcium - Redefining the coronary artery calcium score of zero? J Cardiovasc Comput Tomogr 2021; 16:155-157. [PMID: 34862148 DOI: 10.1016/j.jcct.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, USA.
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, USA
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