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Malik RF, Sun KJ, Azadi JR, Lau BD, Whelton S, Arbab-Zadeh A, Wilson RF, Johnson PT. Opportunistic Screening for Coronary Artery Disease: An Untapped Population Health Resource. J Am Coll Radiol 2024; 21:880-889. [PMID: 38382860 DOI: 10.1016/j.jacr.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Coronary artery disease is the leading cause of death in the United States. At-risk asymptomatic adults are eligible for screening with electrocardiogram-gated coronary artery calcium (CAC) CT, which aids in risk stratification and management decision-making. Incidental CAC (iCAC) is easily quantified on chest CT in patients imaged for noncardiac indications; however, radiologists do not routinely report the finding. OBJECTIVE To determine the clinical significance of CAC identified incidentally on routine chest CT performed for noncardiac indications. DESIGN An informationist developed search strategies in MEDLINE, Embase, and SCOPUS, and two reviewers independently screened results at both the abstract and full text levels. Data extracted from eligible articles included age, rate of iCAC identification, radiologist reporting frequency, impact on downstream medical management, and association of iCAC with patient outcomes. RESULTS From 359 unique citations, 83 research publications met inclusion criteria. The percentage of patients with iCAC ranged from 9% to 100%. Thirty-one investigations measured association(s) between iCAC and cardiovascular morbidity and mortality, and 29 identified significant correlations, including nonfatal myocardial infarction, fatal myocardial infarction, major adverse cardiovascular event, cardiovascular death, and all-cause death. iCAC was present in 20% to 100% of the patients in these cohorts, but when present, iCAC was reported by radiologists in only 31% to 44% of cases. Between 18% and 77% of patients with iCAC were not on preventive medications in studies that reported these data. Seven studies measured the effect of reporting on guideline directed medical therapy, and 5 (71%) reported an increase in medication prescriptions after diagnosis of iCAC, with one confirming reductions in low-density lipoprotein levels. Twelve investigations reported good concordance between CAC grade on noncardiac CT and Agatston score on electrocardiogram-gated cardiac CT, and 10 demonstrated that artificial intelligence tools can reliably calculate an Agatston score on noncardiac CT. CONCLUSION A body of evidence demonstrates that patients with iCAC on routine chest CT are at risk for cardiovascular disease events and death, but they are often undiagnosed. Uniform reporting of iCAC in the chest CT impression represents an opportunity for radiology to contribute to early identification of high-risk individuals and potentially reduce morbidity and mortality. AI tools have been validated to calculate Agatston score on routine chest CT and hold the best potential for facilitating broad adoption.
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Affiliation(s)
- Rubab F Malik
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristie J Sun
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Javad R Azadi
- Assistant Professor of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Assistant Professor of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Seamus Whelton
- Associate Professor of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Armin Arbab-Zadeh
- Director of Cardiac CT, Professor of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Renee F Wilson
- Evidence Based Practice Center, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Pamela T Johnson
- Vice President of Care Transformation, Vice Chair of Quality and Safety in Radiology, and Professor of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Osborne-Grinter M, Ali A, Williams MC. Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis. Eur Radiol 2023:10.1007/s00330-023-10439-z. [PMID: 38133672 DOI: 10.1007/s00330-023-10439-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/02/2023] [Accepted: 09/07/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC. METHODS Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model. RESULTS A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports. CONCLUSION CAC is a common, but underreported, finding on non-gated CT with important prognostic implications. CLINICAL RELEVANCE STATEMENT Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT. KEY POINTS • Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.
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Affiliation(s)
- Maia Osborne-Grinter
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
- University of Bristol, Bristol, UK.
| | - Adnan Ali
- School of Medicine, University of Dundee, Dundee, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
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Kim JY, Suh YJ, Han K, Choi BW. Reliability of Coronary Artery Calcium Severity Assessment on Non-Electrocardiogram-Gated CT: A Meta-Analysis. Korean J Radiol 2021; 22:1034-1043. [PMID: 33856134 PMCID: PMC8236368 DOI: 10.3348/kjr.2020.1047] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The purpose of this meta-analysis was to investigate the pooled agreements of the coronary artery calcium (CAC) severities assessed by electrocardiogram (ECG)-gated and non-ECG-gated CT and evaluate the impact of the scan parameters. MATERIALS AND METHODS PubMed, EMBASE, and the Cochrane library were systematically searched. A modified Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to evaluate the quality of the studies. Meta-analytic methods were utilized to determine the pooled weighted bias, limits of agreement (LOA), and the correlation coefficient of the CAC scores or the weighted kappa for the categorization of the CAC severities detected by the two modalities. The heterogeneity among the studies was also assessed. Subgroup analyses were performed based on factors that could affect the measurement of the CAC score and severity: slice thickness, reconstruction kernel, and radiation dose for non-ECG-gated CT. RESULTS A total of 4000 patients from 16 studies were included. The pooled bias was 62.60, 95% LOA were -36.19 to 161.40, and the pooled correlation coefficient was 0.94 (95% confidence interval [CI] = 0.89-0.97) for the CAC score. The pooled weighted kappa of the CAC severity was 0.85 (95% CI = 0.79-0.91). Heterogeneity was observed in the studies (I² > 50%, p < 0.1). In the subgroup analysis, the agreement between the CAC categorizations was better when the two CT examinations had reconstructions based on the same slice thickness and kernel. CONCLUSION The pooled agreement of the CAC severities assessed by the ECG-gated and non-ECG-gated CT was excellent; however, it was significantly affected by scan parameters, such as slice thickness and the reconstruction kernel.
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Affiliation(s)
- Jin Young Kim
- Department of Radiology, Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea
| | - Young Joo Suh
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Best practice for the nuclear medicine technologist in CT-based attenuation correction and calcium score for nuclear cardiology. Eur J Hybrid Imaging 2020; 4:11. [PMID: 34191150 PMCID: PMC8218053 DOI: 10.1186/s41824-020-00080-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/16/2020] [Indexed: 12/12/2022] Open
Abstract
The use of hybrid systems is increasingly growing in Europe and this is progressively important for the final result of diagnostic tests. As an integral part of the hybrid imaging system, computed tomography (CT) plays a crucial role in myocardial perfusion imaging diagnostics. Throughout Europe, a variety of equipment is available and also different university curricula of the nuclear medicine technologist are observed. Hence, the Technologist Committee of the European Association of Nuclear Medicine proposes to identify, through a bibliographic review, the recommendations for best practice in computed tomography applied to attenuation correction and calcium score in myocardial perfusion imaging, which courses in the set of knowledge, skills, and competencies for nuclear medicine technologists. This document aims at providing recommendations for CT acquisition protocols and CT image optimization in nuclear cardiology.
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Healy A, Berus JM, Christensen JL, Lee C, Mantsounga C, Dong W, Watts JP, Assali M, Ceneri N, Nilson R, Neverson J, Wu WC, Choudhary G, Morrison AR. Statins Disrupt Macrophage Rac1 Regulation Leading to Increased Atherosclerotic Plaque Calcification. Arterioscler Thromb Vasc Biol 2020; 40:714-732. [PMID: 31996022 DOI: 10.1161/atvbaha.119.313832] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Calcification of atherosclerotic plaque is traditionally associated with increased cardiovascular event risk; however, recent studies have found increased calcium density to be associated with more stable disease. 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitors or statins reduce cardiovascular events. Invasive clinical studies have found that statins alter both the lipid and calcium composition of plaque but the molecular mechanisms of statin-mediated effects on plaque calcium composition remain unclear. We recently defined a macrophage Rac (Ras-related C3 botulinum toxin substrate)-IL-1β (interleukin-1 beta) signaling axis to be a key mechanism in promoting atherosclerotic calcification and sought to define the impact of statin therapy on this pathway. Approach and Results: Here, we demonstrate that statin therapy is independently associated with elevated coronary calcification in a high-risk patient population and that statins disrupt the complex between Rac1 and its inhibitor RhoGDI (Rho GDP-dissociation inhibitor), leading to increased active (GTP bound) Rac1 in primary monocytes/macrophages. Rac1 activation is prevented by rescue with the isoprenyl precursor geranylgeranyl diphosphate. Statin-treated macrophages exhibit increased activation of NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells), increased IL-1β mRNA, and increased Rac1-dependent IL-1β protein secretion in response to inflammasome stimulation. Using an animal model of calcific atherosclerosis, inclusion of statin in the atherogenic diet led to a myeloid Rac1-dependent increase in atherosclerotic calcification, which was associated with increased serum IL-1β expression, increased plaque Rac1 activation, and increased plaque expression of the osteogenic markers, alkaline phosphatase and RUNX2 (Runt-related transcription factor 2). CONCLUSIONS Statins are capable of increasing atherosclerotic calcification through disinhibition of a macrophage Rac1-IL-1β signaling axis.
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Affiliation(s)
- Abigail Healy
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Joshua M Berus
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Jared L Christensen
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Cadence Lee
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Chris Mantsounga
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Willie Dong
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Jerome P Watts
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Maen Assali
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Nicolle Ceneri
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Rachael Nilson
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Jade Neverson
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Wen-Chih Wu
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Gaurav Choudhary
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
| | - Alan R Morrison
- From the Department of Medicine (Section of Cardiovascular Medicine) and Research Services, Providence VA Medical Center, RI; and Department of Internal Medicine (Section of Cardiovascular Medicine), Alpert Medical School at Brown University, Providence, RI
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Christensen JL, Sharma E, Gorvitovskaia AY, Watts JP, Assali M, Neverson J, Wu WC, Choudhary G, Morrison AR. Impact of Slice Thickness on the Predictive Value of Lung Cancer Screening Computed Tomography in the Evaluation of Coronary Artery Calcification. J Am Heart Assoc 2020; 8:e010110. [PMID: 30620261 PMCID: PMC6405734 DOI: 10.1161/jaha.118.010110] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Image reconstruction thickness may impact quantitative coronary artery calcium scoring (CACS) from lung cancer screening computed tomography (LCSCT), limiting its application in practice. Methods and Results We evaluated Agatston‐based quantitative CACS from 1.25‐mm LCSCT and cardiac computed tomography for agreement in 87 patients. We then evaluated Agatston‐based quantitative CACS from 1.25‐, 2.5‐, and 5.0‐mm slice thickness LCSCT for agreement in 258 patients. Secondary analysis included the impact of slice thickness on predictive value of 4‐year outcomes. Median age of patients who underwent 1.25‐mm LCSCT and cardiac computed tomography was 63 years (interquartile interval, 57, 68). CACS from 1.25‐mm LCSCT and cardiac computed tomography demonstrated a strong Pearson correlation, R=0.9770 (0.965, 0.985), with good agreement. The receiver operating characteristic curve areas under the curve for cardiac computed tomography and LCSCT were comparable at 0.8364 (0.6628, 1.01) and 0.8208 (0.6431, 0.9985), respectively (P=0.733). Median age of patients who underwent LCSCT with 3 slice thicknesses was 66 years (interquartile interval, 63, 73). Compared with CACS from 1.25‐mm scans, CACS from 2.5‐ and 5.0‐mm scans demonstrated strong Pearson correlations, R=0.9949 (0.9935, 0.996) and R=0.9478 (0.9338, 0.959), respectively, though bias was largely negative for 5.0‐mm scans. Receiver operating characteristic curve areas under the curve for 1.25‐, 2.5‐, and 5.0‐mm scans were comparable at 0.7040 (0.6307, 0.7772), 0.7063 (0.6327, 0.7799), and 0.7194 (0.6407, 0.7887), respectively (P=0.6487). When using individualized high‐risk thresholds derived from respective receiver operating characteristic curves, all slice thicknesses demonstrated similar prognostic value. Conclusions Slice thickness is an important consideration when interpreting Agatston CACS from LCSCTs. Despite the absence of ECG gating, it appears reasonable to report CACS from either 1.25‐ or 2.5‐mm slice thickness LCSCT to help stratify cardiovascular risk. Conversely, 5.0‐mm scans largely underidentify calcium, limiting practical use within the established CACS values used to categorize cardiovascular risk.
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Affiliation(s)
- Jared L Christensen
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Esseim Sharma
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Anastassia Y Gorvitovskaia
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Jerome P Watts
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Maen Assali
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Jade Neverson
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Wen-Chih Wu
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Gaurav Choudhary
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
| | - Alan R Morrison
- 1 Providence Veterans Affairs Medical Center, Ocean State Research Institute, Inc, and the Warren Alpert Medical School at Brown University Providence RI
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