The prevalence of osteopenia and osteoporosis after heart transplantation assessed using CT

OBJECTIVE

Osteoporosis is frequently observed in patients after heart transplantation (HT), although the prevalence long-term post-HT is unknown. Most studies investigating bone mineral density (BD) after HT were performed using dual-energy X-ray absorptiometry. In this study BD, including the prevalence of osteopenia and osteoporosis, was investigated using coronary computed tomography (CCT) long-term post-HT. Moreover, risk factors for abnormal BD were investigated.

METHODS

All first CCT scans between February 2018 and June 2020 used for the annual screening for cardiac allograft vasculopathy were included. Retransplantations and scans with not fully imaged vertebrae were excluded. BD was measured as a mean of the BD of three consecutive thoracic vertebrae and categorized into normal BD, osteopenia or osteoporosis. Binary logistic regression was used to find determinants for an abnormal BD. Linear regression was used to explore determinants for the mean Hounsfield unit (HU) value of the BD.

RESULTS

In total, 140 patients were included (median age 55.2 [42.9-64.9] years, 51 (36%) female). Time between HT and CT scan was 11.0 [7.3-16.1] years. In total, 80 (57%), 43 (31%), and 17 (12%) patients had a normal BD, osteopenia, or osteoporosis, respectively. Osteoporotic fracture or vertebrae fractures was seen in 11 (8%) patients. Determinants for an abnormal BD were recipient age (OR 1.10 (1.06-1.14), p<0.001) and prednisolone use (OR 3.75 (1.27-11.01), p=0.016). In linear regression, left ventricular assist device use pre-HT (p=0.024) and time since HT (p=0.046) were additional BD determinants.

DISCUSSION

Osteopenia and osteoporosis are frequently seen on CCT post-HT. More investigation on appropriate measures to maintain a normal BD in these patients are needed.

Changes in intra- and extracranial carotid plaque calcification: a 2-year follow-up study

Extra- and intracranial carotid plaque calcification might have plaque-stabilizing effects, yet information on changes in plaque calcification remains scarce. We evaluated changes in carotid plaque calcification over 2 years follow-up in patients with symptomatic carotid artery disease. This study is based on the PARISK-study, a multicenter cohort study, with TIA/minor stroke patients with ipsilateral mild-to-moderate carotid artery stenosis (< 70%). We included 79 patients (25% female, mean age 66 years) who underwent CTA imaging with 2 year interval. We assessed the volume of extra- and intracranial carotid artery calcification (ECAC and ICAC) and calculated the difference between baseline and follow-up ECAC and ICAC volume. We performed multivariable regression analyses to investigate the association between change of ECAC or ICAC with cardiovascular determinants. ECAC. We found increase (46.2%) and decrease (34%) in ECAC volume during 2 year follow-up, both significantly correlation with baseline ECAC volume (OR = 0.72, 95% CI 0.58-0.90 respectively OR = 2.24, 95% CI 1.60-3.13).We found significant correlation for change in ECAC volume with diabetes (β = 0.46, 95% CI 0.03-0.89) and baseline ECAC volume (β = 0.81, 95% CI 0.73-0.88). ICAC. We found increase (45.0%) and decrease (25.0%) in ICAC volume. The ICAC decrease was significantly correlated with baseline ICAC volume (OR = 2.17, 95% CI 1.48-3.16), age (OR = 2.00, 95% CI 1.19-3.38) and use of antihypertensive drugs (OR = 3.79, 95% CI 1.20-11.96]).The overall change of ICAC volume was also significantly correlated with diabetes (β = 0.92, 95% CI 1.59-7.02), use of oral hypoglycemic drugs (β = 0.86, 95% CI 0.12-1.59) and baseline ICAC volume (β = 0.71, 95% CI 0.55-0.87). We provide novel insights into the dynamics of carotid plaque calcification in symptomatic stroke patients.

Vendor independent coronary calcium scoring improves individual risk assessment – the Multi-Ethnic Study of Atherosclerosis (MESA)

Background

Coronary artery calcium (CAC) scoring improves event prediction of coronary heart disease (CHD) and can be used to guide initiation or deferral of statin therapy in asymptomatic individuals at low-to-intermediate risk. However, there is substantial variation of CAC scores acquired with different CT scanners. Therefore, CAC scoring discrepancies may lead to suboptimal patients' treatment and harmonization is needed.

Purpose

The aim of our study was twofold. Our first aim was to develop a calibration tool resulting in vendor neutral Agatston Score (vnAS). Second, we aimed to assess the effect of using this calibration tool in the existing Multi-Ethnic Study of Atherosclerosis (MESA) study cohort on both risk prediction of coronary heart disease (CHD), and initiation of statin therapy.

Methods

Two static anthropomorphic phantoms containing multiple CAC inserts were imaged on seven different CT systems and one EBT system. For each CT system, the vnAS calculator parameters were derived using regression analysis based on Agatston scores from EBT and CT. To validate our vnAS, we used CAC scoring information and clinical data of participants from MESA study. All included participants (Cohort I, n=3181) were assigned to one out of four calcium groups, which were defined as zero-calcium (AS and vnAS of 0), low-calcium (AS and vnAS of 1–99) high-calcium (AS and vnAS ≥100), and reclassified individuals (AS &lt;100 and vnAS ≥100). The occurrence of CHD events in each group was assessed and multivariable Cox regression models were used to assess the added value of the vnAS in the prediction of CHD events

For a sub-cohort of 890 participants at intermediate cardiovascular risk, the potential benefit from statin therapy was estimated based on the number needed to treat (NNT). NNT were determined for patients with vnAS ≥100 and vnAS ≥300 with original AS below 100 (group I) or 300 (group II), respectively.

Results

For all CT systems, a high degree of correlation with EBT Agatston scores was shown (R2 &gt;0.932). Using the vnAS, 85 individuals (2.7%) were reclassified from a lower to a higher risk category. For the reclassified participants, CHD event rates increased significantly from 7% to 15% (p=0.008) with a CHD hazard ratio of 3.39 (95% CI 1.82–6.35, p=0.001) (Figure 1). In intermediate risk cohort, the NNT was smaller for reclassified individuals as compared to their original (low) calcium group, at 7 vs 12 for group I and 2 vs 15 for group II, respectively. The summary of vnAS applicability is depicted in Figure 2.

Conclusions

We developed a calibration tool, which enables to calculate vendor neutral AS (vnAS). Based on vnAS, 85 individuals from MESA study, who were reclassified from a lower to a higher calcium category, did indeed have a higher CHD event rate. Consequently, the potential benefit from statin therapy, based on vnAS, was also increased for reclassified participants at intermediate cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None.

Arterial calcification over time in pseudoxanthoma elasticum: a repeated measurements study

Background

Pseudoxanthoma elasticum (PXE) is a rare genetic disorder, characterized by progressive systemic arterial calcification and an elevated cardiovascular disease risk. Although arterial calcification is an established risk factor of cardiovascular morbidity and mortality, insights into its artery-specific changes over time in PXE remain lacking.

Objectives

To assess artery-specific changes in arterial calcification over time in PXE and to investigate the associations of cardiovascular risk factors with these changes.

Methods

We prospectively included 311 PXE patients (mean age 53.1 years, 185 [59.5%] females). During a median follow-up of 3.7 (25th–75th percentiles 1.3–4.2) years patients underwent 472 full-body, non-contrast computed tomography (CT) scans (maximum of 6 CTs per patient) to quantify the volume (μL) of intracranial carotid artery calcification (ICAC), extracranial carotid artery calcification (ECAC), coronary artery calcification (CAC), aortic calcification (AoC), iliac artery calcification (IAC), and leg artery calcification (LAC) and total body calcification (sum of all arteries). We calculated absolute yearly change (follow-up volume × baseline volume / time difference) and relative yearly change (absolute change divided by baseline volume × 100%) in calcification. The correlations amongst arteries in absolute and relative calcification change were assessed using Spearman's correlation coefficients. Risk factors for change in arterial calcification were assessed using linear mixed models (including age as time variable and with all risk factors entered simultaneously into models).

Results

Calcification volume change ranged from 3% to 12% increase per year, with a total body calcification progression of 11% per year. The correlations amongst arteries in absolute and relative yearly progression of calcification were only weak to moderate (correlation coefficients ranged from 0.23 between CAC and ECAC to 0.38 between CAC and LAC). Hypertension was markedly associated with increased AoC (multiplicative change in calcification per 5 years of age 1.46 [95% CI 1.13–1.89]). Moreover, the strongest predictor of ICAC change was ever smoking (1.23 [95% CI 1.03–1.46]) and of ECAC change was hypercholesterolemia (1.21 [95% CI 1.02–1.43]).

Conclusions

Arterial calcification volume progressed with 11% per year in PXE, with considerable variation between and only moderate correlation amongst arteries. Moreover, we found several modifiable, artery-specific risk factors for the progression of calcification. Although both PXE and risk factor presence are considered systemic in nature, our findings highlight that considerable differences exist between arteries in susceptibility to calcification. As such, our results provide important insights into the mechanisms underlying arterial calcification in PXE, which might be used for more targeted treatment and prevention.

Funding Acknowledgement

Type of funding sources: None.

Aortic valve calcium in relation to subclinical cardiac dysfunction and risk of heart failure in the general population

Background

Emerging evidence suggests that aortic valve calcium (AVC) is associated with adverse cardiovascular outcomes, while the association of (early) AVC with subclinical cardiac dysfunction and with risk of heart failure (HF) remains unclear.

Purpose

To determine the association of CT-assessed AVC with echocardiographic measurements of cardiac dysfunction, and with HF in the general population.

Methods

We included 2,348 participants (mean age 68.5 years, 52% women) of the Rotterdam Study, who had AVC measured between 2003 and 2006, and without a history of HF at baseline. Linear regression models were used to explore cross-sectional associations of AVC with echocardiographic measures at baseline. All participants were followed for HF event until December 2016. Cox proportional hazard models were used to assess the association of AVC with incident HF. Models were adjusted for potential confounders.

Results

The presence of AVC was associated with 3.14 g/m2 (95% CI, 1.50 to 4.79) higher mean left ventricular mass indexed by body surface area. One-unit larger log (AVC+1) was associated with 0.01 mm (95% CI 0.01 to 0.02) larger mean left atrial size. During a median follow-up of 9.8 years, 182 incident HF cases were identified. Presence of AVC was associated with 37% greater risk for HF (HR, 1.37; 95% CI, 1.01 to 1.87). One-unit larger log (AVC+1) was associated with 11% larger risk of HF (HR, 1.11; 95% CI, 1.04 to 1.18). Compared with the AVC =0, AVC ≥100 had 1.70 folded risk of HF (HR, 1.70; 95% CI, 1.17 to 2.49).

Conclusions

The levels of AVC were associated with markers of left ventricular structure and with risk of HF, independent of traditional cardiovascular risk factors. Larger CT-assessed AVC is an indicative of increased risk for development of HF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Netherlands Organization for the Health Research and Development (ZonMw)Dutch Heart Foundation (03-004-2021-T050)

Intracranial carotid arteriosclerosis mediates the association between blood pressure and cerebral small vessel disease: the Rotterdam Study

Background

Cerebral arteriosclerosis could explain the physiopathological mechanisms linking high blood pressure (BP) and cerebral small vessel disease (CSVD).

Objectives

To test the hypothesis that ICAC mediates the association between BP and CSVD.

Methods

1458 stroke-free participants from the Rotterdam Study underwent nonenhanced computed tomography to quantify ICAC and brain magnetic resonance imaging scans to assess CSVD. ICAC subtypes included atherosclerotic (intimal) and non-atherosclerotic internal elastic lamina (IEL) calcifications. We analyzed systolic BP (SBP), diastolic BP (DBP), pulse pressure (PP), and mean arterial pressure (MAP). Mediation analysis included a two way decomposition to compute the natural direct effect (NDE), natural indirect effect (NIE) and percentage of mediation (%) of ICAC on the association between BP and CSVD.

Results

The study population had a mean age of 68.0 years old, and 52% (n=758) of the participants were women. In analyses including participants with predominantly IEL calcification, we observed that larger log-ICAC volume was positively related to a higher pulse pressure (β=0.020; P&lt;0.001), and lower diastolic BP (β=0.024; P=0.001). None of the BP components were associated with log-ICAC volume among participants with predominantly intimal calcifications (β≤0.008; P≥0.060). Among all participants, log-ICAC volume mediated the association of DBP (NIE, 0.003; −14.5%) and PP (NIE,0.003; 16.5%) with log-white matter hyperintensities (log WMH). In participants with IEL calcification, log-ICAC volume mediated the association of DBP with log-WMH (NIE, 0.004, −19.5%); no mediations were observed for intimal ICAC. For Lacunes, in all participants, log-ICAC volume mediated the association of DBP (NIE, −0.015, −40%) and PP (NIE,0.015; 26.9%). In participants with IEL calcification; the NIE was 0.020 (45.8%) for DBP and 0.017 (18.2%) for PP. No interactions were detected.

Conclusions

ICAC mediated the association between BP and CSVD. Non-atherosclerotic IEL calcification, considered a proxy of arterial stiffness, was the main physiopathological mechanism explaining how BP links to CSVD due to cerebral arteriosclerosis.

Funding Acknowledgement

Type of funding sources: None.

Imaging-based body fat depots and new-onset atrial fibrillation in general population

Background

Obesity is a well-established risk factor for incident atrial fibrillation (AF). Whether different body fat depots differentially associate with AF development remains largely unknown.

Purpose

We aimed to investigate the associations between various body fat depots and the risk of new-onset AF among middle-aged and elderly individuals from general population.

Methods

In the prospective population-based cohort study, body composition was assessed using dual-energy X-ray absorptiometry (DXA) and total body mass, lean mass, fat mass, android and gynoid fat were analyzed (N=3468). Liver fat and epicardial fat were assessed using computed tomography (CT) (N=2145). A body fat score was defined by adding tertiles of each fat depot. All participants were followed for the occurrence of AF until 1st Jan. 2014. Principle component analysis was conducted to identify body fat distribution patterns. Time-to-event analyses were performed using Cox proportional hazards regression analysis. Hazard ratios (HR) and 95% confidence-intervals (95% CI), adjusted for cardiovascular risk factors, were calculated.

Results

Mean (standard deviation) of age for participants in DXA study and CT study was 74.42 (6.85) and 68.66 (6.41) years, respectively. AF incidence rate was 13.1 per 1000 person-years during a median follow-up time of 9.62 years. In the adjusted model, fat mass (HR; 95% CI: 1.33; 1.05–1.68), lean mass (1.40; 1.15–1.72), gynoid fat mass (1.36; 1.12–1.65), and total body mass (1.51; 1.21–1.89) were significantly associated with new-onset AF. Of note, android-to-gynoid fat ratio was inversely associated with incident AF (HR; 95% CI: 0.81; 0.70–0.94). Larger body fat score was associated with increased risk of incident AF (P for trend &lt;0.01). Two fat distribution patterns were identified. Adherence to the fat- and gynoid fat- pattern (P for trend = 0.035), but not muscle- and visceral fat- pattern (P for trend = 0.35), was significantly associated with larger risk of new-onset AF.

Conclusions

Various body fat depots were associated with new-onset AF. Larger values of total body mass carried the highest risk for incident AF. The inverse association between android to gynoid fat ratio with AF presents a novel finding. A significant dose-response relationship between body fat accumulation and risk of new-onset AF was observed, implying a collective impact of fat depots on AF development. Findings also suggest that various fat depots, characterized by different fat distribution patterns, may exert differential combined effect on the risk of incident AF.

Funding Acknowledgement

Type of funding sources: None. Fat depots and atrial fibrillation

Lipoprotein(a) is associated with incidence but not progression of aortic valve calcium

Background

Lipoprotein(a) [Lp(a)] has been implicated in the etiology of aortic valve stenosis. Although Lp(a) is strongly associated with the presence of aortic valve calcium (AVC), there are no data evaluating the relationship of Lp(a) with AVC incidence and AVC progression.

Purpose

To assess whether high Lp(a) levels are associated with AVC incidence and progression.

Methods

In 922 individuals from the population-based Rotterdam Study (mean age 66.0±4.2 years, 47.7% men) for whom Lp(a) measurements were available, non-enhanced cardiac CT imaging was performed at baseline and after a median follow-up of 14.0 [13.9–14.2] years. AVC incidence was defined as an AVC score &gt;0 on the second scan, in absence of AVC on the first scan. We performed logistic regression analyses to evaluate the relationship of Lp(a) with AVC incidence and linear regression analyses to assess the relationship between Lp(a) and AVC progression. All analyses were corrected for age, sex, body mass index, smoking, non-high-density lipoprotein cholesterol, use of lipid-lowering medication, and hypertension. Additionally, we analyzed the progression conditional on the baseline AVC-score.

Results

Of the 702 (76.1%) individuals without AVC at baseline, 415 (59.1%) showed incident AVC at follow-up. The 220 (23.9%) individuals with AVC on baseline had a median AVC score of 52 [15–131], with a median yearly progression of 13 [5–38]. Lp(a) concentration was independently associated with AVC incidence (OR 1.32 for each 105 nmol/L Lp(a) increase; 95% CI: 1.03–1.68), but not with AVC progression (β −4.3 AU/year for each 105 nmol/L Lp(a) increase; 95% CI: −12.3–3.7).

Conclusions

Lp(a) is associated with AVC incidence but not AVC progression, suggesting that Lp(a)-lowering interventions may be futile after AVC has been established. Future studies should focus on whether Lp(a) lowering interventions can prevent the development of AVC in high-risk individuals.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Rotterdam Study is supported by Erasmus MC and Erasmus University Rotterdam and the Netherlands Organization for Scientific Research

Sex steroids and markers of micro- and macrovascular damage among women and men from the general population

AIMS

The contribution of sex hormones to micro- and macrovascular damage might differ among women and men. In particular, little is known about the association between sex hormones and small vessel disease. Therefore, we examined the association of total oestradiol, total testosterone, free-androgen index (FAI), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and androstenedione levels with micro- and macrovascular diseases.

METHODS AND RESULTS

This cross-sectional study included 2950 women and 2495 men from the population-based Rotterdam Study. As proxy of microvascular damage, we measured diameters of retinal arterioles and venules. Markers of macrovascular damage included carotid intima-media thickness and carotid plaque, coronary artery calcification (CAC), and peripheral artery disease. Linear and logistic regression models were used and adjusted for age, cardiovascular risk factors, and years since menopause. Associations with microvasculature: In women, total testosterone [mean difference per 1-unit increase in natural-log transformed total testosterone (95% confidence interval, CI): 2.59 (0.08-5.09)] and androstenedione [4.88 (1.82-7.95)] and in men DHEAS [2.80 (0.23-5.37)] and androstenedione [5.83 (2.19-9.46)] were associated with larger venular caliber. Associations with markers of large vessel disease: In women, higher total testosterone [-0.29 (-0.56 to -0.03)], FAI [-0.33 (-0.56 to -0.10)], and androstenedione levels [-0.33 (-0.64 to -0.02)] were associated with lower CAC burden and FAI [odds ratio (95% CI): 0.82 (0.71-0.94)] was associated with lower prevalence of plaque.

CONCLUSION

A more androgenic profile was associated with more microvascular damage in both women and men. Among women, however, higher androgen levels were also associated with less macrovascular damage. Our findings suggest that androgens might have distinct effects on the vasculature, depending on the vascular bed and stages of the atherosclerosis process.

Circulating levels of metabolic biomarkers of site-specific and sex-specific arterial calcification in the multi-cohort BBMRI setting

Background/Introduction

Increasing evidence shows that greater arterial calcification leads to an elevated risk of atherosclerotic cardiovascular disease. Risk factors and prognosis of arterial calcification seems to vary per site and between women and men. However, the underlying biological mechanisms of site-specific calcification and the associated sex differences are largely unknown. Within the BBMRI framework, we performed a multi-cohort study on the associations of the circulating levels of metabolic biomarkers with arterial calcification at various sites among women and men.

Purpose

To examine the associations of the circulating levels of metabolic biomarkers with coronary artery (CAC), aortic arch (AAC) and the aortic valve (AVC) calcifications among women and men.

Methods

We included a total of 1,114 participants from the population-based Rotterdam Study and 390 from the Leiden Longevity Study. Study populations were comparable concerning study characteristics. Blood samples were used to determine a wide range of plasma metabolic biomarkers by proton nuclear magnetic resonance (NMR). Participants underwent non-contrast computed tomography to quantify the volume of CAC, AAC, and AVC. Linear regression modelling adjusted for relevant covariates was used to assess the associations of 166 metabolic biomarkers with CAC, AAC, and AVC. Correction for multiple testing was based on 33 independent metabolic biomarkers (p-value 0.05/33 = 1.5 x 10–3).

Results

Mean (standard deviation - SD) age was 69.5 (6.8) and 780 (52.0%) of the study population were women. One SD increase in concentration of a1-acid glycoprotein, was associated with a 0.10 SD (standard error (SE) = 0.03) increase in AAC (p-value = 9.5x10–4) in the overall population (Figure 1). When we stratified our analyses based on sex, this association was mainly driven by men [beta (SE) per SD: 0.12 (0.05), p-value = 0.007]. Moreover, an SD increase in acetate was associated with a 0.14 SD (SE = 0.04) decrease in CAC (p-value 1.7x10–4) in women but not in men [beta (SE) per SD: −0.04 (0.03), p-value = 0.22] (Figure 1).

Conclusion(s)

Higher levels of circulating glycoproteins were associated with increased AAC in men. Moreover, lower levels of circulating acetate were associated with increased CAC in women. These results provide evidence for location-specific differences and sex-specific effects in the underlying biological mechanisms of atherosclerosis. Our findings carry the potential to contribute to the early detection of individuals at increased risk for developing atherosclerotic cardiovascular disease and to a better understanding of disease etiology.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was performed within the framework of the BBMRI Metabolomics Consortium funded by BBMRI-NL, a research infrastructure financed by the Dutch government through Netherlands Organisation for Scientific Research (NWO) (Grant Nos. 184.021.007 and 184033111). MK was supported by VENI grant (91616079) from The Netherlands Organization for Health Research and Development (ZonMw).

Lipoprotein(a) is a strong risk factor for Aortic Valve Calcium

Background

Aortic valve calcium (AVC) is an important hallmark of aortic valve stenosis, which is the most common valvular heart disease in the Western world. Studies suggesting an important role for lipoprotein(a) [Lp(a)] in the etiology of AVC are accumulating, yet population-based evidence is scarce. Therefore, we investigated the association of Lp(a) with the presence of AVC in two large cohorts.

Methods

A total of 2412 participants from the population-based Rotterdam Study (52% women, mean age=69.6±6.3), and 859 asymptomatic persons from the Amsterdam Medical Center outpatient clinic for familial premature (non-valvular) atherosclerosis (57%women, mean age=45.9±11.6) underwent blood sampling to determine serum Lp(a) and non-enhanced cardiac CT-scan to assess AVC. We combined both cohorts and investigated the association of Lp(a) with the presence and amount of AVC using logistic and linear regression models, adjusting for age, sex, smoking, body mass index, non-high density lipoprotein cholesterol and use of antihypertensive medication.

Results

Out of a total of 3271 subjects with an average age of 63.4±7.98, AVC was present in 844 (25.8%) individuals. Higher levels of Lp(a) were associated with the presence of AVC, independent of age, sex and cardiovascular risk factors [Odds ratio (OR) per 1-SD increase in Lp(a): 1.39 (95% CI:1.27; 1.51). In persons with AVC, a higher level of Lp(a) was also related to larger volume of AVC [β per 1-SD increase in Lp(a): 0.76 (95% CI:1.27; 1.51)]. All findings were similar across both cohorts.

Conclusion

Lp(a) is a prominent and independent marker of the presence and amount of AVC in the general population. Future studies investigating the effect of Lp(a) lowering on the progression of AVC are warranted.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NESTOR program for geriatric research, the Netherlands Heart Foundation, the Netherlands Organization for Scientific Research, the Health Research and Development Council (28-2975 and 97-1-364), and the Municipality of Rotterdam

Male-female specific aortic growth after 10 year follow-up in an aged population

Background

Aortic diameters are known to increase with age. However, longitudinal data on normal thoracic aortic growth rate over the adult life course are lacking. To better understand and recognize pathological aortic growth and factors influencing aortic dilatation, it is crucial to study aortic growth patterns in the general population.

Purpose

To study sex- and age-specific aortic growth rates in the general population, and to identify factors associated with aortic growth rate and developing aortic pathology.

Methods

Participants of the prospective population-based Rotterdam Study who underwent non-enhanced cardiac CT (2003–2006) were invited for a follow-up non-enhanced cardiac CT (2018–2019). On both CT-scans, diameters of the ascending (AA) and descending aorta (DA) were measured at the level of the pulmonary bifurcation. Mean aortic growth rates and 95th percentiles were calculated. Linear regression models were built to identify factors associated with aortic growth.

Results

In this preliminary analysis, 933 participants were included (52% females, median age 65 years). During a mean follow-up time of 14 years, the mean aortic growth rates of the ascending aorta (AA) were 0.08 mm/year in males and 0.07 mm/year in females. For the descending aorta (DA) these were 0.07 mm/year in males and 0.05mm/year in females. Participants with AA diameters of ≥40 mm (n=147) or DA diameters of ≥35 mm (n=11) at baseline did not show accelerated growth compared to the other participants. Higher systolic blood pressure (SBP), and use of antithrombotic agents were associated with less AA growth. Age, diastolic blood pressure (DBP) and male sex were associated with more AA growth. For the DA, higher DBP and smoking were associated with a higher growth rate. Higher SBP, diabetes and use of antithrombotic agents were associated with less DA growth.

Conclusion

Thoracic aortic growth rates in the general population are low. Differences in growth were found between men and women, although these differences may not be clinically relevant. Antithrombotic medication use was related to lower thoracic aortic growth rates, emphasizng the need for further investigation into the potential effect of this treatment.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The Rotterdam Study is funded by Erasmus MC and Erasmus University, Rotterdam, the Netherlands; the Netherlands Organisation for Scientific Research (NWO); the Netherlands Organisation for Health Research and Development (ZonMw); the Research Institute for Diseases in the Elderly (RIDE); the Ministry of Education, Culture and Science; the Ministry for Health, Welfare and Sports; the European Commission (DG XII); and the Municipality of Rotterdam. MK is supported by a VENI grant (91616079) from ZonMw. JWR-H, LRB, CGET, ALG, MMM and JJMT are supported by the Dutch Heart Foundation (2013T093) and ZonMW (849200014).

Arterial calcification in the prediction of atherosclerotic cardiovascular disease among women and men

Background

The Coronary Artery Calcium (CAC) Score has emerged as a valuable tool in atherosclerotic cardiovascular disease (ASCVD) risk stratification. However, data on the relevance of arterial calcification in different vascular territories for ASCVD risk prediction is lacking.

Purpose

First, to assess the sex-specific distribution of arterial calcification in different vessel beds across ASCVD risk categories. Second, to determine the added value of arterial calcification in different vascular territories for ASCVD risk prediction.

Methods

From a large population-based study, 2,139 participants (mean age 69 years, 55% women) underwent non-contrast computed tomography to quantify CAC, aortic arch calcification (AAC), extracranial- (ECAC) and intracranial carotid artery calcification (ICAC), and vertebrobasilar artery calcification (VBAC). The outcome measure, incident ASCVD, composed of fatal and nonfatal myocardial infarction (MI), other coronary heart disease (CHD) mortality, and stroke. We fitted sex-specific prediction models according to the Pooled Cohort Equations (PCE), and categorized participants into low- (&lt;5%), borderline- (5% to 7.5%), intermediate- (7.5% to 20%), and high ASCVD risk (≥20%), based on the American College of Cardiology (ACC) and American Heart Association (AHA) guideline. Subsequently, we determined the distribution of calcifications in different vascular territories across the risk categories. Next, we extended the PCE prediction model with calcification volumes and calculated the c-statistic and the net reclassification improvement for events (NRIe) and non-events (NRIne).

Results

The median follow-up for ASCVD was 9.3 years. Among women, 38% was classified as low-risk, 19% as borderline risk, 31% as intermediate risk, and 12% as high risk. Among men, 2% was classified as low-risk, 10% as borderline risk, 60% as intermediate risk, and 28% as high risk. With increasing risk of ASCVD, a larger burden of calcification was observed. In women, simultaneously adding calcification volumes in all vessel beds led to the largest increase in c statistic (from 0.71 to 0.75) for the prediction of ASCVD and the most beneficial reclassification (NRIe: 11%, NRIne: 2%). Among men, the addition of CAC alone most substantially improved the prediction of ASCVD (c statistic improved from 0.65 to 0.68, NRIe and NRIne were 4% and 14%, respectively).

Conclusions

Our findings suggest a potential role for comprehensive assessment of calcification in different vessel beds for ASCVD risk stratification in particular among women.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Rotterdam Study is supported by Erasmus MC and Erasmus University Rotterdam; the Netherlands Organization for Scientific Research; the Netherlands Organization for Health Research and Development (ZonMw); the Research Institute for Diseases in the Elderly; the Netherlands Genomics Initiative; the Ministry of Education, Culture, and Science; the Ministry of Health, Welfare, and Sports; European Commission; and the Municipality of Rotterdam. Dr. Kavousi is supported by the VENI grant (91616079) from ZonMw. Dr. Bos was supported by a fellowship of the BrightFocus Foundation (A2017424F). Oscar L. Rueda-Ochoa receives a scholarship from COLCIENCIAS-Colombia and support from Universidad Industrial de Santander,UIS-Colombia. None of the funders had any role in study design; study conduct; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article.

Extracting hypertrophic cardiomyopathy features from cardiac magnetic resonance reports by natural language processing

Objective

Determine if information regarding hypertrophic cardiomyopathy (HCM) can be accurately retrieved from cardiac magnetic resonance (CMR) reports using natural language processing (NLP).

Background

CMR imaging is used for diagnosis and risk stratification of HCM. Manual annotation of information from CMR is time-consuming. NLP is an artificial intelligence method for automating extraction of information from narrative text.

Methods

We identified 200 HCM patients who had CMR reports from 1998 to 2018. These patients were randomly allocated into training (100 patients with 185 CMR reports) and testing sets (100 patients with 206 reports). An NLP system with 2 tiers was developed; the first extracted information regarding HCM diagnosis while second extracted categorical or numeric concepts for HCM classification. NLP performance was compared with gold-standard manual annotation.

Results

NLP algorithms achieved very high performance across all concepts with mean positive predictive value (PPV) = 0.96. An outlier was the performance for abstracting the presence of an apical pouch from CMR reports, which had noticeably lower PPV= 0.78 which be attributed to the low number of cases with this finding.

Conclusions

The algorithms developed can be translated to clinical decision support systems to increase efficiency and contribute to improved quality of care.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Study supported by the National Heart, Lung and Blood Institute of National Institutes of Health (K01HL124045), the Mayo Clinic Center for Clinical and Translational Science (CCaTS), and the Mayo Clinic K2R award. Content is solely the responsibility of authors and does not necessarily represent official views of the National Institutes of Health.

Infective endocarditis in patients after percutaneous pulmonary valve implantation with the stent-mounted bovine jugular vein valve: Clinical experience and evaluation of the modified Duke criteria

AIMS

Percutaneous pulmonary valve implantation (PPVI) has proven good hemodynamic results. As infective endocarditis (IE) remains a potential complication with limited available clinical data, we reviewed our patient records to improve future strategies of IE prevention, diagnosis and treatment.

METHODS

Medical records of all patients diagnosed with Melody® valve IE according to the modified Duke criteria were retrospectively analyzed in three Belgian tertiary centers.

RESULTS

23 IE episodes in 22 out of 240 patients were identified (incidence 2.4% / patient year) with a clear male predominance (86%). Median age at IE was 17.9 years (range 8.2-45.9 years) and median time from PPVI to IE was 2.4 years (range 0.7-8 years). Streptococcal species caused 10 infections (43%), followed by Staphylococcus aureus (n = 5, 22%). In 13/23 IE episodes a possible entry-point was identified (57%). IE was classified as definite in 15 (65%) and as possible in 8 (35%) cases due to limitations of imaging. Echocardiography visualized vegetations in only 10 patients. PET-CT showed positive FDG signals in 5/7 patients (71%) and intracardiac echocardiography a vegetation in 1/1 patient (100%). Eleven cases (48%) had a hemodynamically relevant pulmonary stenosis at IE presentation. Nine early and 6 late percutaneous or surgical re-interventions were performed. No IE related deaths occurred.

CONCLUSIONS

IE after Melody® valve PPVI is associated with a relevant need of re-interventions. Communication to patients and physicians about risk factors is essential in prevention. The modified Duke criteria underperformed in diagnosing definite IE, but inclusion of new imaging modalities might improve diagnostic performance.

Receptor-Targeted Photodynamic Therapy of Glucagon-Like Peptide 1 Receptor-Positive Lesions

Treatment of hyperinsulinemic hypoglycemia is challenging. Surgical treatment of insulinomas and focal lesions in congenital hyperinsulinism is invasive and carries major risks of morbidity. Medication to treat nesidioblastosis and diffuse congenital hyperinsulinism has varying efficacy and causes significant side effects. Here, we describe a novel method for therapy of hyperinsulinemic hyperglycemia, highly selectively killing β-cells by receptor-targeted photodynamic therapy (rtPDT) with exendin-4-IRDye700DX, targeting the glucagon-like peptide 1 receptor (GLP-1R). Methods: A competitive binding assay was performed using Chinese hamster lung (CHL) cells transfected with the GLP-1R. The efficacy and specificity of rtPDT with exendin-4-IRDye700DX were examined in vitro in cells with different levels of GLP-1R expression. Tracer biodistribution was determined in BALB/c nude mice bearing subcutaneous CHL-GLP-1R xenografts. Induction of cellular damage and the effect on tumor growth were analyzed to determine treatment efficacy. Results: Exendin-4-IRDye700DX has a high affinity for the GLP-1R, with a half-maximal inhibitory concentration of 6.3 nM. rtPDT caused significant specific phototoxicity in GLP-1R–positive cells (2.3% ± 0.8% and 2.7% ± 0.3% remaining cell viability in CHL-GLP-1R and INS-1 cells, respectively). The tracer accumulates dose-dependently in GLP-1R–positive tumors. In vivo, rtPDT induces cellular damage in tumors, shown by strong expression of cleaved caspase-3, and leads to a prolonged median survival of the mice (36.5 vs. 22.5 d, respectively; P < 0.05). Conclusion: These data show in vitro as well as in vivo evidence of the potency of rtPDT using exendin-4-IRDye700DX. This approach might in the future provide a new, minimally invasive, highly specific treatment method for hyperinsulinemic hypoglycemia.

Targeted Optical Imaging of the Glucagonlike Peptide 1 Receptor Using Exendin-4-IRDye 800CW

The treatment of choice for insulinomas and focal lesions in congenital hyperinsulinism (CHI) is surgery. However, intraoperative detection can be challenging. This challenge could be overcome with intraoperative fluorescence imaging, which provides real-time lesion detection with a high spatial resolution. Here, a novel method for targeted near-infrared (NIR) fluorescence imaging of glucagonlike peptide 1 receptor (GLP-1R)–positive lesions, using the GLP-1 agonist exendin-4 labeled with IRDye 800CW, was examined in vitro and in vivo. Methods: A competitive binding assay was performed using Chinese hamster lung (CHL) cells transfected with GLP-1R. Tracer biodistribution was determined in BALB/c nude mice bearing subcutaneous CHL-GLP-1R xenografts. In vivo NIR fluorescence imaging of CHL-GLP-1R xenografts was performed. Localization of the tracer in the pancreatic islets of BALB/c nude mice was examined using fluorescence microscopy. Laparoscopic imaging was performed to detect the fluorescent signal of the tracer in the pancreas of mini pigs. Results: Exendin-4-IRDye 800CW binds GLP-1R with a half-maximal inhibitory concentration of 3.96 nM. The tracer accumulates in CHL-GLP-1R xenografts. Subcutaneous CHL-GLP-1R xenografts were visualized using in vivo NIR fluorescence imaging. The tracer accumulates specifically in the pancreatic islets of mice, and a clear fluorescent signal was detected in the pancreas of mini pigs. Conclusion: These data provide the first in vivo evidence of the feasibility of targeted fluorescence imaging of GLP-1R–positive lesions. Intraoperative lesion delineation using exendin-4-IRDye 800CW could benefit open as well as laparoscopic surgical procedures for removal of insulinomas and focal lesions in CHI.

P1818Descending aortic thoracic diameter: a risk marker for major adverse cardiovascular outcomes in women

Background

Thoracic aortic diameters have been associated with cardiovascular risk factors and atherosclerosis. However, limited evidence regarding the role of thoracic aortic diameters as risk markers for major cardiovascular outcomes among women and men exist.

Purpose

To evaluate the independent associations between crude and indexed ascending and descending aortic (AA and DA) diameters with major cardiovascular outcomes among women and men and to provide optimal cutoff values associated with increased cardiovascular risk.

Methods and results

2178 women and men ≥55 years from the prospective population-based Rotterdam Study underwent multi-detector CT scan of thorax. Crude diameters of the AA and DA were measured and indexed by height, weight, body surface area (BSA) and body mass index (BMI). Incidence of stroke, coronary heart disease (CHD), heart failure (HF), cardiovascular and all-cause mortality were evaluated during 13 years of follow-up.

Weight-, BSA-, or BMI-indexed AA diameters showed significant associations with total or cardiovascular mortality in both sexes and height-indexed values showed association with HF in women. Crude AA diameters were associated with stroke in men and HF in women. For DA, crude and almost all indexed diameters showed significant associations with either stroke, HF, cardiovascular or total mortality in women. Only weight-, BSA- and BMI-indexed values were associated with total mortality in men. For crude DA diameter, the risk for stroke increased significantly at the 75th percentile among men while the risks for HF and cardiovascular mortality increased at the 75th and 85th percentiles respectively in women.

Conclusions

Our study suggests a role for descending thoracic aortic diameter as a marker for increased cardiovascular risk, in particular for stroke, heart failure and cardiovascular mortality among women. The cut points for increased risk for several of cardiovascular outcomes were below the 95th percentile of the distribution of aortic diameters.

An Intelligent Computer-Assisted Instruction System Designed for Rural Health Workers in Developing Countries

This paper describes an intelligent computer-assisted instruction system that was designed for rural health workers in developing countries. This system, called Consult-EAO, includes an expert module and a coaching module. The expert module, which is derived from the knowledge-based decision support system Tropicaid, covers most of medical practice in developing countries. It allows for the creation of outpatient simulations without the help of a teacher. The student may practice his knowledge by solving problems with these simulations. The system gives some initial facts and controls the simulation during the session by guiding the student toward the most efficient decisions. All student answers are analyzed and, if necessary, criticized. The messages are adapted to the situation due to the pedagogical rules of the coaching module. This system runs on PC-compatible computer.

Non-invasive in vivo determination of viable islet graft volume by 111In-exendin-3

Pancreatic islet transplantation is a promising therapy for patients with type 1 diabetes. However, the duration of long-term graft survival is limited due to inflammatory as well as non-inflammatory processes and routine clinical tests are not suitable to monitor islet survival. 111In-exendin-SPECT (single photon emission computed tomography) is a promising method to non-invasively image islets after transplantation and has the potential to help improve the clinical outcome. Whether 111In-exendin-SPECT allows detecting small differences in beta-cell mass (BCM) and measuring the actual volume of islets that were successfully engrafted has yet to be demonstrated. Here, we evaluated the performance of 111In-exendin-SPECT using an intramuscular islet transplantation model in C3H mice. In vivo imaging of animals transplanted with 50, 100, 200, 400 and 800 islets revealed an excellent linear correlation between SPECT quantification of 111In-exendin uptake and insulin-positive area of islet transplants, demonstrating that 111In-exendin-SPECT specifically and accurately measures BCM. The high sensitivity of the method allowed measuring small differences in graft volumes, including grafts that contained less than 50 islets. The presented method is reliable, convenient and holds great potential for non-invasive monitoring of BCM after islet transplantation in humans.

Cortical abnormalities in adults and adolescents with major depression based on brain scans from 20 cohorts worldwide in the ENIGMA Major Depressive Disorder Working Group

The neuro-anatomical substrates of major depressive disorder (MDD) are still not well understood, despite many neuroimaging studies over the past few decades. Here we present the largest ever worldwide study by the ENIGMA (Enhancing Neuro Imaging Genetics through Meta-Analysis) Major Depressive Disorder Working Group on cortical structural alterations in MDD. Structural T1-weighted brain magnetic resonance imaging (MRI) scans from 2148 MDD patients and 7957 healthy controls were analysed with harmonized protocols at 20 sites around the world. To detect consistent effects of MDD and its modulators on cortical thickness and surface area estimates derived from MRI, statistical effects from sites were meta-analysed separately for adults and adolescents. Adults with MDD had thinner cortical gray matter than controls in the orbitofrontal cortex (OFC), anterior and posterior cingulate, insula and temporal lobes (Cohen's d effect sizes: -0.10 to -0.14). These effects were most pronounced in first episode and adult-onset patients (>21 years). Compared to matched controls, adolescents with MDD had lower total surface area (but no differences in cortical thickness) and regional reductions in frontal regions (medial OFC and superior frontal gyrus) and primary and higher-order visual, somatosensory and motor areas (d: -0.26 to -0.57). The strongest effects were found in recurrent adolescent patients. This highly powered global effort to identify consistent brain abnormalities showed widespread cortical alterations in MDD patients as compared to controls and suggests that MDD may impact brain structure in a highly dynamic way, with different patterns of alterations at different stages of life.

[Incidental findings on brain MRIPrevalence, clinical management and natural course]

OBJECTIVE

Diagnostic brain imaging has been performed increasingly since the 1990s. A direct result of this is the rise in the detection of incidental findings. The objective of this study is to provide insight into the prevalence, clinical relevance and natural course of incidental findings on brain magnetic resonance imaging (MRI) scans.

DESIGN

Prospective cohort study.

METHOD

Within the framework of the Rotterdam study, 5800 participants underwent a brain MRI scan during the period 2005-2014. Their average age was 64.9 years, and 55.1% were female. Trained reviewers and experienced neuroradiologists evaluated all scans for clinically relevant incidental findings. We calculated the prevalence of abnormalities discovered, and investigated which clinical management followed in those participants who were referred. On the basis of subsequent scans within the framework of the Rotterdam study we investigated the natural course of findings found in participants who were not referred.

RESULTS

There were incidental findings in 549 of 5800 (9.5%) participants. The most common abnormalities were meningiomas in 143 participants (2.5%) and aneurysms in 134 participants (2.3%). A total of 188 participants (3.2%) were referred to a medical specialist, who chose for a wait-and-see policy or discharge after the initial consultation in 144 participants (76.6%). The majority of meningiomas and aneurysms not referred or untreated, remained stable in size during the average follow-up period of 48-60 months.

CONCLUSION

Incidental findings on brain MRI are made relatively frequently in people of middle age or older. In 3% of these people these findings are reason for additional clinical evaluation, mostly without further clinical consequences.

Structural Brain Alterations in Community Dwelling Individuals with Chronic Joint Pain

BACKGROUND AND PURPOSE

Central sensitization in chronic pain involves structural brain changes that influence vulnerability to pain. Identifying brain regions involved in pain processing and sensitization can provide more insight into chronic pain. This study examines structural brain changes in chronic pain and experimental pain in a large population-based study.

MATERIALS AND METHODS

For 3892 participants in the Rotterdam study, global and regional MR imaging brain volumes were automatically segmented and quantified. Chronic joint pain was defined as pain for more than half of all days during the past 6 weeks. Heat pain thresholds were measured in a subset of 1538 individuals. The association between the presence of chronic joint pain and global and lobar brain volumes was studied. Subsequently, literature was reviewed and the association of chronic pain and heat pain thresholds with 11 brain regions associated with musculoskeletal pain in previous publications was studied.

RESULTS

Total gray matter volume was smaller in women with chronic pain (β = -0.066, P = .016). This effect was primarily driven by lower gray matter volume in the temporal lobe (β = 0.086, P = .005), the frontal lobe (β = -0.060, P = .039), and the hippocampus (β = -0.099, P = .002). In addition, we observed that a lower heat pain threshold was associated with smaller volumes of the hippocampus (β = 0.017, P = .048), the thalamus (β = 0.018, P = .009), and the anterior cingulate cortex (β = -0.016, P = .037). In men, no significant associations were observed.

CONCLUSIONS

The primary identified brain areas, the temporal and frontal lobes and the hippocampus, indicated involvement of emotional processing. The volumetric differences found indicated a sex-specific neuroplasticity in chronic pain. These results emphasized sex-specific and multidisciplinary pain treatment.

Observations of the Response of Ningaui yvonneae (Marsupialia: dasyuridae) to Pit-Fall Drift Fences

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Social comparison preferences among cancer patients as related to neuroticism and social comparison orientation

Effects of neuroticism and social comparison orientation on social comparison among cancer patients were examined. A computer program that enabled patients to access information about fellow patients' disease-related experiences was developed. Patients selected more interviews concerning more as compared to less fortunate others, spent more time reading, and showed more favorable reactions to such information. Individuals with a strong comparison orientation in particular tended to engage in and to respond to social comparison. Neuroticism was associated with higher interest in social comparison and with less favorable reactions, regardless of its direction. High-neurotic individuals reacted more positively to upward than to downward comparisons, whereas the reactions of low-neurotic individuals were unaffected by comparison direction. The latter effect was replicated using a general affect measure, but solely among individuals with a strong comparison orientation.

Social comparison preferences among cancer patients as related to neuroticism and social comparison orientation

Effects of neuroticism and social comparison orientation on social comparison among cancer patients were examined. A computer program that enabled patients to access information about fellow patients' disease-related experiences was developed. Patients selected more interviews concerning more as compared to less fortunate others, spent more time reading, and showed more favorable reactions to such information. Individuals with a strong comparison orientation in particular tended to engage in and to respond to social comparison. Neuroticism was associated with higher interest in social comparison and with less favorable reactions, regardless of its direction. High-neurotic individuals reacted more positively to upward than to downward comparisons, whereas the reactions of low-neurotic individuals were unaffected by comparison direction. The latter effect was replicated using a general affect measure, but solely among individuals with a strong comparison orientation.

An intelligent computer-assisted instruction system designed for rural health workers in developing countries

This paper describes an intelligent computer-assisted instruction system that was designed for rural health workers in developing countries. This system, called Consult-EAO, includes an expert module and a coaching module. The expert module, which is derived from the knowledge-based decision support system Tropicaid, covers most of medical practice in developing countries. It allows for the creation of outpatient simulations without the help of a teacher. The student may practice his knowledge by solving problems with these simulations. The system gives some initial facts and controls the simulation during the session by guiding the student toward the most efficient decisions. All student answers are analyzed and, if necessary, criticized. The messages are adapted to the situation due to the pedagogical rules of the coaching module. This system runs on PC-compatible computer.