Abstract P674: Associations Between Visceral Adipose Tissue Area and Density With Renal Artery Calcification

Introduction: Visceral adipose tissue (VAT) has been associated with higher levels of atherosclerosis. Renal artery calcification (RAC) secondary to atherosclerosis has been found to be associated with hypertension and an increase in all-cause mortality.

Hypothesis: There are significant associations between VAT area and density with the presence and extent of renal artery calcification.

Methods: Within the Multi-Ethnic Study of Atherosclerosis (MESA) abdominal aortic calcification ancillary study, 1,978 participants from five of the six field centers around the US underwent abdominal CT imaging to measure VAT and RAC. Standardized questionnaires were used to obtain demographic and health history data. Blood samples were assayed for lipid, glucose, creatinine, and adipokine levels. Rate ratio regression was used to estimate prevalence ratios (PRs) for the presence of RAC, while linear regression was used to estimate linear coefficients for the severity of RAC among participants with RAC > 0.

Results: Of the 1,978 participants, 1,196 participants had complete visceral adiposity and renal artery measurements. After controlling for sociodemographic variables, CVD risk factors, adipokine levels, and VAT density, VAT area was not associated with RAC presence (PR 1.02, 95% CI 0.89, 1.16, p = 0.80), while greater VAT density was borderline protective for RAC presence (PR 0.89, 95% CI 0.78, 1.02, p = 0.10) when controlling for the same factors and VAT area. 354 participants had RAC > 0 and were included in linear regression analyses assessing RAC severity. After controlling for sociodemographic variables, CVD risk factors, adipokine levels, and VAT density, VAT area was significantly associated with RAC severity (slope 63.32, 95% CI 11.84, 114.81, p = 0.02), while VAT density was not associated with RAC severity (slope 9.78, 95% CI -40.87, 60.44, p = 0.71).

Conclusions: In this relatively large, multi-ethnic cohort of adults from five communities in the US, we have demonstrated that higher density VAT may be protective for RAC presence, while greater VAT area is significantly associated with RAC severity. While this is the first study examining the relationship between VAT and RAC, our results are consistent with previous studies describing associations between increased VAT area and decreased VAT density with outcomes including hypertension, hypercholesterolemia, and metabolic syndrome.

Category: Subclinical Cardiovascular Disease

Abstract P139: Association Of Thoracic Aorta Calcification And Aortic Arch Stiffness: The Multi-ethnic Study Of Atherosclerosis

Background: Arterial stiffness (AS) is a robust risk factor for HTN and CVD. It remains unclear how thoracic aortic calcification (TAC) presence, volume, and density relate to AS in the aortic arch. Improved understanding of central AS may provide insight to future mechanistic approaches to prevent and control CVD.

Methods: We evaluated 1,385 participants from MESA Exam 5 with TAC data throughout the thoracic aorta via Chest CT and pulse wave velocity (PWV) as a measure of AS across the aortic arch via MRI. We used linear regression models to assess cross-sectional associations of TAC presence, volume, and density with aortic arch PWV with adjustment for 1) age, sex, and race; and 2) age, sex, race, BMI, diabetes, estimated glomerular filtration rate, HTN-medication use, SBP, DBP, total cholesterol/high-density lipoprotein ratio, smoking status, CAC volume, CAC density, education, physical activity, and sedentary behavior.

Results: Participants were a mean age of 69 years (SD 9) [717 (52%) female; 509 (37%) White, 359 (26%) Black, 285 (21%) Hispanic/Latino, and 232 (17%) Chinese]. Calcification was present in 1,263 (91%) and 1,228 (89%) participants in the entire thoracic aorta and aortic arch, respectively, compared to 848 (61%) and 138 (10%) in the descending and ascending aorta segments. Calcium volume in the entire thoracic aorta and aortic arch were highly correlated (r=0.94) with respective means of 866 (SD 1,724) and 564 (1,014) mm 3 . Mean PWV across the aortic arch was 9 m/sec (SD 4). After full adjustment, the presence of aortic arch calcification, compared to no aortic arch calcification, was associated with a 0.76 m/sec higher mean PWV (95% CI: 0.34 - 1.18; p<0.01), while a 1,000 mm 3 increment in aortic arch calcium volume was associated with 0.36 m/sec higher mean PWV (95% CI: 0.08-0.64; p=0.01). Results were similar when calcification in the entire thoracic aorta was the primary predictor variable. Conversely, there were no significant associations between mean or maximum calcium density measures and aortic arch PWV.

Conclusion: TAC is highly prevalent in the thoracic aorta, especially the aortic arch. Calcification presence and higher calcification volume in the thoracic aorta, as well as the aortic arch itself, are associated with greater aortic arch AS.

Coronary artery calcium incidence and changes using direct plaque measurements: The MASALA study

BACKGROUND AND AIMS

We aimed to identify predictors of change in direct measures of coronary artery calcium (CAC) volume and density in South Asian participants.

METHODS

We used data from participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study with prevalent CAC and direct measures of CAC by serial computed tomography (CT) exams (2010-2013, 2016-2018). We examined the distribution of incident CAC volume and peak density, as well as progression and identified risk factors for progression of change in volume and density in multivariable models.

RESULTS

The study cohort consisted of 102 participants with incident CAC and 285 with CAC progression. CAC volume and density were highest, and incident CAC was most common in the left anterior descending artery (LAD). The greatest progression in volume was in the right coronary artery and the greatest change in density was in the left main. In linear regression models for CAC progression adjusted for baseline density, volume, risk factors, smoking (β +190.1, p = 0.02), baseline volume (β +0.24 per mm³, p < 0.01), and scan interval (β +0.15 per day, p = 0.01) were associated with change in total volume whereas Lp(a) (β +0.81 per mg/dL, p = 0.03), exercise (β +0.19 per 10 MET-min/week, p = 0.01), and baseline volume (β +0.15 per mm³, p < 0.01) and density (β -0.55 per unit, p < 0.01) were associated with change in total density.

CONCLUSIONS

In this South Asian cohort, smoking was associated with CAC volume progression, while Lp(a) and exercise were associated with progression of peak CAC density.

Associations of endogenous sex hormone levels with the prevalence and progression of valvular and thoracic aortic calcification in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Sex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants.

METHODS

We studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately.

RESULTS

The mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors.

CONCLUSIONS

In this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.

Systolic dysfunction in patients with methamphetamine use and heart failure with preserved ejection fraction

BACKGROUND

We aimed to evaluate for occult systolic dysfunction and the effect of methamphetamine cessation among patients with methamphetamine use (MU) and heart failure with preserved ejection fraction (HFpEF).

METHODS

A retrospective cohort of patients with HFpEF with serial echocardiograms was stratified by MU and evaluated using myocardial strain analysis on echocardiograms at baseline and 1 year to measure global longitudinal strain (GLS). Contemporaneous controls with an ICD diagnosis of HF within 3 days of an MU case were chosen.

RESULTS

Patients with MU (n = 31) were younger (49 ± 10 vs 59 ± 16 years, p < 0.01) and more frequently male (55% vs 26%, p = 0.04) than controls (n = 23). There was no baseline difference in ejection fraction (EF) (median 66% [IQR 58,71%] vs 62% [56,69%], p = 0.33) or GLS (-13.0% [-16.3,-10.9%] vs -14.8% [-16.0,-11.3%], p = 0.40). At one-year follow-up, MU cessation (n = 15) was associated with improvement in GLS (absolute change -4.4% [-6.5,-1.7%], p < 0.01), while no absolute change was observed with continued MU (n = 16) (0.74% [-1.2,-2.8%], p = 0.22) or controls without MU (-0.6% [-2.1,2.8%], p = 0.78). Of those with abnormal baseline GLS, normalization was observed in 46% with MU cessation, none with continued MU, and 5% of controls (p < 0.001). Among MU patients, improvement in GLS was associated with decreased HF admissions per year [HR 0.74 per 1% change in GLS, 95% CI 0.55,0.98, p = 0.04].

CONCLUSIONS

Patients with MU and HFpEF may have occult systolic dysfunction as demonstrated by abnormal GLS, and MU cessation at 1 year is associated with improvement in GLS and a reduction in risk of HF admissions.

Methamphetamine-Associated Heart Failure Hospitalizations Across the United States: Geographic and Social Disparities

Background Although methamphetamine abuse is associated with the development of heart failure (HF), nationwide data on methamphetamine-associated HF (MethHF) hospitalizations are limited. This study evaluates nationwide HF hospitalizations associated with substance abuse to better understand MethHF prevalence trends and the clinical characteristics of those patients. Methods and Results This cross-sectional period-prevalence study used hospital discharge data from the National Inpatient Sample to identify adult primary HF hospitalizations with a secondary diagnosis of abuse of methamphetamines, cocaine, or alcohol in the United States from 2002 to 2014. All 2014 MethHF admissions were separated by regional census division to evaluate geographical distribution. Demographics, payer information, and clinical characteristics of MethHF hospitalizations were compared with all other HF hospitalizations. Total nationwide MethHF hospitalizations increased from 547 in 2002 to 6625 in 2014 with a predominance on the West Coast. Methamphetamine abuse was slightly more common among primary HF hospitalizations compared with all-cause hospitalizations (7.4 versus 6.4 per 1000; Cohen h=0.012; P<0.001). Among HF hospitalizations, patients with MethHF were younger (mean age, 48.9 versus 72.4 years; Cohen d=1.93; P<0.001), more likely to be on Medicaid (59.4% versus 8.8%; Cohen h=1.16; P<0.001) or uninsured (12.0% versus 2.6%; Cohen h=0.36; P<0.001), and more likely to present to urban hospitals (43.8% versus 28.3%; Cohen h=0.32; P<0.001) than patients with non-methamphetamine associated HF. Patients with MethHF had higher rates of psychiatric comorbidities and were more likely to leave the hospital against medical advice. Conclusions MethHF hospitalizations have significantly increased in the United States, particularly on the West Coast. Coordinated public health policies and systems of care are needed to address this rising epidemic.

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Left Ventricular Thrombus

BACKGROUND

Use of direct oral anticoagulants (DOACs) for the treatment of left ventricular (LV) thrombus has gained considerable interest.

OBJECTIVE

We aimed to evaluate if DOACs are effective in the treatment of LV thrombus compared with warfarin.

METHODS

We evaluated the medical records of patients diagnosed with a new LV thrombus at a tertiary medical center. The primary outcome was the composite of thrombus persistence, stroke, or systemic embolism. We adjusted for potential confounders using multiple logistic regression. The safety outcome was the composite of hemorrhagic stroke or bleeding requiring blood transfusion.

RESULTS

A total of 129 patients were treated with warfarin and 22, with a DOAC. In unadjusted analysis, 54.3% of patients treated with warfarin met criteria for the efficacy outcome as compared with 40.9% of patients treated with a DOAC (P = 0.25). In adjusted analysis, no difference between groups was observed (odds ratio = 0.39; 95% CI = 0.14-1.06; P = 0.07 for DOAC vs warfarin). In all, 3.9% of patients treated with warfarin met safety criteria as compared with 4.5% of patients treated with a DOAC. A total of 8 patients in the warfarin group had a stroke or systemic embolism as compared with 0 patients in the DOAC group (P = 0.37).

CONCLUSION AND RELEVANCE

Our data suggest that DOACs may be reasonable alternatives for treatment of LV thrombus. When added to the totality of available studies, this study demonstrates that the effectiveness of DOACs in LV thrombus remains uncertain. Randomized clinical trials are needed.

Clinical and echocardiographic outcomes in heart failure associated with methamphetamine use and cessation

OBJECTIVE

Methamphetamine use is associated with systolic dysfunction, pulmonary arterial hypertension and may also be associated with diastolic dysfunction. The impact of methamphetamine cessation on methamphetamine-associated heart failure (MethHF) remains poorly characterised. We aimed to longitudinally characterise methamphetamine-associated heart failure patients with reduced (METHrEF) and preserved (METHpEF) left ventricular ejection fraction (EF), and evaluate the relationship between methamphetamine cessation and clinical outcomes.

METHODS

We performed a retrospective cohort study, and reviewed medical records of patients with METHrEF, METHpEF and heart failure controls without methamphetamine use. Echocardiographic variables were recorded for up to 12 months, with clinical follow-up extending to 24 months.

RESULTS

Among METHrEF patients (n=28, mean age 51±9 years, 82.1% male), cessation was associated with improvement in EF (+10.6±13.1%, p=0.009) and fewer heart failure admissions per year compared with continued use (median 0.0, IQR 0.0-1.0 vs median 2.0, IQR 1.0-3.0, p=0.039). METHpEF patients (n=28, mean age 50±8 years, 60.7% male) had higher baseline right ventricular systolic pressure (median 53.44, IQR 43.70-84.00 vs median 36.64, IQR 29.44-45.95, p=0.011), and lower lateral E/E' ratio (8.1±3.6 vs 11.2±4., p<0.01) compared with controls (n=32). Significant improvements in echocardiographic parameters and clinical outcomes were not observed following cessation in this group.

CONCLUSIONS

METHrEF patients who cease methamphetamine use have significant improvement in left ventricular systolic function and fewer heart failure admissions, suggesting that METHrEF may be reversible. Echocardiographic parameters suggest that some patients with METHpEF may have pulmonary hypertension in the absence of overt signs of left ventricular diastolic dysfunction, but additional study is needed to characterise this patient cohort.

Progression of valvular calcification and risk of incident stroke: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Prevalent valvular calcification (VC) is associated with stroke but little is known about associations of VC progression with stroke.

METHODS

Progression (interval increase >0 Agatston units/year) of aortic valvular calcification (AVC) and mitral annular calcification (MAC) was assessed by two cardiac CTs over a median of 2.4 years. We determined the risk of adjudicated total and ischemic stroke using Cox regression adjusted for cardiovascular disease (CVD) risk factors.

RESULTS

We studied 5,539 MESA participants free of baseline CVD and atrial fibrillation. Baseline mean ± SD age was 62 ± 10 years; 53% were women; 83% had no progression of VC; 15%, progression at one site (AVC or MAC), and 3%, progression at both sites. Over a median of 12 years, 211 total and 167 ischemic strokes occurred. The number of sites with VC progression (range 0-2) was not associated with total and ischemic stroke (all p > 0.05). We found MAC progression to be associated with increased risk of total stroke [adjusted hazard ratio (95% CI) 1.59 (1.11, 2.28)] and ischemic stroke [1.64 (1.10, 2.45)]. Results remained significant after further adjustment for baseline coronary artery calcification. After excluding participants with interim atrial fibrillation and coronary heart disease, findings were no longer statistically significant in fully-adjusted models. There was no interaction by age, sex, or race/ethnicity. There was no association with AVC progression and stroke.

CONCLUSIONS

Progression of MAC but not AVC over 2.4 years is associated with increased risk of total and ischemic stroke.

The Impact of Substance Abuse on Heart Failure Hospitalizations

BACKGROUND

The burden of substance abuse among patients with heart failure and its association with subsequent emergency department visits and hospital admissions are poorly characterized.

METHODS

We evaluated the medical records of patients with a diagnosis of heart failure treated at the University of California-San Diego from 2005 to 2016. We identified substance abuse via diagnosis codes or urine drug screens. We used Poisson regression to evaluate the incidence rate ratios (IRR) of substance abuse for emergency department visits or hospitalizations with a primary diagnosis of heart failure, adjusted for age, sex, race, medical insurance status, and medical diagnoses.

RESULTS

We identified 11,268 patients with heart failure and 15,909 hospital encounters for heart failure over 49,712 person-years of follow-up. Substance abuse was diagnosed in 15.2% of patients. Disorders such as methamphetamine abuse (prevalence 5.2%, IRR 1.96, 95% confidence interval [CI] 1.85-2.07), opioid use and abuse (8.2%, IRR 1.54, 95% CI 1.47-1.61), and alcohol abuse (4.5%, IRR 1.51, 95% CI 1.42-1.60) were associated with a greater number of hospital encounters for heart failure, with associations that were comparable to diagnoses such as atrial fibrillation (37%, IRR 1.78, 95% CI 1.73-1.84), ischemic heart disease (24%, IRR 1.67, 95% CI 1.62-1.73), and chronic kidney disease (26%, IRR 1.57, 95% CI 1.51-1.62).

CONCLUSIONS

Although less prevalent than common medical comorbidities in patients with heart failure, substance-abuse disorders are significant sources of morbidity that are independently associated with emergency department visits and hospitalizations for heart failure. Greater recognition and treatment of substance abuse may improve outcomes among patients with heart failure.

Associations of recreational and non-recreational physical activity with coronary artery calcium density vs. volume and cardiovascular disease events: the Multi-Ethnic Study of Atherosclerosis

AIMS

The benefits of physical activity (PA) on cardiovascular disease (CVD) are well known. However, studies suggest PA is associated with coronary artery calcium (CAC), a subclinical marker of CVD. In this study, we evaluated the associations of self-reported recreational and non-recreational PA with CAC composition and incident CVD events. Prior studies suggest high CAC density may be protective for CVD events.

METHODS AND RESULTS

We evaluated 3393 participants of the Multi-Ethnic Study of Atherosclerosis with prevalent CAC. After adjusting for demographics, the highest quintile of recreational PA was associated with 0.07 (95% confidence interval 0.01-0.13) units greater CAC density but was not associated with CAC volume. In contrast, the highest quintile of non-recreational PA was associated with 0.08 (0.02-0.14) units lower CAC density and a trend toward 0.13 (-0.01 to 0.27) log-units higher CAC volume. There were 520 CVD events over a 13.7-year median follow-up. Recreational PA was associated with lower CVD risk (hazard ratio 0.88, 0.79-0.98, per standard deviation), with an effect size that was not changed with adjustment for CAC composition or across levels of prevalent CAC.

CONCLUSION

Recreational PA may be associated with a higher density but not a higher volume of CAC. Non-recreational PA may be associated with lower CAC density, suggesting these forms of PA may not have equivalent associations with this subclinical marker of CVD. While PA may affect the composition of CAC, the associations of PA with CVD risk appear to be independent of CAC.

Characteristics and Outcomes of Methamphetamine Abuse Among Veterans With Heart Failure

Methamphetamine is one of the most commonly abused illicit substances worldwide. Chronic methamphetamine abuse (MA) is associated with the development of a dilated cardiomyopathy. MA in patients with heart failure (MethHF) is increasingly reported yet poorly characterized. This was a retrospective cohort study of veterans treated at the VA Medical Center in San Diego between 2005 and 2015 with a diagnosis of HF and a history of MA. The incidence of MA each year was calculated, and clinical characteristics and outcomes of veterans with HF with and without MA were compared. Among 9,491 veterans with HF, 429 were identified as having a history of MA. Between 2006 and 2015, the incidence of MA in veterans with HF doubled from 3.44% to 6.70%. Of the 429 identified, 106 veterans had a hospitalization for HF and they were compared with veterans with HF without evidence of MA (HF). Compared with veterans with HF, veterans with MethHF were significantly younger (60.7 ± 7.3 vs 71.6 ± 11.6 years, p <0.001), with more frequent co-morbid post-traumatic stress disorder (16.8% vs 4.4%, p = 0.006), depression (28.7% vs 11.0%, p = 0.002), homelessness (27.9% vs 8.9%, p = 0.001), and unemployment (55.8% vs 30.0%, p <0.001). Despite their younger age, veterans with MethHF had high rates of HF readmission or emergency room visit (49% vs 38% in MethHF vs HF, p = 0.34) and mortality at 6 months (27% vs 38% in MethHF vs HF, p = 0.10) compared with HF. In conclusion, MA in veterans with HF is on the rise. Certain demographic and clinical characteristics of veterans with MethHF may contribute to their poor outcomes.

Thoracic Aorta Calcification and Noncardiovascular Disease-Related Mortality

Objective- Arterial calcification is highly correlated with underlying atherosclerosis. Arterial calcification of the thoracic aorta is evident in many older individuals at high susceptibility to aging-related diseases and non-cardiovascular disease (CVD)-related mortality. In this study, we evaluated the association of thoracic aorta calcification (TAC) with non-CVD morbidity and mortality. Approach and Results- We analyzed data from participants in the Multi-Ethnic Study of Atherosclerosis, a prospective cohort study of subclinical atherosclerosis, in which participants underwent cardiac computed tomography at baseline and were followed longitudinally for incident CVD events and non-CVD events. Using modified proportional hazards models accounting for the competing risk of CVD death and controlling for demographics, CVD risk factors, coronary artery calcium, and CVD events, we evaluated whether TAC was independently associated with non-CVD morbidity and mortality. Among 6765 participants (mean age, 62 years), 704 non-CVD deaths occurred for a median follow-up of 12.2 years. Compared with no TAC, the highest tertile of TAC volume was associated with a higher risk of non-CVD mortality (hazard ratio, 1.56; 95% confidence interval, 1.23-1.97), as well as several non-CVD diagnoses, including hip fracture (2.14; 1.03-4.46), chronic obstructive pulmonary disease (2.06; 1.29-3.29), and pneumonia (1.79; 1.30-2.45), with magnitudes of association that were larger than for those of coronary artery calcium. Conclusions- TAC is associated with non-CVD morbidity and non-CVD mortality, potentially through a pathway that is unrelated to atherosclerosis. TAC may be a general marker of biological aging and an indicator of increased risk of non-CVD and death.

Progression of calcium density in the ascending thoracic aorta is inversely associated with incident cardiovascular disease events

Aims

Little is known regarding the risk of atherosclerotic cardiovascular disease (ASCVD) conferred by changes in the volume and density of ascending thoracic aorta calcium (ATAC) over time. We evaluated changes in ATAC volume and density scores and incident ASCVD events.

Methods and results

The Multi-Ethnic Study of Atherosclerosis is a prospective cohort study of individuals without baseline clinical ASCVD. Ascending thoracic aorta calcium was measured from baseline and follow-up (mean interval 2.4 years) cardiac computed tomography (CT). Cox proportional hazard regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) per standard deviation for events after the follow-up exam adjusted for ASCVD risk factors, baseline ATAC and coronary artery calcium (CAC) volume and density, and changes in CAC volume and density. Among 5887 participants, 296 (5.0%) had detectable ATAC at baseline, follow-up, or both exams. A total of 403 events occurred over 9.5 years. An increase in ATAC volume was associated with coronary heart disease (CHD) (HR 1.90, 95% CI 1.14-3.16), ASCVD (HR 1.93, 95% CI 1.26-2.94), and ischaemic stroke (HR 2.14, CI 1.21-3.78). An increase in ATAC density was inversely associated with CHD (HR 0.29, 95% CI 0.14-0.60) and ASCVD (HR 0.42, 95% CI 0.23-0.76), but not stroke (HR 0.61, CI 0.23-1.61).

Conclusion

Ascending thoracic aorta calcium is uncommon on serial cardiac CT. However, changes in ATAC volume and density are both associated with incident ASCVD events, but in opposite directions. Serial assessments in those with baseline ATAC may provide insight into an individual's trajectory of ASCVD risk.

The novel inflammatory marker GlycA and the prevalence and progression of valvular and thoracic aortic calcification: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

GlycA is a novel composite biomarker of systemic inflammation reflecting posttranslational glycosylation of acute phase reactants. GlycA has been associated with coronary artery calcium, cardiovascular disease (CVD) events and mortality. Vascular calcifications outside of the coronary arteries are risk markers of CVD and mortality. Whether GlycA is linked to extra-coronary calcifications (ECC) is not well established.

METHODS

We studied 6462 MESA participants free of clinical CVD who had plasma GlycA measured at baseline. ECCs [calcification in aortic valve (AVC), mitral annulus (MAC), ascending and descending thoracic aorta (ATAC, DTAC)] were ascertained at baseline and follow-up visit (median 2.3-yrs later) by cardiac CT. Poisson regression models with robust variance estimation assessed associations of GlycA with prevalent and incident ECC. Linear mixed models assessed the cross-sectional and 2-year change in ECC. Models were adjusted for demographic and lifestyle factors.

RESULTS

In cross-sectional analysis, GlycA (per SD increment) was positively associated with prevalent AVC, ATAC and DTAC with adjusted prevalence ratios (95% CI) of 1.08 (1.01-1.14), 1.18 (1.03-1.34) and 1.10 (1.06-1.14), respectively. There was also a significant association between GlycA and baseline extent of both ATAC and DTAC. Longitudinally, GlycA was positively associated with incident MAC and DTAC, with adjusted incidence ratios of 1.18 (1.03-1.37) and 1.17 (1.07-1.28), respectively. GlycA was also associated with 2-year change in MAC and DTAC extent.

CONCLUSIONS

In this diverse cohort free from clinical CVD, we found GlycA was positively associated with prevalent and incident ECC measures, in particular for progression of MAC and DTAC.

The evolving view of coronary artery calcium and cardiovascular disease risk

Calcification of the coronary artery is a complex pathophysiologic process that is intimately associated with atherosclerosis. Extensive investigation has demonstrated the value of identifying and quantifying coronary artery calcium (CAC) in atherosclerotic cardiovascular disease (CVD) prognostication. However, over the last several years, an increasing body of evidence has suggested that CAC has underappreciated aspects that modulate, and at times attenuate, future CVD risk. The most commonly used measure of CAC, the Agatston unit, effectively models both higher density and higher area of CAC as risk factors for future CVD events. Recent findings from the Multi-Ethnic Study of Atherosclerosis (MESA) have challenged this assumption, demonstrating that higher density of CAC is protective for coronary heart disease and CVD events. Statins may be associated with an increase in CAC, an unexpected finding given their clear benefits in the prevention and treatment of CVD. Studies utilizing intracoronary ultrasound and coronary computed tomography angiography have demonstrated that calcified atherosclerotic plaque-as compared with noncalcified or sparsely calcified plaque-is associated with fewer CVD events. These studies lend support to the often-asserted (but as yet unvalidated) view that calcification may play a role in plaque stabilization. Furthermore, vascular calcification, though a surrogate for atherosclerotic plaque burden, may also possess identifiable aspects that can refine CVD risk assessment.

Density of calcium in the ascending thoracic aorta and risk of incident cardiovascular disease events

BACKGROUND AND AIMS

The volume and density of coronary artery calcium (CAC) both independently predict cardiovascular disease (CVD) beyond standard risk factors, with CAC density inversely associated with incident CVD after accounting for CAC volume. We tested the hypothesis that ascending thoracic aorta calcium (ATAC) volume and density predict incident CVD events independently of CAC.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) is a prospective cohort study of participants without clinical CVD at baseline. ATAC and CAC were measured from baseline cardiac computed tomography (CT). Cox regression models were used to estimate the associations of ATAC volume and density with incident coronary heart disease (CHD) events and CVD events, after adjustment for standard CVD risk factors and CAC volume and density.

RESULTS

Among 6811 participants, 234 (3.4%) had prevalent ATAC and 3395 (49.8%) had prevalent CAC. Over 10.3 years, 355 CHD and 562 CVD events occurred. One-standard deviation higher ATAC density was associated with a lower risk of CHD (HR 0.48 [95% CI 0.29-0.79], p<0.01) and CVD (HR 0.56 [0.37-0.84], p<0.01) after full adjustment. ATAC volume was not associated with outcomes after full adjustment.

CONCLUSIONS

ATAC was uncommon in a cohort free of clinical CVD at baseline. However, ATAC density was inversely associated with incident CHD and CVD after adjustment for CVD risk factors and CAC volume and density.

Association of cardiovascular disease risk factors with coronary artery calcium volume versus density

OBJECTIVES

Recently, the density score of coronary artery calcium (CAC) has been shown to be associated with a lower risk of cardiovascular disease (CVD) events at any level of CAC volume. Whether risk factors for CAC volume and CAC density are similar or distinct is unknown. We sought to evaluate the associations of CVD risk factors with CAC volume and CAC density scores.

METHODS

Baseline measurements from 6814 participants free of clinical CVD were collected for the Multi-Ethnic Study of Atherosclerosis. Participants with detectable CAC (n=3398) were evaluated for this study. Multivariable linear regression models were used to evaluate independent associations of CVD risk factors with CAC volume and CAC density scores.

RESULTS

Whereas most CVD risk factors were associated with higher CAC volume scores, many risk factors were associated with lower CAC density scores. For example, diabetes was associated with a higher natural logarithm (ln) transformed CAC volume score (standardised β=0.44 (95% CI 0.31 to 0.58) ln-units) but a lower CAC density score (β=-0.07 (-0.12 to -0.02) density units). Chinese, African-American and Hispanic race/ethnicity were each associated with lower ln CAC volume scores (β=-0.62 (-0.83to -0.41), -0.52 (-0.64 to -0.39) and -0.40 (-0.55 to -0.26) ln-units, respectively) and higher CAC density scores (β= 0.41 (0.34 to 0.47), 0.18 (0.12 to 0.23) and 0.21 (0.15 to 0.26) density units, respectively) relative to non-Hispanic White.

CONCLUSIONS

In a cohort free of clinical CVD, CVD risk factors are differentially associated with CAC volume and density scores, with many CVD risk factors inversely associated with the CAC density score after controlling for the CAC volume score. These findings suggest complex associations between CVD risk factors and these components of CAC.

Abstract 12: Volume of Calcium in the Descending Thoracic Aorta Predicts All Cause Mortality Beyond Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis

Introduction: Coronary artery calcium (CAC) volume and density differentially predict incident cardiovascular disease (CVD), with CAC density inversely associated with these outcomes. Whether similar associations exist between descending thoracic aortic calcium (DTAC) volume and density and all cause mortality (ACM) are unknown. We hypothesized that DTAC volume and density predict ACM independently of CAC.

Methods: The Multi-Ethnic Study of Atherosclerosis enrolled 6,814 participants free of clinical CVD at baseline and followed them for incident adverse events. Cardiac CT at baseline visualized the segment of the descending thoracic aorta posterior to the heart. Only participants with prevalent DTAC were included (necessary to evaluate DTAC density). DTAC and CAC volumes were natural log transformed to adjust for skewness. Cox regression models estimated the associations of DTAC volume and density with ACM after adjustment for age, gender, ethnicity, CVD risk factors, statin use, and CAC volume and density. The incremental predictive values of DTAC volume and density were evaluated by area under receiver operating characteristic (AUC) curves.

Results: Of the total cohort, 1,850 participants (27%) had prevalent DTAC and 491 deaths occurred over 10.3 years. In separate regression models, DTAC volume was independently associated with ACM after adjustment for CAC volume (HR 1.21 [95% CI 1.09-1.35]) and additional adjustment for CAC density (1.18 ([1.06-1.32]). After the same adjustments, DTAC density was not significantly associated with ACM (0.94 [0.84-1.06]). The AUC for the base Model 1 (risk factors + CAC volume) was 0.706 (0.680-0.732), which increased to 0.716 (0.690-0.742) with the addition of DTAC volume in Model 2 (p=0.03 compared to Model 1). Further addition of DTAC density in Model 3 did not improve the AUC significantly (0.717 [0.692-0.743], p=0.23 compared to Model 2).

Conclusions: In a cohort free of baseline clinical CVD, DTAC visualized on cardiac CT was common. When DTAC was present, DTAC volume (but not density) was independently associated with ACM. DTAC volume also significantly improved ACM risk prediction beyond risk factors and CAC volume.

The association of renal artery calcification with hypertension in community-living individuals: the multiethnic study of atherosclerosis

Hypertension (HTN) is a modifiable risk factor for cardiovascular disease (CVD). Renal artery calcium (RAC) may signal the presence of flow-limiting atherosclerotic disease that may contribute to changes in the kidney's regulation of blood pressure. We hypothesized that RAC is independently associated with HTN. We examined a multiethnic cohort of 1285 participants who underwent abdominal computed tomography scans in five US communities. After adjustment for age, gender, race/ethnicity, CVD risk factors, abdominal aortic calcium score, and kidney function, the presence of RAC was associated with a 50% higher odds of HTN (odds ratio: 1.54; 95% confidence interval 1.11-2.13). Similarly, the presence of RAC was associated with a 8.5 mm Hg higher systolic blood pressure, a 2.1 mm Hg higher diastolic blood pressure, and a 7.4-mm Hg higher pulse pressure. In conclusion, independent of CVD risk factors, abdominal aortic calcium, and kidney function, the presence of RAC is associated with HTN prevalence.

Delayed gadolinium enhancement in the atrial wall: a novel finding in 3 patients with rheumatic heart disease

Carditis is a well-recognized finding in rheumatic heart disease and is one of the major criteria in the diagnosis of rheumatic fever. Cardiovascular magnetic resonance with gadolinium enhancement has been used in the evaluation of several disease entities, most commonly in the imaging of myocardial infarctions. We retrospectively evaluated cardiovascular magnetic resonance studies within our institution to identify patients with rheumatic heart disease. Herein, we report the cases of 3 patients who had clinical and imaging findings of rheumatic heart disease, and in whom cardiovascular magnetic resonance revealed delayed gadolinium enhancement in the walls of 1 or both atria. In 1 patient, the delayed enhancement was also evident in both atrioventricular valves.To our knowledge, this is the 1st report of atrial-wall or atrioventricular-valve delayed gadolinium enhancement in the presence of rheumatic heart disease. Further studies may clarify whether atrial delayed gadolinium enhancement is seen in rheumatic heart disease more often than in other diseases that cause atrial fibrillation, and the diagnostic and prognostic significance of such a finding.