Median Coronary Artery Calcium Score Research Articles

Downstream testing after an halted coronary CT angiography due to high coronary artery calcium score

Abstract Background and aim In many centers, coronary artery calcium score (CACS) is performed immediately before coronary CT angiography (CCTA) in order to exclude heavy calcification that could hamper test performance. When high CACS values are found, CCTA is usually aborted and other tests suggested. However, there are no recommendations on which test to pursue, and little data on their diagnostic yield in this setting. The aim of this study was to assess the type and results of downstream testing among patients whose CCTA study was halted due to high CACS. Methods Single-centre retrospective study of consecutive patients undergoing CCTA for suspected obstructive coronary artery disease (CAD). A CACS threshold of >400 was generally used to cancel CCTA. Downstream testing and its results were assessed using electronic medical records. A group of consecutive patients with CACS <400 who underwent CCTA was used for comparison. Results Of the 795 patients who performed CCTA for suspected CAD, 86 (10.8%), had their test halted due to high CACS (57 men, mean age 71±11 years). In this subgroup, the median pre-test probability for CAD was 27% (interquartile range 25) and the median CACS was 983 (interquartile range 930). Compared to patients who underwent CCTA, those who saw their tests cancelled were older, more frequently male, and had higher prevalence of cardiovascular risk factors and higher pre-test probability for CAD. Patient's downstream testing is illustrated in Figure. From the 86 patients enrolled, 12 are currently waiting for downstream tests and were excluded from further analysis. Overall, 35 patients ended up performing invasive coronary angiography (ICA, 47.3%) of whom 19 (54.3%) had significant CAD. Among those who underwent non-invasive testing (N=19, 25.7%), 10 (52.6%) had significant ischemia and 4 (21%) underwent additional testing with ICA. In 24 patients (32.4%), no downstream testing was pursued. Finally, 17 (22.3%) patients underwent coronary revascularization, either percutaneous (N=10, 13.5%) or surgical (N=7, 10.8%). Conclusion Invasive coronary angiography is the most frequently used downstream test when CCTA is halted due to high CACS values, and shows significant CAD in roughly half of the cases. Considering the high prevalence of significant CAD, direct referral for ICA (with the possibility of invasive functional testing) seems a reasonable approach. Funding Acknowledgement Type of funding source: None

Prediction of myocardial ischaemia in position emission tomography with clinical data, coronary artery calcium score and machine learning algorithms

Abstract Background With the present evolution of demographics and medical costs, algorithms able to predict the likelihood of coronary artery disease (CAD) may be valuable gatekeepers before advanced cardiac testing, but their value is unknown. Purpose We assessed whether clinical data, with or without coronary artery calcium score (CACS), combined with machine learning algorithms can predict ischaemia in position emission tomography (PET). Methods All consecutive patients undergoing 82Rb myocardial perfusion PET with CACS from 2016 to 2019 at our hospital were enrolled. Patients with known CAD were excluded. As clinical data, we used demographics, classical risk factors, chest pain type, dyspnoea and electrocardiogram with pathological Q waves or abnormal repolarization. CACS was measured from low-dose computed tomography scans in Agatston units (AU). Ischaemia was defined as a summed difference score ≥4 in PET. As prediction models, we compared the classical logistic regression, regularized regression (elastic net), decision trees, random forests and a boosting algorithm. The patient cohort was split into a 80% training cohort and a 20% test cohort. Models were carefully optimized with 10-fold cross-validation on the training cohort and applied to the test cohort to assess area under the curve (AUC) for ischaemia with 95% confidence intervals in receiver operating characteristic (ROC) analysis. Results We included 927 patients, of which 743 were in the training cohort and 184 in the test cohort. Mean age was 64.3±11.1 years, median CACS 55 AU (interquartile range 358) and 179 patients had ischaemia (19.3%). In the test cohort, we found the following AUC (see Figure): logistic regression with clinical data 0.62 (0.52–0.72, light blue) and CACS 0.73 (0.63–0.82, dark blue) with P=0.012, elastic net regression with clinical data 0.63 (0.54–0.73, light violet) and CACS 0.81 (0.75–0.88, dark violet) with P<0.001, decision trees with clinical data 0.5 (0.5–0.5, light green) and CACS 0.76 (0.68–0.84, dark green) with P<0.001, random forests with clinical data 0.59 (0.48–0.70, light orange) and CACS 0.76 (0.69–0.84, dark orange) with P=0.001, and boosting algorithm with clinical data 0.68 (0.58–0.77, light red) and CACS 0.84 (0.77–0.90, dark red) with P<0.001. Thus, adding CACS substantially improved each prediction model. Compared with classical logistic regression, prediction using clinical data tended to improve with the boosting algorithm (P=0.09). For prediction including CACS, both elastic net regression and the boosting algorithm were superior to logistic regression (P=0.007 and P<0.001). Conclusion Prediction of myocardial ischaemia is limited with clinical data only, but can be greatly improved with the use of CACS and machine learning with elastic net regression or a boosting algorithm, reaching a good performance. This approach could be further developed as a gatekeeper to select appropriate patients for further cardiac imaging. ROC curves: Prediction on test cohort Funding Acknowledgement Type of funding source: None

Coronary artery calcium progresses rapidly and discriminates incident cardiovascular events in chronic kidney disease regardless of diabetes: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background and aimsChronic kidney disease (CKD) is associated with high prevalence of cardiovascular disease (CVD) events. We sought to assess the prognostic utility of coronary artery calcium (CAC) scores in discriminating incident CVD events among subpopulations of CKD, particularly those without diabetes mellitus (DM). MethodsUsing the Multi-Ethnic Study of Atherosclerosis, we identified 4 groups based on present/absent CKD/diabetes (CKD-/DM-, n = 5308; CKD-/DM+, n = 586, CKD+/DM-, n = 620; CKD+/DM+, n = 266). Baseline and follow-up CAC (Agatston units) measurements, and association between CAC and incident CVD events in median follow-up of 13 years were evaluated using proportional hazards regression adjusting for demographics, clinical, biomarker variables. ResultsPrevalence of CKD and DM in the cohort was 13% and 12.5% respectively. Annual progression in adjusted median CAC score was 24.8%, 27.9%, 26.7%, 36.8% and unadjusted cumulative incident CVD rates were 12.6%, 22.3%, 23.1%, 39.8% for CKD-/DM-, CKD-/DM+, CKD+/DM-, CKD+/DM+, respectively. After full adjustment (CKD-/DM-referent), hazard ratios (HR, 95% CI) for incident CVD events were 1.25 (1.01–1.53) CKD-/DM+, 1.10 (0.90–1.33) CKD+/DM- and 2.18 (1.73–2.76) CKD+/DM+. Using CKD-/DM-/baseline CAC = 0 referent, adjusted HRs (95% CI) for incident CVD in CKD+/DM- were 1.30 (0.81–2.07), 2.05 (1.4–2.99), and 4.15 (2.94–5.86) for baseline CAC = 0, 1–100, and >300 Agatston units respectively while for CKD+/DM+, adjusted HRs were 3.15 (2.04–4.86), 3.56 (2.26–5.62), 7.90 (5.35–11.67), respectively. ConclusionsCAC provides incremental prognostic information to predict incident CVD events in CKD regardless of DM. Moreover, baseline CAC categories discriminate incident CVD among CKD without DM, which may have implications in individualizing approach to primary prevention in this high-risk population.

Coronary artery calcium scoring in cardiovascular risk assessment of people with family histories of early onset coronary artery disease.

To assess the predictive value of the Australian absolute cardiovascular disease risk (ACVDR) calculator and other assessment tools for identifying Australians with family histories of early onset coronary artery disease (CAD) who have coronary artery calcification. People without known CAD were recruited at seven Australian hospitals, October 2016 - January 2019. Participants were aged 40-70 years, had a family history of early onset CAD, and a 5-year ACVDR of 2-15%. CT coronary artery calcium score greater than zero (any coronary calcification) or greater than 100 (calcification warranting lipid therapy). 1059 participants were recruited; 477 (45%) had non-zero coronary artery calcium scores (median 5-year ACVDR, 4.8% [IQR, 2.9-7.6%]; median coronary artery calcium score, 41.7 [IQR, 8-124]); 582 (55%) did not (median 5-year ACVDR, 3.2% [IQR, 2.0-4.6%]). Of 151 participants with calcium scores of 100 or more, 116 (77%) were deemed to be at low cardiovascular risk by Australian guidelines, while 14 of 75 participants at intermediate risk (19%) had zero calcium scores. The sensitivity of the ACVDR calculator for identifying people with non-zero calcium scores (area under receiver operator curve [AUC], 0.674) was lower than that of the pooled cohort equation (AUC, 0.711; P<0.001). ACVDR (10-year)- and Multi-Ethnic Study of Atherosclerosis (MESA)-predicted risk categories concurred for 511 participants (48%); classifications were concordant for 925 participants (87%) when the ACVDR was supplemented by calcium scores. Coronary artery calcium scoring should be considered as part of the heart health check for patients at intermediate ACVDR risk and with family histories of early onset CAD. Alternative risk calculators may better select such patients for further diagnostic testing and primary prevention therapy. Australian New Zealand Clinical Trials Registry, ACTRN 12614001294640; 11 December 2014 (prospective).

Vitamin D Analogues and Coronary Calcification in CKD Stages 3 and 4: A Randomized Controlled Trial of Calcitriol Versus Paricalcitol

Rationale & ObjectiveMineral and bone disorder in chronic kidney disease (CKD) is associated with progression of coronary artery calcification (CAC). Mineral and bone disorder often is treated with calcitriol and other vitamin D receptor activators, including paricalcitol, agents that may have differential effects on calcium, phosphate, and parathyroid hormone levels. Accordingly, we investigated whether these agents have differential effects on CAC progression in patients with CKD.Study DesignRandomized, double-concealed, 48-week clinical trial.Setting & ParticipantsCKD stage 3 or 4 with secondary hyperparathyroidism with CAC score > 0 and no prior treatment with activated vitamin D.InterventionCalcitriol versus paricalcitol.OutcomesThe primary outcome was log-transformed CAC change. Secondary outcomes included percent change in CAC volume, valvular calcifications, and bone mineral metabolism markers.ResultsAmong 44 individuals randomly assigned, mean age was 65 years and mean estimated glomerular filtration rate was 27 mL/min/1.73 m2. Median CAC score was 140 (IQR, 55-277) Agatston units at baseline. There was no significant difference in CAC progression between treatment arms (P = 0.06). After adjustment for baseline CAC score (log), treatment group remains nonsignificant (P = 0.08). Further adjustment for creatinine level and/or CKD stage did not change the association. In secondary analyses adjusting for dose level of activated vitamin D, treatment group was significant (P = 0.01), and when dose level was also included in the model, the coefficient for individuals in the paricalcitol group was significantly associated with CAC progression (P = 0.02). An interaction term between dosing level and CKD stage was significant at the highest dosing level (P = 0.04).LimitationsPilot single-center study.ConclusionsIn patients with CKD with secondary hyperparathyroidism naive to activated vitamin D therapy, there was no difference in CAC or valvular progression in participants receiving calcitriol compared with paricalcitol during a 48-week period.FundingAbbvie, Inc.Trial RegistrationNCT00752102

P1696VASCULAR CALCIFICATION IN RENAL TRANSPLANTED PATIENTS

Abstract Background and Aims Chronic kidney disease – mineral and bone disorder (CKD-MBD) is a well-known syndrome in end stage renal disease. Vascular calcifications are one of its components. Renal transplantation seemed to halt the progression of vascular calcifications. The aim of this study was to analyse the progression of vascular calcifications in a cohort of renal transplanted patients, and the associations of those with the old and new bone-derived hormones. Method We performed a prospective cohort study of a consecutive sample of de novo single renal transplanted patients in our unit. All patients were submitted to a bone biopsy and laboratorial evaluation at baseline (time 0) including measurements of calcium (Ca), phosphorus (Pi), magnesium (Mg), vitamin D (vitD), calcitonin, parathyroid hormone (PTH), bone alkaline phosphatase (bAP) and total alkaline phosphatase (tAP), alpha-klotho, fibroblast grow-factor 23 (FGF23) and sclerostin. Patients were followed for 12 months, after which performed a second bone biopsy and laboratorial evaluation (time 1). At inclusion, demographic, clinical and transplant-related data were collected, X-ray of the pelvis and hands (Adragão score) and echocardiographic findings were recorded. At the end of the study, echocardiogram, X-ray of pelvis and hands, bone densitometry and non-contrast cardiac CT (Agatston score) were performed. Immunosuppression included induction therapy followed by tacrolimus, mycophenolate mofetil and prednisolone. Continuous variables are presented as medians and categorical variables as frequencies. Associations between variables were performed using Wilcoxon rank sum test and Spearman correlation test. STATA software was used and p &amp;lt; 0.05 was considered statistically significant. Results We recruited 85 patients from 1st October 2015 to 1st March 2018. Mean age 50.1±12.7 years, 59 men (69.4%), 66 caucasian (77.6%), median BMI 25.1±3.4. At the end of 12 months, 6 patients refuse to perform the 2nd evaluation, 5 had primary non-function of the kidney graft, 1 had no sample on bone biopsy in time 0 and 4 patients died. We performed a 2nd evaluation in 69 patients and included those in this study. The median baseline and 12 months Adragão score had no differences [1 (0 – 2)]. The median coronary artery calcium score was 48.5 (0 – 535) and median percentile was 80 (0 – 92.5). Valvular calcifications were present in 15 and 16 patients at baseline and after 1 year respectively, with no statistical difference between the two time points. Coronary artery calcium scores were correlated with age (p&amp;lt;0.001), two time points Adragão score (p&amp;lt;0.001), presence of valvular calcification in time 1 evaluation (p=0.004), baseline calcium (p=0.02), baseline and 1-year sclerostin (p=0.01; p=0.04). Coronary artery calcium scores were higher in patients with highest values of FGF23 at baseline (p=0.04). Using a pairwise correlation, vitamin D levels (r=0.4, p=0.0004), iPTH (r=0.6, p&amp;lt;0.001) and total cholesterol levels (r=-0.3, p=0.01) were correlated with the score. Coronary calcium Percentile (adjusted for age, gender and race) was correlated with Adragão score in the two time points (p=0.0001; p=0.002), with presence of valvular calcifications in time 1 evaluation (p=0.02), baseline and 1-year calcium serum levels (p=0.004; p=0.02) and baseline sclerostin (p=0.01). Conclusion In conclusion, vascular calcifications stabilize after renal transplant. Adragão score, that is a less expensive exam than cardiac CT, can assess vascular calcifications in renal transplanted patients. Only calcium and sclerostin correlated with both Agatston scores and coronary calcium percentiles.

P1283BASELINE CHARACTERISTICS IN THE “IPACK-HD” STUDY (INHIBIT PROGRESSION OF CORONARY ARTERY CALCIFICATION WITH VITAMIN K IN HEMODIALYSIS PATIENTS): A PHASE 2, MULTI-CENTRE, DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED PILOT TRIAL

Abstract Background and Aims The leading cause of mortality for patients with end-stage kidney disease (ESKD) is cardiovascular disease (CVD). This is due, in part, to vascular calcification (VC) where calcium becomes deposited within arterial walls causing narrowing of the arteries and altering their flexibility. Matrix Gla protein (MGP), a vitamin k-dependent protein, is a key local inhibitor of VC and becomes up-regulated adjacent to sites of calcification. There is a very high prevalence of vitamin K deficiency in patients across the chronic kidney disease (CKD) spectrum and vitamin K has been shown to prevent VC in experimental models. To date, no trial has examined whether vitamin K supplementation prevents the progression of coronary artery calcification in patients with ESKD, a group in which high risk has been established. The aim of the iPACK-HD pilot study is to determine whether a trial to determine whether vitamin K has a favourable effect on coronary artery calcium (CAC) scores in patients with ESKD is feasible. Method The iPACK-HD pilot trial is a phase 2 multi-centre, double-blind, randomized, placebo-controlled clinical trial conducted in three sites (Kingston, Ottawa and London) in Ontario, Canada. Adult patients with ESKD on chronic dialysis with a baseline CAC score of ≥30 Agatston units (AUs) are randomized to receive 10 mg of vitamin K1 or matching placebo administered post-hemodialysis 3x/week for a total of 12 months. Exclusions include medical conditions that require anticoagulation and a history of either coronary artery bypass, grafting or stenting. Randomization is stratified based on diabetes and study centre. Baseline CAC scores are determined by computed tomography (CT) and demographic and laboratory data at study entry are obtained by participant interview and medical chart review. Results A total of 85 participants are randomized into this trial. Baseline characteristics of trial participants are reported as mean ± SD, median [IQR], or %. The mean age is 63 ± 13 years. There are a higher proportion of males (57%) than females and whites (85%) compared to all other ethnicities. Forty-four percent of participants have diabetes and 77% have hypertension. Dialysis vintage is 0.9 [0.4,2.7] years. Most participants take calcium-based phosphate binders (89%) and over half of participants take an HMG-CoA reductase inhibitor (53%) or vitamin D (61%). Clinical laboratory values are presented in Table 1. Total median CAC and volume calcium scores are 587 [252,1416] AUs and 482 [206,1170] mm3, respectively. Sixty-five (76%) participants had a study exit CT scan performed upon completion of the study. Of 156 doses, a median of 150 [123,155] were received and 2 [1,6] were missed. Conclusion Participants in the iPACK-HD study have a high burden of calcification but are similar in baseline characteristics to the Canadian hemodialysis population. Loss to trial completion is 24%, but the most frequent reason is kidney transplantation. Adherence to study drug is very high with few reported side effects.

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-out Significant Coronary Artery Disease.

Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD. Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 mL iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay. Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B. Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster.

Quantified Vascular Calcification at the Dialysis Access Site: Correlations with the Coronary Artery Calcium Score and Survival Analysis of Access and Cardiovascular Outcomes.

Vascular calcification is a major contributor to mortality in end-stage renal disease (ESRD) patients. In this study, we investigated whether there was a correlation between the coronary artery calcium score (CACS) and the vascular calcification score (VCS), and whether higher VCS increased the incidence of interventions and major adverse cardiac and cerebrovascular events (MACCE). ECG-gated CT, including vascular access and the coronary vessel, was taken. CACS and VCS were calculated by the Agatston method. A comparison of CACS and survival analysis according to VCS groups was performed. Using a cutoff of VCS = 500, 77 patients were divided into two groups. The vintage was significantly older in the higher VCS group. The median CACS was higher in the higher VCS group (21 [0, 171] vs. 552 [93, 2430], p < 0.001). The hazard ratio (HR) for interventions and MACCEs in the higher VCS group increased by 3.2 and 2.3, respectively. Additionally, a longer duration of hemodialysis and higher magnesium levels (>2.5 mg/dL) showed lower HRs for interventions (<1). We quantified VCS and found that it was associated with the CACS. Additionally, higher VCS increased the risk of access interventions and MACCE. VCS of the access site may be suggested as a biomarker to predict ESRD patients.

Predictors of coronary artery calcium among 20-30-year-olds: The Coronary Artery Calcium Consortium

Background and aimsWe sought to understand the risk factor correlates of very early coronary artery calcium (CAC), and the potential investigational value of CAC phenotyping in adults aged 20–30 years. MethodsWe studied all participants aged 20–30 years at baseline (N = 373) in the Coronary Artery Calcium Consortium, a large multi-center cohort study of patients aged 18 years or older without known atherosclerotic cardiovascular disease (ASCVD) at baseline, referred for CAC scoring for clinical risk stratification. We described the prevalence of CAC in men and women, the frequency of risk factors by the presence of CAC (CAC = 0 vs CAC >0), and assessed the association between traditional non-demographic CVD risk factors (hypertension, hyperlipidemia, smoking, family history of CHD, and diabetes) and prevalent CAC, using age- and sex-adjusted logistic regression models. ResultsThe mean age of the study participants was 27.5 ± 2.4 years; 324 (86.9%) had CAC = 0, and 49 (13.1%) had CAC >0. Among the 49 participants with CAC, 38 (77.6%) were men, and median CAC score was low at 4.6. In age- and sex-adjusted models, there was a graded increase in the odds of CAC >0 with increasing traditional cardiovascular disease (CVD) risk factor burden (p = 0.001 for linear trend). Participants with ≥3 traditional risk factors had a statistically significant higher odds of having prevalent CAC (OR 5.57, 95% CI; 1.82–17.03) compared to participants with no risk factors. ConclusionsOur study demonstrates the non-negligible prevalence of CAC among very high-risk young US adults, reinforcing the critical importance of traditional risk factors in the earliest development of detectable subclinical ASCVD.

Prevalence of Coronary Artery Calcium in Patients With Atrial Fibrillation With and Without Cardiovascular Risk Factors

The burden of coronary artery atherosclerosis in patients with atrial fibrillation (AF) is unknown. We aimed to assess the coronary artery calcium (CAC) in AF patients. We retrospectively analyzed 324 consecutive patients with AF who had CT angiogram before AF ablation and their cardiovascular risk were prospectively collected. Mean age of the cohort was 66 years and 71% were male. The previous history of coronary artery disease (CAD) was present in 19% (n = 63) and CAC was positive in all. In patients without known CAD (n = 261), CAC was present in 70% (n = 182) with a comparable prevalence between men and women, which raised the prevalence of coronary atherosclerosis to 76% (n = 245) for the entire cohort. The median CAC score was 170 (range 1 to 6,157) and largely in multivessel distribution in patients without known CAD. Presence of CAC increased with an increasing number of cardiovascular risk factors. Nevertheless, CAC was present in 58% (n = 40) of patients without conventional cardiovascular risk factors. If CAC score >100 was considered as CAD equivalent as 10-year risk of incident atherosclerotic cardiovascular diseases is >7.5% it would have resulted in higher CAD prevalence of 52% and significant reclassification of CHA2DS2-VASc score in 41% of patients without known CAD. In conclusion, coronary calcium is highly prevalent in AF patients, including those without cardiovascular risk factors. Advanced CAC can potentially shift CHA2DS2-VASc score in many AF patients. Our findings suggest that characterizing CAC in AF may be clinically valuable in thromboembolic risk stratification and management of preventive cardiac therapies.

Abstract 07: Association of Social Network Characteristics With Cardiovascular Health and Coronary Artery Calcium in South Asians: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study

Introduction: South Asian Americans (SAs) have disproportionately high burden of poor cardiovascular health (CVH) and CVD, which may be influenced by people within their social network (SN). We examined the association of SN characteristics and SN member (“alter”) health with CVH and coronary artery calcium (CAC) in SAs to identify targets for CVD prevention in this high-risk community. Hypothesis: Smaller SN size and worse alter health is associated with poor CVH and CAC in SAs. Methods: In 699 SAs in the MASALA Study, SN characteristics (size, density, proportion of kin or SA ethnicity), alter health status (self-report of an alter with high blood pressure [HTN], hyperlipidemia [HL], heart disease, diabetes, or stroke), CVH score (0-14, based on poor, intermediate, or ideal blood pressure, cholesterol, glucose, physical activity, diet, weight, and smoking), and CAC data were collected between 2016-2018. Multiple logistic regression evaluated the association of SN characteristics or alter health with prevalent CVH and CAC. Results: Participants were mean age 59±9 years and 43% women. Mean CVH score was 8.9±1.9, median CAC score 8 (range 0 - 4217). SNs were mean 6±3 people, density 79±26%, 72±28% kin, 88±23% SA ethnicity; 48% had an alter with HTN, 42% with HL, 18% with heart disease, 40% with diabetes, and 2% with stroke. A 1-person larger SN size was associated with a 19% higher odds of ideal vs. poor CVH in men (p=0.02), and an 11% lower odds of CAC in women (p=0.05, Table). In men, having at least 1 alter with HTN or HL was associated with a 58% or 54% lower odds of ideal vs. poor CVH (p=0.03, p=0.04), and having at least 1 alter with HL was associated with a 78% higher odds of CAC (p=0.05). No associations were seen between other SN characteristics, nor alters with other CVD risk factors, and CVH or CAC. Conclusions: In SAs, larger SN size was associated with better CVH. Having a SN member with HTN or HL may be associated with poorer CVH and CAC. Interventions to increase SN size or target SN member CVH may promote CVH in this high-risk population.

Abstract P126: Comparing Cardiovascular Risk Factor Progression Between South Asian Men and Women With Diabetes: A Longitudinal Analysis From the Masala Study

Introduction: South Asians have a high incidence of type 2 diabetes(DM) and cardiovascular disease (CVD). Women with DM may have greater CVD risk compared to men with DM and women without DM. No study has determined whether the incidence or progression of coronary artery calcium (CAC) score, a measure of atherosclerosis burden, differs between South Asian men and women with DM. Hypothesis: We hypothesize that CAC progression is greater in women with DM as compared to men with DM and women without DM. Methods: We used the data from the MASALA study, a community-based prospective cohort of South Asians from 2 clinical sites without CVD at baseline. We conducted a longitudinal analysis of diabetic participants who were reassessed after 5 years and compared with those without diabetes. We classified incident CAC as any CAC at exam 2 in a participant who had no CAC at baseline. To examine the progression of CVD risk factors over time, we compared change in CAC score, waist circumference, systolic and diastolic blood pressure, HbA1c and lipid levels amongst the diabetic and non-diabetic population by sex. We conducted multivariable linear regression models stratified by diabetes status to determine whether sex was independently associated with change in CAC score and other CVD risk factors. Results: Of 749 participants who were seen in follow-up, 176 (23%) had diabetes at baseline, 65% were men, and mean age was 58 years. Approximately 64% women with DM vs. 28% men with DM had CAC=0, and men had higher median CAC score (49 (IQR 0-247) vs. 0 (IQR 0-46, p&lt;0.001). After mean follow-up of 4.8±0.8 years, incident CAC did not differ between men and women with diabetes (p=0.85). Progression of CAC was greater in men with DM (94, IQR 13-290) compared to women with DM (0, IQR 0-30) (p &lt;0.001). Baseline statin and aspirin use was lower in women with DM (statins: 37% in women vs. 56% in men, p&lt;0.001; aspirin 16% in women vs. 43% in men, p&lt;0.001). In multivariable models, the fold-change in CAC in women (0.22, 95% CI 0.10 - 0.47) was lower than in men (4.54, 95% CI 2.08 - 9.89) and comparable to women without DM (0.30 95%CI 0.21 -0.43), after adjusting for age, baseline CAC, systolic and diastolic blood pressure, total and LDL cholesterol, duration of diabetes, smoking and any medication use (statin, diabetes, or hypertension med). Sex was not associated with change in any CVD risk factor among those with diabetes; but women without DM had greater change in total and LDL cholesterol and waist circumference than men without DM. Conclusion: In this South Asian population, change in CAC score was lower in women with DM than in men with DM, and was comparable to women without DM. These results suggest among South Asians with DM, overall CVD risk may be greater in men than in women.Continued follow-up of the MASALA cohort will determine whether there are sex differences in CVD outcomes.

The significance of coronary artery calcium score as a predictor of coronary artery stenosis in individuals referred for CT angiography.

Introduction: Cardiovascular diseases, including coronary artery disease (CAD), are among the most common causes of death in the elderly population. Recent studies have found that coronary artery calcium score (CACS) is a strong independent predictor of CAD. Here we aimed to investigate the association between CACS and demographic, clinical, laboratory, and CT angiographic findings inpatients with suspected CAD. Methods: From June 2008 to August 2018, we retrospectively reviewed 219 consecutive patients suspected with CAD who were referred for CT angiography in Rajaie Cardiovascular, Medical, and Research Center. Medical records were reviewed, and relevant demographic, clinical, laboratory and imaging were collected. Results: A total of 219 patients with an average age of 62.64±12.39 were included. Twelve patients(5.5%) had normal coronary angiography, and 50.2% had mild CAD. An obstructive CAD was found in97 patients (44.3%). The median CACS was 76.4 (IQR, 13.0-289.1). The frequency of obstructive CAD was 28.1% in the CACS <100 group, and 67.0% in CACS >100 group (P < 0.001). On multiple logistic regression analysis, age (OR=1.04 [1.01-1.07], P = 0.006), CACS (OR= 4.31 [2.33-7.98], P < 0.001), and neutrophil to lymphocyte ratio (NLR) (OR = 0.82 [0.68-0.98], P = 0.027) were independent predictors of obstructive CAD. Conclusion: We found a direct association between higher CACS and obstructive patterns in coronary CT angiography. Our findings indicate that the possibility of the presence of obstructive CAD was higher among symptomatic patients with older age, lower NLR, and CACS >100.

Coronary artery calcification is associated with mortality independent of pulmonary embolism severity: a retrospective cohort study

To assess coronary artery calcification (CAC) and vascular calcification in patients with pulmonary embolism (PE) and correlate this with mortality. PE severity was quantified using computed tomography pulmonary angiography (CTPA) in 400 consecutive cases using the modified Miller score (1-5, mild; 6-11, moderate; 12-16, severe). Right ventricle strain was assessed using the right/left ventricle diameter (RV/LV) ratio. CAC score (CACS) was assessed using a four-point scale (CACS mild 1-3, moderate 4-8, severe 9-12) for each vessel and summed to give the total CACS. Follow-up for mortality was obtained at 3 years. PE severity was classified as mild in 48%, moderate in 21%, and severe in 32% of cases. The median modified Miller score was 6 (Interquartile range [IQR] 2, 14) and median total CACS was 2 (IQR 0, 7). All-cause mortality occurred in 128 (32%) patients. Patients with CAC were three times more likely to die than patients without CAC (Hazard ratio [HR] 2.96; 95% CI 1.84, 4.77; p<0.001), and patients with severe CAC were at the highest risk (HR 4.62; 95% CI 2.73, 7.83, p<0.001). Gender, modified Miller score and RV/LV ratio were not predictive of mortality. In multivariate analysis both CACS and age were independent predictors of 3-year all-cause mortality. Of the patients with CAC who died, the presence of coronary artery disease was only documented in 34 (32%). CACS is an independent predictor of all-cause mortality in patients with PE, and has important implications for subsequent patient management.

False-Negative Low Tube Voltage Coronary CT Angiography: High Intravascular Attenuation at Coronary CT Angiography Can Mask Calcified Plaques.

To determine the impact of low tube voltage coronary CT angiography on detection of subclinical atherosclerosis. Retrospective sampling of an emergency department coronary CT angiography registry was performed. All patients in the registry underwent a noncontrast coronary artery calcium (CAC) scoring scan at 120 kV before coronary CT angiography. The study sample (n = 264) constituted patients with subclinical atherosclerosis (Coronary Artery Disease Reporting and Data System™ [CAD-RADS] 1 or 2) randomly mixed one-to-one with patients without atherosclerosis (CAD-RADS 0). The patients with coronary CT angiography performed at 70-90 kV were considered the low tube voltage group (n = 159) and patients with coronary CT angiography performed at 100-120 kV were considered the standard tube voltage group (n = 105). The number of coronary plaques and overall CAD-RADS classification (per patient) were evaluated twice: initially, by reading coronary CT angiography alone, and then, by coronary CT angiography in combination with a CAC scan. Considering the combined reading (CT angiography plus CAC scan) as the reference standard, the performance of coronary CT angiography alone was assessed for plaque detection and appropriate CAD-RADS (per patient) classification. The comparisons were made between the low tube voltage and standard tube voltage groups by using a Fisher exact test and χ2 test for proportions and a Mann-Whitney test and Kruskal-Wallis test for means. In total, 455 plaques were identified in 118 patients (70 of 159 patients in the low tube voltage group; 48 of 105 in the standard tube voltage group). When reading coronary CT angiographic images alone, 97 of 455 (21%) plaques were missed that led to an incorrect CAD-RADS classification in 16 of 264 (6%) studies (interpreted as CAD-RADS 0 instead of CAD-RADS 1 or 2). Missed plaques were significantly more frequent in the low tube voltage group versus the standard tube voltage group (41% [85 of 206] vs 5% [12 of 249], respectively; P < .001). Incorrect CAD-RADS classification was also seen more commonly in the low tube voltage group (8.8% [14 of 159] vs 2% [two of 105]; P = .01), typically at low plaque burden (median CAC score, 1; range, 1-4). Calcified plaques that appeared isodense to luminal contrast material attenuation were seen more frequently in the low tube voltage group compared with the standard tube voltage group (20% [32 of 159] vs 7.6% [eight of 105], respectively; P = .005). Coronary artery plaques may be missed at low tube voltage coronary CT angiographic examination performed without a concomitant CAC scan.© RSNA, 2019Supplemental material is available for this article.See also the commentary by Truong in this issue.

Different type and dosage of heparin were not associated with the progression of coronary artery calcification in haemodialysis patients

ABSTRACTAimSeveral studies have verified that unfractionated heparin (UFH) and low molecular heparin (LWMH) can induce bone loss, and bone mineral density has been inversely associated with vascular calcification in some clinical researches. But few have focused on the relationship between types and dosages of heparin and the progression of vascular calcification. We observed the progression of coronary artery calcification (CAC) in maintenance haemodialysis (MHD) patients who were treated with UFH and LMWH.MethodsThis was a prospective prevalent cohort study of MHD patients. Computed tomography was performed at enrolment and 2 years after enrolment, and CAC score was obtained. Demographic and clinical data, baseline and time‐average laboratory indices were collected. Multiple linear regression and logistic regression were used to estimate the influencing factors of progression of CAC.ResultsIn this study, (i) we initially enrolled 69 HD patients, and then 56 patients finished the follow‐up. (ii) Among the total 56 patients, 27 patients (48.2%) were treated with UFH, 14 (25.0%) with LMWH and 15 (26.8%) with both. The median baseline CAC scores of three groups (UFH, LMWH and both users) were 91.0 (1.0, 1052.0), 134.0 (0, 1292.0) and 250.5 (27.0, 1139.0), respectively, with no significant difference (P = 0.663); the median CAC progression scores were 42.0 (0, 364.0), 172.0 (7.0, 653.0) and 118.5 (0, 434.0), respectively, with no significant difference (P = 0.660). (iii) Pearson and spearman correlation analysis shown that the progression of CAC was not associated with cumulative dosage of heparin used. (iv) After adjusted for diabetes mellitus, time‐averaged intact parathyroid hormone, phosphate and alkaline phosphatase, logistic regression analysis showed using different types of heparin was not an independent risk factor for CAC progression; and multiple linear regression analysis showed that the type of heparin used was not associated with CAC progression.ConclusionThere were no significant differences in the effects of the types and dosages of heparin on CAC progression in patients on haemodialysis.

Duration of type 2 diabetes mellitus and systolic blood pressure as determinants of severity of coronary stenosis and adverse events in an asymptomatic diabetic population: PROCEED study

BackgroundEvidence from imaging studies suggests a high prevalence of coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). However, there are no criteria for initiating screening for CAD in this population. The current study investigated whether clinical and demographic characteristics can be used to predict significant CAD in patients with T2DM.MethodsComputed tomography coronary angiography (CTCA) and laboratory assessments were performed in 259 patients diagnosed with T2DM attending clinics in Northwest London, UK. Coronary artery calcium (CAC) was calculated during CTCA. Significant plaque was defined as one causing more than 50% luminal stenosis. Associations between groups and variables were evaluated using Student’s t test, Chi-square tests and univariate and multivariate regression analysis. P < 0.05 was considered statistically significant.ResultsAmong patients with a median duration of T2DM of 13 years and a mean age of 62.0 years, median CAC score was 105.91 Agatston Units. In a multivariate analyses, duration of diabetes, CAC score and the presence and number of coronary artery plaques and presence of significant plaque were significant predictors of cardiovascular adverse events. Systolic blood pressure (SBP) had borderline significance as a predictor of cardiovascular events (p = 0.05). In a receiver operating characteristic curve (ROC) analysis, duration of diabetes of > 10.5 years predicted significant CAD (sensitivity, 75.3%; specificity 48.2%). Area under the ROC curve was 0.67 when combining duration of T2DM > 10.5 years and SBP of > 139 mm Hg. Adverse cardiovascular events after a median follow-up of 22.8 months were also significantly higher in those with duration of T2DM > 10.5 years and SBP > 140 mm Hg (log rank p = 0.02 and 0.009, respectively).ConclusionsRoutine screening for CAD using CTCA should be considered for patients with a diagnosis of T2DM for > 10.5 years and SBP > 140 mm Hg.Trial registration Clinicaltrials.gov identifier: NCT02109835, 10 April 2014 (retrospectively registered)

Influence of coronary calcification on hyperemic response during fractional flow reserve measurements

AimDuring invasive fractional flow reserve (FFR) adenosine and nitrates are used to obtain maximal hyperemia. Severe coronary artery calcification (CAC) is associated with impaired vasodilation. We investigated the hyperemic response during FFR in vessels with severe versus mild CAC. Methods and resultsWe retrospectively selected 236 patients who underwent both CAC scoring and invasive FFR. FFR was performed in 304 vessels with intermediate stenoses. Delta (Δ) FFR, the pressure gradient before the administration of adenosine minus FFR after the administration of adenosine, was used to investigate the hyperemic response. Mean age of the total population was 65 ± 10 years, 65% was male. Median CAC score was 510 (range 0 to 6141). Mean pressure gradient before the administration of adenosine was comparable in vessels with severe versus mild CAC. FFR was more often ≤0.80 in vessels with severe CAC (p = 0.045). Patients with a large Δ FFR were younger (p = 0.05). There was no association between Δ FFR and severity of calcifications. Regression analysis did not demonstrate an association between CAC score and the hyperemic response (p = 0.49). ConclusionWe did not find an association between the severity of CAC and the hyperemic response during invasive FFR.

Coronary Calcification and Male Gender Predict Significant Stenosis in Symptomatic Patients in Northern and Southern Europe and the USA: A Euro-CCAD Study

Background and Aims: Significant stenosis is the principal cause of stable angina but its predictors and their variation by geographical region are unclear.Methods and Results: From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 5515 symptomatic patients from northern Europe (Denmark, France, Germany), southern Europe (Italy, Spain) and USA. All had conventional cardiovascular risk factor assessment, angiography and CT scanning for coronary artery calcium (CAC) scoring. There were differences in the patient characteristics between the groups, with the USA patients being younger and having more diet and lifestyle-related risk factors, although hypertension may have been better controlled than in Europe. USA patients had a two-fold increase in prevalence of significant stenosis and a three-fold increase in median CAC score. In all three groups, the log CAC score proved to be the strongest predictor of &gt;50% stenosis followed by male gender. In the USA group, there were no additional independently predictive risk factors, although in northern Europe obesity, hypertension, smoking and hypercholesterolaemia remained predictive, with all risk factors other than hypertension proving to be predictive in the southern Europe group. Without the CAC score as a variable, male gender followed by diabetes were the most important predictors in all three regions, with hypertension also proving predictive in northern Europe.Conclusion: In symptomatic patients, the CAC score and male gender were the two most important predictors of significant stenosis in symptomatic patients in northern and southern Europe and the USA.