Risk Of Adverse Coronary Events Research Articles

The Pharmacological Approach to Oncologic Patients with Acute Coronary Syndrome.

Among acute coronary syndrome (ACS) patients, 15% have concomitant cancer, especially in the first 6 months after their diagnosis, as well as in advanced metastatic stages. Lung, gastric, and pancreatic cancers are the most frequent malignancies associated with ACS. Chemotherapy and radiotherapy exert prothrombotic, vasospastic, and proinflammatory actions. The management of cancer patients with ACS is quite challenging: percutaneous revascularization is often underused, and antiplatelet and anticoagulant pharmacological therapy should be individually tailored to the thrombotic risk and to the bleeding complications. Sometimes oncological patients also show different degrees of thrombocytopenia, which further complicates the pharmacological strategies. The aim of this review is to summarize the current evidence regarding the treatment of ACS in cancer patients and to suggest the optimal management and therapy to reduce the risk of adverse coronary events after ACS in this high-risk population.

Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris

Recent European guidance supports a diminished role for exercise electrocardiography (ECG) in the assessment of suspected stable angina. To evaluate the utility of exercise ECG in contemporary practice and assess the value of combined functional and anatomical testing. This is a post hoc analysis of the Scottish Computed Tomography of the Heart (SCOT-HEART) open-label randomized clinical trial, conducted in 12 cardiology chest pain clinics across Scotland for patients with suspected angina secondary to coronary heart disease. Between November 18, 2010, and September 24, 2014, 4146 patients aged 18 to 75 years with stable angina underwent clinical evaluation and 1417 of 1651 (86%) underwent exercise ECG prior to randomization. Statistical analysis was conducted from October 10 to November 5, 2019. Patients were randomized in a 1:1 ratio to receive standard care plus coronary computed tomography (CT) angiography or to receive standard care alone. The present analysis was limited to the 3283 patients who underwent exercise ECG alone or in combination with coronary CT angiography. The primary clinical end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years. Among the 3283 patients (1889 men; median age, 57.0 years [interquartile range, 50.0-64.0 years]), exercise ECG had a sensitivity of 39% and a specificity of 91% for detecting any obstructive coronary artery disease in those who underwent subsequent invasive angiography. Abnormal results of exercise ECG were associated with a 14.47-fold (95% CI, 10.00-20.41; P < .001) increase in coronary revascularization at 1 year and a 2.57-fold (95% CI, 1.38-4.63; P < .001) increase in mortality from coronary heart disease death at 5 years or in cases of nonfatal myocardial infarction at 5 years. Compared with exercise ECG alone, results of coronary CT angiography had a stronger association with 5-year coronary heart disease death or nonfatal myocardial infarction (hazard ratio, 10.63; 95% CI, 2.32-48.70; P = .002). The greatest numerical difference in outcome with CT angiography compared with exercise ECG alone was observed for those with inconclusive results of exercise ECG (5 of 285 [2%] vs 13 of 283 [5%]), although this was not statistically significant (log-rank P = .05). This study suggests that abnormal results of exercise ECG are associated with coronary revascularization and the future risk of adverse coronary events. However, coronary CT angiography more accurately detects coronary artery disease and is more strongly associated with future risk compared with exercise ECG. ClinicalTrials.gov Identifier: NCT01149590.

P1469Comparison prognostic values of coronary flow velocity assessment and ejection fraction during routine echocardiography

Abstract Background Ejection fraction (EF) is a parameter that has traditionally been used for prognostic aims during echocardiography. However, it is known that its prognostic role is accurate only if EF has clearly decreased. So, in the large group of patients who had no prior myocardial infarction, with normal EF but with severe narrowing of main coronary arteries, it is impossible to predict a high risk of adverse coronary events in the near future with transthoracic echocardiography at rest. The aim of the study was to compare prognostic values of coronary flow velocity assessment and EF during transthoracic echocardiography. Methods A prospective cohort study comprises 747 patients (380 males; age 58+13 years) referred for echocardiography. Left side coronary artery (left main - LM, left descending – LAD, and circumflex arteries -LCx) flows were scanned in addition to conventional echocardiography. Cardiac death, nonfatal myocardial infarction (MI), acute coronary syndrome and revascularization were defined as major adverse cardiac events (MACE). The period of follow-up was 3 years. Results During a median follow-up of 36 months, 192 patients experienced 224 MACE. Twenty-six deaths, 16 non-fatal MI, 2 acute coronary syndromes, 180 revascularizations were observed. EF and maximal velocity in proximal segments of coronary arteries were independents predictors of death/MI/acute coronary syndromes. The maximal velocity had a significantly higher predictive value (p&lt;0.004) in the whole group (Figure 1A) as well as among the patients with near normal/normal EF (Figure 1B, 1C). The maximal velocity had a significantly higher predictive value (p&lt;0.0001) of MACE (Figure 1D). Conclusion Coronary artery scan assessment had the statistically significantly higher predictive accuracy of MACE in comparison with traditional EF in the whole group and in the subgroups with different degrees of decreasing EF.

Therapeutic strategies for ischemic heart disease

Abstract The original concept of onco-cardiology was developed as cardiotoxicity associated with anticancer treatment; however, recently, the number of cases in which atherosclerotic cardiovascular diseases coexist with malignant diseases has increased, and increasing attention is being paid to the relationship between malignant diseases and cardiovascular diseases, based on the long-term surveillance of cancer survivors. Several studies have described a high risk of cardiovascular disease events in cancer survivors. Similarly, a history of cardiovascular disease also confers higher risk incident cancer. Thus, this relationship has been drawing attention as a new aspect of onco-cardiology. The most troublesome issue in cancer patients is antithrombotic therapy. The clinical benefits of using dual anti-platelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with ischemic heart diseases (acute coronary syndrome (ACS) or after percutaneous coronary intervention [PCI]) has been well established; premature discontinuation of DAPT increases the risk of adverse coronary events in those patients. In this joint symposium by JSMO and the Japanese Circulation Society(JCS), we present therapeutic strategies for ischemic heart disease.

Coronary Vessel Wall Imaging: State of the Art and Future Directions

The purpose of this paper is to review the latest advancements and developments in non-invasive coronary magnetic resonance (MR) and hybrid positron emission tomography (PET)/MR imaging. Coronary MRI has advanced in recent years in different aspects, especially regarding technical developments, scan protocols, and molecular probes. Recently introduced hybrid PET/MR scanners have already demonstrated great potential in improving cardiovascular imaging. Coronary atherosclerosis and acute myocardial infarction remain major threats to physical health worldwide. Several techniques, from invasive intravascular imaging to non-invasive imaging methods, are studied extensively to identify patients with vulnerable plaques at risk for adverse coronary events. While imaging of vulnerable plaques is getting more and more sophisticated, the clinical impact of molecular plaque imaging on prognosis and disease management still has to be fully defined.

Optimal management of cancer patients with acute coronary syndrome.

Cancer at various stages and therapy is observed in about 15% of patients with acute coronary syndrome (ACS). Current guidelines for invasive and conservative treatment of ACS cannot be applied to all patients with cancer. The choice of antiplatelet and anticoagulant drugs should be individualized with clopidogrel as a key P2Y12 inhibitor in this population. Major challenges of therapy in patients with ACS and cancer include limitations for the use of the recommended antithrombotic therapy (particularly in case of cancer-related thrombocytopenia or when anticoagulation is needed due to concomitant atrial fibrillation or venous thromboembolism), the management of bleeding complications, eligibility criteria for cancer surgery, and reinitiation of chemotherapy or radiotherapy after ACS. This review summarizes the current evidence and our own experience in the treatment of ACS in cancer patients. Since prognosis has considerably improved in many cancer patients in the last decade, optimal therapy of ACS may increase the life expectancy and reduce the risk of adverse coronary events after ACS in this high-risk population.

Will Diet and Exercise Save Us All?

Will Diet and Exercise Save Us All?

CRT-200.66 Biomechanical and Geometric Analysis of Left Coronary Artery Bifurcation Motion and Compliance: Implications for Stent Development and Evaluation

Coronary bifurcation stenting is associated with an increased risk of adverse coronary events compared to other regions stented. The purpose of this study was to quantify the motion of the left coronary artery bifurcations over the cardiac cycle and determine differences in vascular geometry, motion

Study of Correlation of Raised Crp Levels in Premenopausal and Postmenopausal Females with Hypothyroidism: Raised Crp Levels in Hypothyroidism

Abstract Objective To evaluate the correlation of raised CRP levels in premenopausal and postmenopausal females with hypothyroidism and to assess the future risk of adverse coronary events amongst them. Methodology This was a prospective,observational,cross-sectional,analytical study,conducted in department of cardiology and medicine,Gandhi medical college,Hamidia hospital,Bhopal from October 2013 to October 2014.Patients having hypothyroidism were subjected to this study. Age matched controls were selected randomly. Purpose of this study was explained and informed consent was obtained. Results Percentage of raised CRP levels in hypothyroid premenopausal females was 13.3% and in hypothyroid postmenopausal females was 24.4%. CRP levels were raised only in 3.3% of premenopausal control group and in 10% of postmenopausal control group. Conclusion This study showed that there is strong association of raised CRP levels with hypothyroidism in both premenopausal and postmenopausal females.

REGRESSED CORONARY ANEURYSM AFTER KAWASAKI DISEASE: AN OPTICAL COHERENCE TOMOGRAPHY (OCT) STUDY FROM A SINGLE INSTITUTION

Coronary artery aneurysms (CAA) are a serious complication of Kawasaki disease (KD). CAA size regresses in nearly 50% of the cases on follow up. Nevertheless, patients with regressed CAA have an increased risk of ischemic heart disease, myocardial infarction and sudden cardiac death on long-term follow-up. Actual imaging techniques often describe these segments as normal, whereas studies have shown significant endothelial and smooth muscle dysfunction. Optical Coherence Tomography (OCT) is a high-resolution intracoronary imaging modality that characterizes coronary artery wall structure. KD patients scheduled for routine coronary angiography underwent OCT imaging between March 2013 and April 2015. The aim of the study was to compare microstructural coronary changes in coronary artery segments with no history of CAA to segments with regressed CAA, and segments with persistent CAA. OCT was performed on 27 patients at 12.4 ± 5.5 years, 9.3 ± 5.3 years following onset of KD. Overall, 22/27 (81.5%) had a history of CAA. Of those, 11/22 (50.0%) had regressed CAA at time of OCT. Data was analyzed according to echocardiographic and angiographic progress of CAA segments. All 19/19 (100.0%) persistent CAA segments and 20/23 (87.0%) regressed CAA segments had significant intimal hyperplasia, compared to 2/19 (10.5%) with no history of segmental CAA (P<0.001), amounting 475.0 ± 179.1 μm, 305.4 ± 164.2 μm and 79.6 ± 78.2 μm respectively (p<0.001). Also, partial disappearance of the media was found more frequently in segments with persistent CAA, 17/19 (89.5%), followed by segments with regressed CAA, 12/23 (52.2%), and those with no history of CAA, 1/19 (5.3%); p<0.001. Neovascularization was found more often in segments with persistent CAA, 8/19 (42.1%), compared to segments with regressed CAA, 3/23 (13.0%), and no history of CAA, 0/19; p=0.002. Calcifications were identified almost exclusively in patients with persistent CAA, 6/19 (31.6%), compared to 1/23 (4.3%) for segments with regressed CAA and 0/19 for segments with no history of CAA (p=0.004). Macrophage accumulation was identified more often in segments with persistent CAA compared to those with regressed CAA and no history of CAA, in 10/19 (52.6%), 3/23 (13.0%) and 3/19 (15.8%) respectively (p=0.007). Despite normal angiographic appearance, regressed CAA segments displayed significant intimal hyperplasia and disruption of the media, among other anomalies, similarly to segments with persistent CAA. These features represent an increased risk for adverse coronary events. The additional diagnostic value of OCT following KD may bring prognostic potential in future chronological series.View Large Image Figure ViewerDownload (PPT)

Abstract 163: Regressed Coronary Aneurysm after Kawasaki Disease: What are they hiding? An Optical Coherence Tomography (OCT) study

Background: Coronary artery aneurysms (CAA) are a serious complication of Kawasaki disease (KD). Regression of CAA occurs in 50% of the cases on follow up. Actual imaging techniques often described these segments as normal, whereas studies have shown significant endothelial and smooth muscle dysfunction. Method: KD patients scheduled for angiographic follow-up between June 2013 and August 2014 underwent OCT imaging. We compared coronary intimal changes in coronary artery segments with no history of CAA to segments with regressed CAA, and segments with persistent CAA. The intima was measured in sections adjacent to the CAA for the segments with persistent CAA, at the former CAA and adjacent sections for those who regressed, and at various corresponding sections for segments with no history of CAA. Results: OCT was performed on 18 patients at 12.4 ± 5.5 years. Overall 14/18 (77.7%) had a history of CAA. Of those, 7/14 (50.0%) had regressed CAA at time of OCT. Data was analyzed according to echocardiographic and angiographic progress of CAA segments. Accordingly, all 18/18 persistent CAA segments and 11/11 regressed CAA segments had significant intimal hyperplasia, compared to 1/13 with no history of segmental CAA (P&lt;0.001). The intensity of intimal hyperplasia is displayed in Table 1. Conclusion: Despite normal angiographic features, regressed CAA segments displayed significant intimal hyperplasia, similarly to those with persistent CAA. These features may present a risk of adverse coronary events.

Fibromyalgia is associated with coronary heart disease: a population-based cohort study.

We examined whether patients with a diagnosis of fibromyalgia have an increased risk of coronary heart disease (CHD), compared with age- and sex-matched control patients. We hypothesized that patients diagnosed with fibromyalgia are at increased risk of adverse coronary events. Using a matched-cohort study design, we analyzed data retrieved from the Longitudinal Health Insurance Database 2000 released by the National Health Research Institute, Taiwan. The Longitudinal Health Insurance Database 2000 includes medical claims data and registration files for 1 million enrollees randomly selected from the 2000 Registry for Beneficiaries (n = 23.72 million) of the National Health Insurance program. Patients treated for fibromyalgia at least once a month for 3 consecutive months following their initial diagnosis were enrolled in our study. The primary end point was the composite of CHD events, including percutaneous coronary interventions and coronary artery bypass grafting procedures. A propensity score was estimated by a logistic regression method, in which the fibromyalgia status was regressed on baseline prognostic factors. The hazard ratios and the 95% confidence intervals were estimated using multivariate Cox proportional-hazards regression models while adjusting for the propensity score. After adjusting for the propensity score, the patients with fibromyalgia showed a significantly higher subsequent risk of a CHD event (hazard ratio, 2.11; 95% confidence interval, 1.46-3.05; P < 0.001) than the patients without fibromyalgia. An association between fibromyalgia and CHD appears to exist.

Should ethnicity be included in cardiovascular risk stratification?

Assessment of patients’ individual cardiovascular risk is common in routine clinical practice. However, the traditional risk factors to stratify risk are based on population estimates and may not directly apply to the individual patient. Patients with a high calculated cardiovascular risk may not suffer an event and vice versa. The Framingham score estimates the 10-year risk of a cardiovascular event based on several clinical and laboratory variables. Ethnicity is known to be related to risk of cardiovascular disease (CVD), but is not included in most risk scores. Also, differences in traditional risk factors do not fully explain the racial differences in CVD risk. To improve the ability to predict individual events, new biomarkers and imaging methods are currently being evaluated. Imaging for atherosclerosis using coronary artery calcium (CAC) and carotid intima media thickness (CIMT) may offer a valuable tool in this approach and is recommended (class IIa) in asymptomatic adults at moderate risk in the current ESC guidelines on cardiovascular disease prevention in clinical practice [1]. Multiple studies have evaluated the association of CAC scores with risk for adverse coronary events, but only a few studies have distinguished between subjects from different ethnic groups. In this issue of the Netherlands Heart Journal, Erqou et al. [2] assessed the racial differences in the burden of CAC and CIMT between Blacks and Whites using data from an on-going community-based prospective cohort study (heart SCORE). The authors conclude that Black race is independently associated with greater CIMT but less CAC than White race, also after adjustment for traditional risk factors. A correlation between ethnicity, CAC, and events was previously reported in the Multi-Ethnic Study of Atherosclerosis (MESA), a large prospective, population-based study of samples from six urban communities [3, 4]. It was reported that the prevalence and extent of coronary calcification differ substantially among ethnic groups [3]. In the MESA study, CAC was measured to predict coronary events in four major ethnic groups [4]. After a median follow-up of nearly 4 years, a strong correlation was found between calcium scores and coronary risk. Adjusting for standard risk factors, a doubling of the CAC score was associated with a 25 % increase in the risk for a major event. However, the association was independent of ethnicity. Unfortunately, Erqou et al. [2] do not present data on cardiovascular events to relate their results to future cardiovascular events. The novelty of the work by Erqou et al. lies in the additional biochemical marker analysis assessment. Six markers were analysed, i.e. small-dense low-density lipoprotein (sdLDL), high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), soluble intercellular adhesion molecule 1 (sICAM-1), CD40 ligand (CD40L), and endostatin. Small-dense LDL was positively associated with increased CIMT (similar association among Blacks and Whites) and IL-6 concentration was positively associated with higher CAC among Blacks (trend in Whites). IL-6 is a promising biomarker for linking inflammation to future vascular events [5]. As the authors suggest, the low CAC and high IL-6 in the Black population might reflect less calcified coronary lesions and a higher inflammatory state and therefore a patient at risk for future cardiac events. This could, hypothetically, be associated with the higher risk of CVD in Blacks. Further studies are needed to confirm such a difference in atherosclerotic pathophysiology between ethnic groups. In conclusion, this study confirms the earlier findings that CAC and CIMT values differ among ethnic groups and points to specific biomarkers that might be used to create race-specific algorithms for risk stratification. Hopefully, in the near future, we may further determine how these tests can be used to achieve better outcomes for individual patients.

Comparative coronary risks of apixaban, rivaroxaban and dabigatran: a meta‐analysis and adjusted indirect comparison

There are concerns regarding increased risk of acute coronary syndrome with dabigatran. We aimed to assess whether alternative treatment options such as rivaroxaban or apixaban carry a similar risk as compared with dabigatran. We searched MEDLINE and EMBASE for randomized controlled trials of apixaban, dabigatran or rivaroxaban against control (placebo, heparin or vitamin K antagonist). We pooled odds ratios (OR) for adverse coronary events (acute coronary syndrome or myocardial infarction) using fixed effect meta-analysis and assessed heterogeneity with I(2) . We conducted adjusted indirect comparisons to compare risk of adverse coronary events with apixaban or rivaroxaban vs. dabigatran. Twenty-seven randomized controlled trials met the inclusion criteria. Dabigatran was associated with a significantly increased risk of adverse coronary events in pooled analysis of nine trials (OR 1.45, 95% CI 1.14, 1.86). There was no signal for coronary risk with apixaban from nine trials (pooled OR 0.89, 95% CI 0.78, 1.03) or rivaroxaban from nine trials (pooled OR 0.81, 95% CI 0.72, 0.93). Overall, adjusted indirect comparison suggested that both apixaban (OR 0.61, 95% CI 0.44, 0.85) and rivaroxaban (OR 0.54; 95% CI 0.39, 0.76) were associated with lower coronary risk than dabigatran. Restricting the indirect comparison to a vitamin K antagonist as a common control, yielded similar findings, OR 0.57 (95% CI 0.39, 0.85) for apixaban vs. dabigatran and 0.53 (95% CI 0.37, 0.77) for rivaroxaban vs. dabigatran. There are significant differences in the comparative safety of apixaban, rivaroxaban and dabigatran with regards to acute coronary adverse events.

Long-Term Risk of Coronary Events after AKI

The incidence rate of AKI in hospitalized patients is increasing. However, relatively little attention has been paid to the association of AKI with long-term risk of adverse coronary events. Our study investigated hospitalized patients who recovered from de novo dialysis-requiring AKI between 1999 and 2008 using patient data collected from inpatient claims from Taiwan National Health Insurance. We used Cox regression with time-varying covariates to adjust for subsequent CKD and ESRD after discharge. Results were further validated by analysis of a prospectively constructed database. Among 17,106 acute dialysis patients who were discharged, 4869 patients recovered from dialysis-requiring AKI (AKI recovery group) and were matched with 4869 patients without AKI (non-AKI group). The incidence rates of coronary events were 19.8 and 10.3 per 1000 person-years in the AKI recovery and non-AKI groups, respectively. AKI recovery associated with higher risk of coronary events (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.36 to 2.04) and all-cause mortality (HR, 1.67; 95% CI, 1.57 to 1.79) independent of the effects of subsequent progression to CKD and ESRD. The risk levels of de novo coronary events after hospital discharge were similar in patients with diabetes alone and patients with AKI alone (P=0.23). Our results reveal that AKI with recovery associated with higher long-term risks of coronary events and death in this cohort, suggesting that AKI may identify patients with high risk of future coronary events. Enhanced postdischarge follow-up of renal function of patients who have recovered from temporary dialysis may be warranted.

Assessment of coronary atherosclerosis using optical coherence tomography.

Optical coherence tomography (OCT) is a catheter-based imaging system that uses near-infrared light to produce cross-sectional images of the coronary arteries. With its extraordinarily high resolution (10-20 μm), OCT allows clinicians to observe various morphological features of coronary atherosclerosis in vivo. For example, intimal thickening presents as homogeneous, signal-rich regions on OCT, while fibroatheroma with a lipid-rich necrotic core is characterized by the presence of signal-poor regions with a diffuse border. Furthermore, plaque rupture is detected in 50〜70% of culprit lesions of acute coronary syndrome (ACS), and plaque erosion develops over areas of intimal thickening and/or thick-cap fibroatheroma. Meanwhile, calcified nodules are common in older patients with hypertension and chronic renal disease. Platelet-rich thrombi are visualized as low backscattering structures and often detected in patients with unstable angina, whereas red blood cell-rich thrombi exhibit a high backscattering structure with signal-free shadowing and are frequently noted in patients with acute myocardial infarction. Moreover, OCT-derived thin cap fibroatheroma has been shown to be a predictor of subsequent plaque progression and acute coronary events, while vasa vasorum and the macrophage density are associated with a thin fibrous cap and large necrotic core as well as increased serum levels of inflammatory biomarkers. One current challenge of OCT examinations is to detect morphologic characteristics capable of discriminating vulnerable from stable plaques. The ability to detect vulnerable plaques in vivo would allow physicians to identify patients at high risk for adverse coronary events, thus significantly helping to prevent ACS.

Implications of Gender Difference in Coronary Calcification as Assessed by CT Coronary Angiography.

BACKGROUNDArterial calcium as measured by 64-slice computed tomography coronary angiography (64-CT) is a reliable predictor of cardiovascular disease risk. Lipid-rich plaques with lower degrees of calcification may pose greater risk for adverse coronary events than more stabilized calcified plaques as a result of the increased risk of plaque rupture, migration, and subsequent acute coronary syndrome. We sought to examine coronary artery calcium scores as measured via 64-CT to assess the extent of calcification and plaque distribution in women compared to men.METHODSA total of 138 patients referred for 64-CT were evaluated. Computerized tomographic angiography was performed using the GE LightSpeed VCT. Subgroup analysis comparing male and female data (including demographic data) was performed. All major coronary arteries were analyzed for coronary stenosis/plaque characterization as well as total vessel calcium (Agatston) score quantification. Patient demographics and coronary risk factors were recorded.RESULTSA total of 552 coronary arteries were evaluated in 138 patients (85 men, 53 women). The average age for females was 64.4 ± 10.8 years and for males 60.0 ± 12.8 years. The only demographic/cardiovascular risk factor in which the difference between men and women was significant was smoking history, where 23.5% of men had a history of smoking while only 9.6% of females endorsed having a smoking history (P < 0.044). On comparison of all total vessel calcium scores, males had a higher total mean calcium score than females in each individual vessel. The results were as follows for males versus females, respectively: left main total vessel calcium score 46.49 versus 16.71 (P = 0.167); left anterior descending 265.21 versus 109.6 (P < 0.003); left circumflex 130.5 versus 39.7 (P < 0.004); and right coronary 213.5 versus 73.8 (P < 0.01). The odds of having a total calcium score >100 (versus not) was 3.62 times greater in males relative to females, given that all the other cardiovascular risk factors are adjusted for (95% confidence interval: 1.37–9.54). On average, men had an average of 2.1 ± 1.5 epicardial vessels with a calcium score ≥11 compared to 1.3 ± 1.4 for women (P < 0.005).CONCLUSIONThere are clear differences between males and females regarding total vessel calcium scores and therefore risk of future adverse coronary events. Males tended to have higher average calcium scores in each coronary artery than females with a greater tendency to have multiple vessel involvement. Using this information, more large-scale, randomized controlled studies should be performed to correlate differences in the extent of coronary calcification with the observed variance in clinical presentation during coronary events between males and females as a means to potentially establish gender-specific therapeutic regimens.

Co-Existence of Carotid Artery Disease, Renal Artery Stenosis, and Lower Extremity Peripheral Arterial Disease in Patients With Coronary Artery Disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Coronary calcium quantification using contrast‐enhanced dual‐energy computed tomography scans

The purpose of this study is to evaluate a direct measure of calcium burden by using dual‐energy computed tomography (DECT) during contrast‐enhanced coronary imaging, potentially eliminating the need for an extra noncontrast X‐ray acquisition. The ambiguity of separation of calcium from contrast material on contrast‐enhanced images was solved by using virtual noncontrast images obtained by DECT. A new threshold CT number was required to detect the calcium carrying potential risk for adverse coronary events on virtual noncontrast images. Two methods were investigated to determine the 130 HU threshold for DECT scoring. An in vitro anthropomorphic phantom with 29 excised patient calcium plaques inserted was used for both a linear and a logistic regression analysis. An IRB approved in vivo prospective study of six patients was also performed to be used for logistic regression analysis. The threshold found by logistic regression model to define the calcium burden on virtual noncontrast images detects the calcium carrying potential risk for adverse coronary events correctly (2.45% error rate). DECT calcium mass and volume scores obtained by using the threshold correlates with both conventional Agatston and volume scores (r=0.98,p<0.001). A conventional CT cardiac exam requires two scans, including a noncontrast scan for calcium quantification and a contrast‐enhanced scan for coronary angiography. With the ability to quantify calcium on DECT contrast‐enhanced images, a DECT cardiac exam could be accomplished with one contrast‐enhanced scan for both calcium quantification and coronary angiography.PACS numbers: 87.57.Q, 87.57.N

Renal angioplasty for atherosclerotic renal artery stenosis

Atherosclerotic renal artery stenosis (ARAS) is frequently associated with concomitant coronary and peripheral arterial disease with a significant impact on cardiovascular morbidity and mortality. Renal angioplasty of ARAS is more challenging because of increased incidence of technical failures, complications, and restenosis; while there is barely perceptible control of hypertension and only marginal improvement in renal function. This is because most of the patient population in recent randomized trials had unmanifested or clinically silent renovascular disease. Manifestations of RAS should be looked for and incorporated in the management plan particularly before deciding for revascularization. In the absence of clinical manifestation like renovascular hypertension, ischemic nephropathy, left ventricular failure, or unstable coronary syndromes; mere presence of RAS is analogous to presence of concomitant peripheral arterial disease which increases risk of adverse coronary events. Dormant-RAS in the absence of any manifestations can be managed with masterly inactivity. Chronological sequence of events and clinical condition of the patient help in decision making by identifying progressive renovascular disease. Selecting patients for renal artery stenting who actually will benefit from revascularization shall also decrease the unnecessary complications inherent with any interventional procedure. The present review is an attempt to analyze the current view on the diagnostic and management issues more specifically about the need and rationale behind angioplasty.