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Intravascular lithotripsy (IVL) is a promising new technology for disrupting de-novo calcified coronary lesions (DNL) before percutaneous coronary intervention (PCI). We assessed 12-month outcomes of IVL in patients undergoing PCI for DNL or intra stent restenosis (ISR) lesions related to device underexpansion. Prospective analysis of patients in the multicentre all-comers French Shock Initiative IVL registry. The primary safety endpoints in this analysis were in-hospital and 12-month major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). The primary effectiveness endpoint was procedural success, defined as <30% residual stenosis without severe angiographic complications. Event rates were analysed for the cohort and for DNL and ISR procedures separately. A total of 220 lesions were treated (76.7% DNL and 23.3% ISR) in 202 patients. Procedural success was achieved in 95.5% of patients (DNL group: 96.5%; ISR group: 92.0%). In-hospital MACE occurred in 6.4% of cases, mainly driven by periprocedural infarctions. The rate of MACE-free survival at 1 year was 86.6% in the overall cohort. Rates of target vessel (TVR) and lesion (TLR) revascularisation were 6.4% and 2.5%, respectively. The 1-year MACE rate was 91.5% in DNL group and 83.8% in ISR group. In this large all-comers IVL cohort, rates of in-hospital and 1-year MACE were moderate. The safety and efficiency of IVL was comparable in DNL and ISR lesions. A comparative study of the impact of IVL on outcomes appears warranted. • A total of 220 lesions (76.7% de novo lesions / DNL and 23.3% intra stentrestenosis/ISR) were treated by intravascular lithotripsy in 202 patients. • Procedural success was achieved in 95.5% of patients, with no difference between DNL and ISR groups (96.5% vs 92%; p=0.24). • MACE-free survival at 1 year was 86.6% in the overall cohort, with no difference between DNL and ISR (91.5% vs 83.8%; p = 0.15). [ABSTRACT FROM AUTHOR]

We explored the association of epicardial fat volume (EFV) with coronary plaque characteristics, coronary artery calcification (CAC) score, coronary stenosis, lesion-specific ischemia in patients with known or suspected coronary artery disease (CAD). 88 controls and 221 patients were analyzed in the study. High-risk plaque was defined as existing≥2 features, including positive remodeling, low attenuation, napkin-ring sign and spotty calcification. EFV, CAC score was measured. The severity of coronary stenosis was quantified using Gensini score. CT-FFR was performed in three major coronary arteries, with a threshold of ≤0.8 considered the presence of ischemia. Univariate and multivariate regression was used to evaluate the association of EFV with CAD, palque characteristics, CAC score, Gensini score, and lesion-specific ischemia derived from CT-FFR. Median EFV was 104.97 cm3 (85.47–136.09) in controls and 129.28cm3 (101.19–159.44) in patients (P < 0.001). Logistic regression analysis revealed a significant association of EFV with CAD even after adjusting for confounding factors (P < 0.05). At linear regression analysis, EFV was significantly correlated with high-risk plaque and lesion-specific ischemia, but not with non-calcified plaque, mixed plaque, calcified plaque, CAC score and Gensini score (P ≥ 0.05). We found that EFV was associated with CAD, suggesting that it may be a promising marker of CAD. EFV was also correlated with high-risk plaque and lesion-specific ischemia, indicating that EAT was likely to be involved in myocardial ischemia and had the potential to definite patients' risk profile. • EFV was associated with adverse plaque characteristics and lesion-specific ischemia in patients with known or suspected CAD. [ABSTRACT FROM AUTHOR]

In breast cancer patients, coincidental detection of CAC at chest CT may be important in determining cardiovascular (CV) outcomes and facilitate CV disease primary prevention strategies. 408 consecutive breast cancer patients referred to cardiac oncology clinic were included in the study. 256 patients without a prior history of coronary artery disease had undergone a chest CT. CT images were reviewed to detect CAC. Framingham risk score (FRS) was calculated and patient electronic medical records were interrogated to document the incidence of a composite clinical end point of all-cause mortality and cardiac events (coronary revascularization, heart failure hospitalization and de novo atrial fibrillation). Prevalence of statin prescribing was also collected. Patients were followed for a median of 6.5 years. 112 clinical events occurred. Clinical follow up was 98%. CAC was found in 26% of patients. On multivariable analysis, CAC and advance cancer stage, but not FRS predicted the composite clinical end point (OR for CAC 2.59, p < 0.01). CAC but not FRS also predicted the incidence of cardiac events (OR for CAC 4.90, p < 0.01). CAC was present in 7.3% of patients with low FRS; none had been prescribed a statin. In patients with CAC and FRS ≥ 10%, 45% were not on a statin. CAC is a common coincidental finding at CT chest in breast cancer patients referred to cardiac oncology. CAC but not FRS was predictive of composite clinical events and cardiac events. Detection of CAC at chest CT could alter the prescribing of primary prevention strategies to help prevent future cardiac events in breast cancer patients. • Chest CT studies are commonly performed in breast cancer patients • Coronary calcium (CAC) is frequently seen on chest CT studies • CAC in breast cancer patients predicted a primary outcome composite of all cause death and cardiac events [ABSTRACT FROM AUTHOR]

Background Increasing coronary lesion calcification is thought to be associated with adverse percutaneous coronary intervention (PCI) and clinical outcomes. We investigated the effects of calcium burden on culprit lesion morphology and clinical events after intravascular ultrasound (IVUS)-guided PCI in the ADAPT-DES study. Methods ADAPT-DES was a prospective, multicenter registry of 8582 consecutive patients undergoing successful PCI using DES. A pre-specified virtual histology (VH)-IVUS substudy of 638 culprit lesions (638 patients) had both pre- and post-PCI VH-IVUS. We divided lesions into tertiles according to pre-PCI percent dense calcium volume (DCV% = dense calcium/plaque volume × 100). Results Compared with low and intermediate DCV% tertiles, patients in the high DCV% tertile had the largest arc of superficial calcium, highest percentage of necrotic core volume, and smallest remodeling index; they were also more likely to have advanced lesion morphology such as attenuated plaque and VH thin-cap fibroatheromas. In the high DCV% tertile IVUS guidance was associated with a minimum stent area that was smaller than tertiles with less calcium ( p = 0.01), but acceptable range, and similar stent expansion (73.8 ± 16.8% vs. 74.0 ± 19.2% vs. 72.4 ± 17.3%, p = 0.62) after more frequent use of rotational atherectomy and higher maximum inflation pressure. There was no significant association between pre-PCI DCV% and 2-year target lesion revascularization or major adverse cardiac events (cardiac death, myocardial infarction, or stent thrombosis). Conclusions Increasing coronary artery calcification burden was associated with more advanced, complex VH-IVUS lesion morphology, but not with adverse clinical outcomes, perhaps due to more aggressive PCI techniques that optimized stent expansion. [ABSTRACT FROM AUTHOR]

Background The association between the dialysate calcium level and coronary artery calcification (CAC) has not yet been evaluated in hemodialysis patients. The objective of this study was to determine whether lowering the dialysate calcium levels would decrease the progression of coronary artery calcification (CAC) compared to using standard calcium dialysate. Methods We conducted an open-label randomized trial with parallel groups. The patients were randomly assigned to either 12-month treatment with low calcium dialysate (LCD; 1.25 mmol/L, n = 36) or standard calcium dialysate (SCD; 1.5 mmol/L, n = 40). The primary outcome was the change in the CAC scores assessed by 64-slice multidetector computed tomography after 12 months. Results During the treatment period, CAC scores increased in both groups, especially significant in LCD group (402.5 ± 776.8, 580.5 ± 1011.9, P = 0.004). When we defined progressors as patients at second and third tertiles of CAC changes, progressor group had a higher proportion of LCD-treated patients than SCD-treated patients ( P = 0.0229). In multivariate analysis, LCD treatment is a significant risk factor for increase in CAC scores (odds ratio = 5.720, 95% CI: 1.219–26.843, P = 0.027). Conclusions Use of LCD may accelerate the progression of CAC in patients with chronic hemodialysis over a 12-month period. Trial registration Clinical Research Information Service [Internet]; Osong (Chungcheongbuk-do): Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea), 2010: KCT0000942. Available from: https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=3572&sLeft=2&type=my [ABSTRACT FROM AUTHOR]

Background Coronary artery calcification (CAC) may be quantified on low-dose computed tomography (CT) of the lung (LDCT). This study aims to evaluate the effects of filter convolution (FC) and displayed field of view (dFOV) in a Toshiba 320-row CT scanner in quantifying CAC, and to compare the CAC scores obtained by LDCT with standard cardiac CT. Methods Fifty subjects (52 to 85 years, mean 68.5, 36 males) with visible CAC underwent both standard cardiac CT and LDCT. CAC scores were obtained from standard cardiac CT using conventional FC12(22) (FC12 with 22-cm dFOV) and four different LDCT protocols: FC02(22), FC02(40), FC08(22), and FC08(40). CAC scores obtained by each LDCT protocol were compared with those obtained by standard cardiac CT. Results CAC scores obtained by all four LDCT protocols were well correlated with those by standard protocol (Pearson's coefficient = 0.978 to 0.987, p < 0.001; kappa = 0.731 to 0.836, p < 0.001). CAC scores obtained by FC08(22) showed the best agreement with standard cardiac CT (kappa = 0.836, p < 0.001). Under fixed dFOV, CAC scores in FC08 were significantly higher than in FC02 (p < 0.001). Under fixed FC, CAC scores were significantly higher in 22-cm dFOV than in 40-cm dFOV (p ≤ 0.006). Conclusions Both FC and dFOV have significant impact on CAC scoring. To obtain reliable data, consistent parameters should be employed when quantifying CAC using LDCT. In a Toshiba 320-row CT scanner, CAC scores obtained by FC08(22) agree well with standard cardiac CT. [ABSTRACT FROM AUTHOR]

Background Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients for overall cardiovascular or coronary events. However; the prognostic value for incident stroke remains controversial. The objective of this study was to investigate the predictive value of CACS obtained by non-contrast electrocardiogram-gated computed tomography for incident stroke. Methods We searched PubMed, EMBASE, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of stroke. Incidence of stroke was compared in patients with and without coronary calcification. Results Three studies evaluated 13,262 asymptomatic patients (mean age = 60 years, 50% men) without apparent cardiovascular diseases. During a follow-up of 7.2 years (median 5 years, range 4.4–9.5 years, 95,434 patient-years), the overall pooled incidence of stroke was 0.26%/year. The pooled risk ratio of CACS > 0 for incident stroke was 2.95 (95% CI: 2.18–4.01, p < 0.001) compared to CACS = 0. The heterogeneity among studies was low (I 2 = 0%). The pooled incidence rate of stroke categorized by CACS was 0.12%/year for CACS 0, 0.26%/year for CACS 1–99, 0.41%/year for CACS 100–399 and 0.70%/year for CACS ≥ 400. Conclusions In asymptomatic patients without apparent cardiovascular diseases, the incidence of stroke was overall low. The presence and severity of coronary artery calcification were associated with incident stroke over mid-long term follow-up. [ABSTRACT FROM AUTHOR]

Background Preliminary data suggests the absence of coronary artery calcification (CAC) excludes ischemic etiologies of cardiomyopathy. We prospectively validate and perform a systematic review to determine the utility of an Agatston score = 0 to exclude the diagnosis of ischemic cardiomyopathy. Methods and results Patients with newly diagnosed LV dysfunction were prospectively enrolled. Patients underwent CAC imaging and were followed until an etiologic diagnosis of cardiomyopathy was made. Eighty-two patients were enrolled in the study and underwent CAC imaging with 81.7% patients having non-ischemic cardiomyopathy. An Agatston score = 0 successfully excluded an ischemic etiology for cardiomyopathy with a specificity of 100% (CI: 74.7–100%) and a positive predictive value of 100% (CI: 85.0%–100%). A systematic literature review was performed and studies were deemed suitable for inclusion if: 1) patients with CHF, cardiomyopathy or LV dysfunction were enrolled, 2) underwent CAC imaging and patients were assessed for an Agatston score = 0 or the absence of CAC, and 3) the final etiologic diagnosis (ischemic or non-ischemic) was provided. Eight studies provided sufficient information to calculate operating characteristics for an Agatston score = 0 and were combined with our validation cohort for a total of 754 patients. An Agatston score = 0 excluded ischemic cardiomyopathy with specificity and positive predictive values of 98.4% (CI: 95.6–99.5%), and 98.3% (CI: 95.5–99.5%), respectively. Conclusions In patients with cardiomyopathy of unknown etiology, an Agatston score = 0 appears to rule out an ischemic etiology. A screening CAC may be a simple and cost-effective method of triaging patients, identifying those who do and do not need additional CAD investigations. [ABSTRACT FROM AUTHOR]

Background Downstream resource utilization and its impact on outcomes after a canceled CCTA have not been well studied. We sought to understand downstream resource utilization and patient outcomes after canceled CCTA. Methods and results Consecutive patients were prospectively enrolled into an institutional cardiac CT registry. Patients who had the CCTA study canceled because of severe coronary calcification were followed for downstream resource utilization and the composite of all-cause mortality and non-fatal myocardial infarction (MI). 463 patients had their CCTA canceled due to severe coronary calcification and follow-up was available for 453 (97.8%) patients (median follow-up = 36.0 months). There were a total of 62 events (41 all-cause deaths and 21 non-fatal MI) with an annualized event rate of 4%. Three hundred and twenty patients underwent downstream CAD (ICA or MPI or EST) investigations. Age, NCEP/ATP III risk, beta-blocker use, Agatston and downstream CAD testing were associated with the primary outcome. There were fewer events in those that received downstream CAD testing (30 (9.7%) versus 32 (22.4%)). The annualized event rates for those who did and did not receive downstream CAD testing were 2.8% and 6.2%, respectively. Multivariable analysis confirmed that downstream CAD testing was an independent predictor of event-free survival and that the absence of additional CAD testing was associated with worse outcome (HR: 2.58 (95% CI: 1.54–4.31)). Conclusions Patients with canceled CCTA due to severe and/or extensive CAC have high rates of death and non-fatal MI. The use of additional CAD testing appears to be associated with improved outcomes. [ABSTRACT FROM AUTHOR]

Aims In this retrospective study we assessed the predictive value of the coronary calcium score for significant (> 50%) stenosis relative to conventional risk factors. Methods and Results We investigated 5515 symptomatic patients from Denmark, France, Germany, Italy, Spain and the USA. All had risk factor assessment, computed tomographic coronary angiogram (CTCA) or conventional angiography and a CT scan for coronary artery calcium (CAC) scoring. 1539 (27.9%) patients had significant stenosis, 5.5% of whom had zero CAC. In 5074 patients, multiple binary regression showed the most important predictor of significant stenosis to be male gender (B = 1.07) followed by diabetes mellitus (B = 0.70) smoking, hypercholesterolaemia, hypertension, family history of CAD and age but not obesity. When the log transformed CAC score was included, it became the most powerful predictor (B = 1.25), followed by male gender (B = 0.48), diabetes, smoking, family history and age but hypercholesterolaemia and hypertension lost significance. The CAC score is a more accurate predictor of > 50% stenosis than risk factors regardless of the means of assessment of stenosis. The sensitivity of risk factors, CAC score and the combination for prediction of > 50% stenosis when measured by conventional angiogram was considerably higher than when assessed by CTCA but the specificity was considerably higher when assessed by CTCA. The accuracy of CTCA for predicting > 50% stenosis using the CAC score alone was higher (AUC = 0.85) than using a combination of the CAC score and risk factors with conventional angiography (AUC = 0.81). Conclusion In symptomatic patients, the CAC score is a more accurate predictor of significant coronary stenosis than conventional risk factors. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. Methods: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (<30%), intermediate (30–70%) or high risk (>70%). Angiographic obstructive CAD (>50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. Results: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p<0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p<0.001). Conclusions: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients. [Copyright &y& Elsevier]

Abstract: Background: Coronary artery calcification (CAC) is correlated with aortic calcification (AC) and predicts coronary atherosclerosis as well as obstructive coronary artery disease (OCAD). This study aims to investigate whether AC predicts OCAD independent of CAC and its incremental value in predicting OCAD with CAC. Methods: Among the consecutive patients who underwent 64-slice multidetector CT (MDCT), we enrolled 120 stable OCAD (luminal narrowing ≥50%) patients and 120 controls without OCAD, matched for cardiovascular risk factors. CAC, thoracic AC, and OCAD were determined by MDCT. Results: The prevalence of AC and CAC were significantly higher in OCAD patients than in controls (64% vs. 48%, p =0.019; 57% vs. 32%, p <0.001, respectively). There is a significant correlation between AC and CAC scores in the overall study population (r=0.528, p <0.001). In univariate analysis, the odds ratios (ORs) of AC and CAC in predicting OCAD were 1.91 (95% CI, 1.14–3.21) and 2.82 (95% CI, 1.67–4.78), respectively. When an adjustment was made for each other, AC did not maintain a significant association with OCAD, whereas CAC persisted the association (OR, 2.52; 95% CI, 1.42–4.47). Both AC and CAC present as compared to both absent was found to be a more potent predictor for OCAD (OR, 3.37; 95% CI 1.78–6.36, p<0.001) than CAC alone. Conclusions: The presence of AC was associated with stable OCAD independently from cardiovascular risk factors, but the association seemed to be based on the close correlation between AC and CAC. However, AC might have an incremental value with CAC for predicting OCAD. [Copyright &y& Elsevier]

Abstract: Introduction: Coronary artery stenoses have been shown in various trials to be moderated by treatment with statins. A similar effect on coronary artery calcification has not been demonstrated. We therefore undertook meta-analyses of trials examining the effect of statin treatment on coronary artery stenoses and coronary artery calcification. Methods: Literature searches identified five controlled trials suitable for inclusion in the analysis of the effect of statins (high dose versus either low dose or placebo) on coronary artery calcification and six trials suitable for inclusion in the analysis of the effect of statins on coronary artery stenoses. Results: All trials reported substantial and significant reductions in LDL-C with statin treatment which results in net reductions of LDL-C in the CAC and coronary stenoses trials of 1.0mmol/L and 0.9mmol/L, respectively. Analysis of the CAC trials did not demonstrate any effect of statins on the progression of calcification. In contrast, in the coronary stenoses trials there was a consistent moderation of stenosis severity progression with statins (p <0.0001). Conclusions: Meta-analyses of the available trials have demonstrated a significant moderation of coronary stenoses associated with the statin-induced reduction in LDL-C. In contrast, there was no effect on coronary calcification despite a similar reduction in LDL-C levels. This suggests that the pathogenesis of the two conditions may be different, if not in aetiology, then certainly in their development. It further suggests that statin use to moderate arterial calcification is not effective. [Copyright &y& Elsevier]

Abstract: Medical practice is moving fast towards non-invasive and non-surgical disease management. While significant progress has been made with coronary artery disease prevention, MDCT stands as an ideal non-invasive tool for its progression. It accurately assesses both arterial lumen and wall disease. Although the main concern of current cardiology practice is the coronary stenotic disease, arterial wall calcification itself may significantly contribute to patients'' symptoms. Thus, in addition to the beneficial use of MDCT in patients with mild to moderate risk for coronary disease, the unique information it provides on wall disease may assist the management of symptomatic patients with no flow-limiting lesions. [Copyright &y& Elsevier]

Abstract: Background: To compare patterns of coronary artery disease in British South Asian and White European men. Methods: 41 South Asian and 42 European men (mean age 64±9 years) with coronary artery disease were studied. All had similar symptoms. Vessel reference diameter and degree of stenosis were calculated using quantitative coronary angiography. Extent of atherosclerotic disease in the LAD was assessed using calcification scores (CAC) measured by multislice Computed Tomography. Fasting bloods and blood pressure were measured. The LAD was subdivided into four 2.5 cm segments for analysis. Results: Most atherosclerosis occurred in the proximal LAD segment, South Asian men had more proximal LAD stenosis than European men (50% vs. 37%, p =0.036), but CAC scores were similar. South Asians with CAC scores in the lowest tertile (0–22 HU), had significantly narrower LAD diameters than Europeans (2.8 mm vs. 3.8 mm, p =0.004, adjusted for body surface area and age). This ethnic difference was not explained by measured risk factors, including diabetes. In contrast, ethnic differences in LAD diameter were abolished in the upper tertiles of CAC scores (23–2416 HU) (South Asians: 3.0 mm, Europeans: 3.1 mm, p =0.6). Calcification scores were negatively correlated with LAD diameter in Europeans (rho=−0.38, p =0.016) but not in South Asians (rho=−0.06, p =0.72). Conclusions: Increased LAD stenosis, despite equivalent levels of calcified disease, in South Asians is attributable to narrower arteries. Reduced LAD diameter is associated with advanced disease in Europeans but not in South Asians, indicative of ethnic differences in vascular remodelling. [Copyright &y& Elsevier]

Background: Coronary calcification is a marker for coronary atherosclerosis. It has been postulated that high levels of high density lipoprotein cholesterol (HDL-C) are associated with a reduced amount of atherosclerotic disease while previous reports have found a lack of association between low density lipoprotein cholesterol (LDL-C) and coronary calcification (CAC). The purpose of this study was to compare the correlation and predictive power of HDL-C with LDL-C for prevalent coronary calcification. Methods: A total of 6093 subjects were studied with respect to coronary calcification, serum cholesterol indices, personal health history and body morphology. Analyses consisted of correlation coefficients, logistic regression and sensitivity analysis to determine the strength of association between HDL-C and coronary calcification after controlling for covariates. Results: The correlation between HDL-C and coronary calcium score (CCS) was three times that of LDL-C. Individuals with an HDL-C level <40 mg/dl had significantly higher calcium scores while increases in HDL-C were associated with a significant reduction in risk for the presence of any calcified plaque. Results of multivariate logistic regression revealed that HDL-C is predictive of calcified plaque development independent of LDL-C. Sensitivities and positive predictive values for both HDL-C and LDL-C were low. Conclusions: Increasing levels of HDL-C were associated with less coronary calcification and a smaller probability of having any calcified disease supporting the antiatherogenic hypothesis for HDL-C. HDL-C predicts the presence of any calcified atherosclerotic plaque independently of LDL-C. However, neither parameter seems suitable as a screening tool for predicting prevalent calcified atheromatous disease. [Copyright &y& Elsevier]