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Keywords: Editorials; coronary atherosclerosis; incidental finding; risk assessment; statins EN Editorials coronary atherosclerosis incidental finding risk assessment statins 715 717 3 03/02/23 20230228 NES 230228 B Article, see p 703 b Statins are a cornerstone of primary prevention but remain underused.[1] Even among adults followed routinely in a clinical setting, <40% of those recommended for a statin for primary prevention are on an appropriate one.[2] Novel approaches are needed to improve statin use in primary prevention. This project echoes previous work showing a large proportion of enrolled patients having no detectable CAC ("CAC zero"), among whom a flexible approach of delaying or avoiding statins may be prudent on the basis of American Heart Association/American College of Cardiology guidelines. In the notification arm, the patients' providers were sent a message notifying them of the existence of previous CAC, with a representative image from previous CT scans and a suggestion to start a statin. [Extracted from the article]

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They lay the groundwork for use of coronary CTA for risk stratification of asymptomatic patients on the basis of an 8-fold increased risk for myocardial infarction in those with extensive coronary disease. Another large coronary CTA trial ([4]) showed that only CAC scans predicted cardiovascular death or myocardial infarction ( I P i = 0.011) in multivariable analysis; coronary CTA findings, adverse plaque characteristics, and obstructive coronary artery disease failed to predict these events. Coronary artery calcification scores are known to closely correlate with total plaque burden by coronary CTA ([2]) In fact, a CAC score of greater than 300 Agatston units was associated with a relative risk for myocardial infarction of 7.05 (3.23 to 15.39) ([1]). [Extracted from the article]

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There are huge gaps in evidence-based cardiovascular care at the national, organizational, practice, and provider level that can be attributed to variation in provider attitudes, lack of incentives for positive change and care standardization, and observed uncertainty in clinical decision making. Big data analytics and digital application platforms--such as patient care dashboards, clinical decision support systems, mobile patient engagement applications, and key performance indicators--offer unique opportunities for value-based healthcare delivery and efficient cardiovascular population management. Successful implementation of big data solutions must include a multidisciplinary approach, including investment in big data platforms, harnessing technology to create novel digital applications, developing digital solutions that can inform the actions of clinical and policy decision makers and relevant stakeholders, and optimizing engagement strategies with the public and informationempowered patients. [ABSTRACT FROM AUTHOR]

Improving patient experience is a fundamental component of patient-centered care and one of the key strategies for improving health care quality, delivery, and outcomes. Several studies have described the association between improved patient experience and better health outcomes among individuals with cardiovascular disease. These findings are important given that cardiovascular disease is a leading cause of morbidity and mortality in the United States and globally. This review summarizes the findings on patient-reported health care experiences and discusses how optimizing these experiences may be a tool to improve health outcomes among individuals with cardiovascular disease. [ABSTRACT FROM AUTHOR]

The article discusses that the emergence of SARS-CoV-2 in December 2019 and the subsequent COVID-19 pandemic could not have been predicted in August of 2019 when we solicited manuscripts. It mentions that the physicians and staff at Houston Methodist and many other health care systems in our country demonstrated high reliability principles as they deferred to expertise.

Objectives: To determine whether optimal patient experiences with healthcare is associated with enhanced and efficient use of healthcare resources and cost.Design: Retrospective cohort study.Setting and Participants: The study population consisted of pooled participants from the 2010-13 Medical Expenditure Panel Survey cohort of adults ≥18 years with a regular healthcare provider and ≥1 visit to a healthcare provider within the survey year. Using a self-administered questionnaire, individual responses to questions related to healthcare experience were used to develop a weighted average for each of these patient-centered care matrices (ease of access to healthcare, patient-provider communication, shared decision-making and overall patient satisfaction).Intervention: None.Outcome Measures: The outcomes of interest included (1) emergency room (ER) visits and hospital stay, (2) annual healthcare costs incurred by the respondents.Results: Overall the study population consisted of 47 969 individuals ≥18 years representing nearly 130 million US non-institutionalized adults. Compared with individuals with a poor report on healthcare experience, participants with positive reports were less likely to utilize the ER and had a lower annual healthcare expenditure. This relationship between patient experience and healthcare expenditure was not demonstrated with shared decision-making and overall patient satisfaction.Conclusion: Our study findings suggest that there is an association between patient experience with healthcare, health resource utilization and healthcare expenditure. Further studies are needed to assess if interventions focused to enhance patient experiences can improve healthcare efficiency. [ABSTRACT FROM AUTHOR]

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Background: The American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy.Objectives: This study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not.Methods: MESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis.Results: The study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years.Conclusions: Significant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy. [ABSTRACT FROM AUTHOR]

Disparities in premature cardiovascular mortality (PCVM) have been associated with socioeconomic, behavioral, and environmental risk factors. Understanding the "phenotypes", or combinations of characteristics associated with the highest risk of PCVM, and the geographic distributions of these phenotypes is critical to targeting PCVM interventions. This study applied the classification and regression tree (CART) to identify county phenotypes of PCVM and geographic information systems to examine the distributions of identified phenotypes. Random forest analysis was applied to evaluate the relative importance of risk factors associated with PCVM. The CART analysis identified seven county phenotypes of PCVM, where high-risk phenotypes were characterized by having greater percentages of people with lower income, higher physical inactivity, and higher food insecurity. These high-risk phenotypes were mostly concentrated in the Black Belt of the American South and the Appalachian region. The random forest analysis identified additional important risk factors associated with PCVM, including broadband access, smoking, receipt of Supplemental Nutrition Assistance Program benefits, and educational attainment. Our study demonstrates the use of machine learning approaches in characterizing community-level phenotypes of PCVM. Interventions to reduce PCVM should be tailored according to these phenotypes in corresponding geographic areas. [ABSTRACT FROM AUTHOR]

Disparities in premature cardiovascular mortality (PCVM) have been associated with socioeconomic, behavioral, and environmental risk factors. Understanding the "phenotypes", or combinations of characteristics associated with the highest risk of PCVM, and the geographic distributions of these phenotypes is critical to targeting PCVM interventions. This study applied the classification and regression tree (CART) to identify county phenotypes of PCVM and geographic information systems to examine the distributions of identified phenotypes. Random forest analysis was applied to evaluate the relative importance of risk factors associated with PCVM. The CART analysis identified seven county phenotypes of PCVM, where high-risk phenotypes were characterized by having greater percentages of people with lower income, higher physical inactivity, and higher food insecurity. These high-risk phenotypes were mostly concentrated in the Black Belt of the American South and the Appalachian region. The random forest analysis identified additional important risk factors associated with PCVM, including broadband access, smoking, receipt of Supplemental Nutrition Assistance Program benefits, and educational attainment. Our study demonstrates the use of machine learning approaches in characterizing community-level phenotypes of PCVM. Interventions to reduce PCVM should be tailored according to these phenotypes in corresponding geographic areas. [ABSTRACT FROM AUTHOR]

The article discusses a study by N.B. Allen and colleagues, published within the issue, which introduces a way for cost estimates for policymakers to make decisions on potential benefits of optimal cardiovascular health (CVH) in terms of reduced healthcare consumption. Topics include authors' finding of a delay in mortality risk due to optimal CVH; limitations of the study in terms of components of resource utilization; and importance of sustainable investments in primordial prevention.

Decreased arterial compliance is an early manifestation of adverse structural and functional changes within the vessel wall. Its correlation with left ventricular (LV) area on computed tomography, a marker of LV remodeling, has not been well demonstrated. The aim of this study was to test the hypothesis that decreasing aortic compliance and increasing arterial stiffness are independently associated with increased LV area. The study population consisted of 3,540 patients (mean age 61 ± 10 years, 46% men) from the Multi-Ethnic Study of Atherosclerosis (MESA) who underwent aortic distensibility (AD) assessment on magnetic resonance imaging and LV area measurement on computed tomography (adjusted to body surface area). Multivariate logistic regression was performed to assess the association between body surface areaenormalized LV area >75th percentile and AD after adjusting for baseline clinical, historical, and imaging covariates. Mean LV area index was 2,153 cm², and mean AD was 1.84 × 10³ mm Hg-1. Subjects in the lowest AD quartile were older, with higher prevalence rates of hypertension, diabetes, and hypercholesterolemia (p <0.05 for all comparisons). Using multivariate linear regression adjusting for demographics, traditional risk factors, coronary artery calcium, and C-reactive protein, each SD decrease was associated with an 18-cm² increase in LV area. In addition, decreasing AD quartiles were independently associated with increasing LV area index, defined as >75th percentile. In conclusion, in this multiethnic cohort, reduced AD was associated with increased LV area. Longitudinal studies are needed to determine if decreased distensibility precedes and directly influences increased LV area. [ABSTRACT FROM AUTHOR]

Arterial remodeling, an early change of atherosclerosis, can cause dilated arterial diameter. We measured coronary artery diameter with use of noncontrast 64-slice multidetector computed tomography (MDCT), and studied its association with coronary artery calcium levels and traditional coronary risk factors. We included 140 patients from the Accuracy trial whose noncontrast MDCT images showed measurable coronary arteries. Using 3 measurements of left main coronary artery (LMCA) and right coronary artery (RCA) diameters within 3 mm of the ostium, we associated the results with traditional coronary risk factors and calcium scores. The prevalence of LMCA and RCA calcium was 22% and 51%, respectively. Mean arterial diameters were 5.67 ± 1.18 mm (LMCA) and 4.66 ± 1.08 mm (RCA). Correlations for LMCA and RCA diameters in 50 randomly chosen patients were 0.91 and 0.93 (interobserver) and 0.98 and 0.93 (intraobserver). Adjusted odds ratios for the relationship of LMCA and RCA diameters to calcium in male versus female patients were 5.65 (95% confidence interval [CI], 2.78-11.5) and 4.35 (95% CI, 2.24-8.47), respectively. Adjusted ratios and 95% CIs for the association of larger RCA diameter with age, hypertension, and body mass index were 1.36 (1.00-1.86), 3.13 (1.26-7.78), and 1.60 (1.16-2.22), respectively. Arterial diameters were larger in women and patients with higher calcium levels, and body mass index and hypertension were predictors of larger RCA diameters. These findings suggest a link between arterial remodeling and the severity of atherosclerosis. [ABSTRACT FROM AUTHOR]

Background: Restrictive cardiomyopathy (RCM) represents a spectrum of disorders with a common physiology but divergent etiologies. RCM commonly leads to progressive heart failure and the need for heart transplantation (HTx). Pediatric RCM is a more homogeneous disorder with post-HTx outcomes comparable to those for non-RCM patients. However, post-HTx outcomes in adult RCM patients have not been studied to date. Methods: Demographic, clinical and survival outcomes of 38,190 adult HTx-only recipients from 1987 to 2010 were acquired from the registry of the United Network of Organ Sharing. The study population included 544 RCM patients (1.4%) and 37,646 non-RCM patients (98.6%). RCM diagnoses included idiopathic (n = 227, 42%), amyloid (n = 142, 26%), sarcoid (n = 81, 15%), radiation/chemotherapy (XRT) (n = 35, 6%) and other (n = 59, 11%). Results: Follow-up began at the time of HTx (74±64 months). During the follow-up period, 224 (41%) patients in the RCM group died, whereas 18,791 (50%) in the non-RCM group died. Crude 1-, 5- and 10-year survival for RCM patients was 84%, 66% and 45%, and for non-RCM patients was 85%, 70% and 50%, respectively. The overall unadjusted hazard ratio of RCM vs non-RCM for all-cause mortality was 1.07 (confidence interval [CI] 0.93 to 1.22). Multivariate Cox proportional hazards regression analysis yielded a hazard ratio of 1.06 (CI 0.91 to 1.25). RCM subgroup analysis showed decreased survival at 1, 5 and 10 years in the XRT (71%, 47% and 32%) and amyloid (79%, 47% and 28%) patient groups. The unadjusted hazard ratio for the XRT and amyloid subgroups vs RCM for all-cause mortality was 1.81 (p = 0.002) and 1.85 (p = 0.0004), respectively. Conclusions: Outcomes for RCM patients post-HTx are comparable to those of non-RCM patients. However, RCM subgroup analysis suggests increased mortality for XRT and amyloid subgroups. Further analysis is warranted to understand the contributing factors. [Copyright &y& Elsevier]

Hypertension is one of the leading causes of disability-adjusted life years and mortality, with approximately 15% prevalence worldwide. Most patients with hypertension from low- to high-income countries do not receive treatment. Among those who receive treatment, the majority remain undertreated and do not achieve their blood pressure goals. Therefore, new hypertension guidelines introduce more conscientious treatment strategies to maximize the probability of achieving the new strict blood pressure goals compared with the previous guidelines. Who should receive treatment for hypertension? Which antihypertensive medications have the strongest supporting data? Are generic and more affordable medications as effective as expensive brand medications? What are the different treatment strategies to maximize success in controlling blood pressure? Here, we briefly review pharmacotherapy for hypertension and provide answers to these questions as well as some other common questions regarding treatment of hypertension. [ABSTRACT FROM AUTHOR]

Atherosclerosis is a complex diffuse disorder. The close correlation between coronary artery calcium (CAC) score on computed tomogram and extent and severity of coronary atherosclerosis is well established. It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. The MESA population included a population-based sample of 4 ethnic groups (12% Chinese, 38% white, 22% Hispanic, and 28% black) of 6,814 women and men 45 to 84 years of age. Computed tomographic scans were performed for all participants. The calcium score of each lesion was calculated by multiplying lesion area by a density factor derived from maximal Hounsfield units. A total calcium score was determined by summing individual lesion scores at each anatomic site. Relative risk regression was used to model the probability of MAC as a function of CAC >0 and CAC categories (0, 1 to 99, 100 to 399, and ≥400) with the referent group being CAC 0. The final study population consisted of 6,814 subjects (mean age 62 ± 10 years, 47% men). Overall 9% and 50% had detectable MAC and CAC, respectively. Of those with absent CAC, only 4% had MAC, whereas 9%, 19%, and 15% had MAC scores with increasing CAC scores of 1 to 99, 100 to 399, and ≥400, respectively (p <0.0001 for trend). After taking into account demographics and other risk factors, the prevalence ratio of MAC in those with mild CAC (1 to 99) was 2.13 (95% confidence interval 1.69 to 2.69) and increased to 7.57 (95% confidence interval 5.95 to 9.62) for CAC ≥400. Similar statistically significant increased risk of MAC was found when CAC was assessed as a continuous variable. In conclusion, we observed a strong association between MAC and increasing burden of CAC. This association weakened but persisted after adjustment for age, gender, and other traditional cardiovascular risk factors. These findings suggest that presence of MAC is an indicator of atherosclerotic burden rather than just a degenerative change of the mitral valve. [Copyright &y& Elsevier]

Abstract: Background: The presence and extent of coronary artery calcium (CAC) is an independent predictor of coronary heart disease (CHD) morbidity and mortality. Few studies have evaluated interactions or independent incremental risk for coronary and thoracic aortic calcification (TAC). The independent predictive value of TAC for CHD events is not well-established. Methods: This study used risk factor and computed tomography scan data from 6807 participants in the multi-ethnic study of atherosclerosis (MESA). Using the same images for each participant, TAC and CAC were each computed using the Agatston method. The study subjects were free of incident CHD at entry into the study. Results: The mean age of the study population (n =6807) was 62±10 years (47% males). At baseline, the prevalence of TAC and CAC was 28% (1904/6809) and 50% (3393/6809), respectively. Over 4.5±0.9 years, a total of 232 participants (3.41%) had CHD events, of which 132 (1.94%) had a hard event (myocardial infarction, resuscitated cardiac arrest, or CHD death). There was a significant interaction between gender and TAC for CHD events (p <0.05). Specifically, in women, the risk of all CHD event was nearly 3-fold greater among those with any TAC (hazard ratio: 3.04, 95% CI: 1.60–5.76). After further adjustment for increasing CAC score, this risk was attenuated but remained robust (HR: 2.15, 95% CI: 1.10–4.17). Conversely, there was no significant association between TAC and incident CHD in men. In women, the likelihood ratio chi square statistics indicate that the addition of TAC contributed significantly to predicting incident CHD event above that provided by traditional risk factors alone (chi square=12.44, p =0.0004) as well as risk factors+CAC scores (chi square=5.33, p =0.02). On the other hand, addition of TAC only contributed in the prediction of hard CHD events to traditional risk factors (chi-square=4.33, p =0.04) in women, without contributing to the model containing both risk factors and CAC scores (chi square=1.55, p =0.21). Conclusion: Our study indicates that TAC is a significant predictor of future coronary events only in women, independent of CAC. On studies obtained for either cardiac or lung applications, determination of TAC may provide modest supplementary prognostic information in women with no extra cost or radiation. [Copyright &y& Elsevier]

Abstract: Background: Mitral annular calcification (MAC) is a fibrous, degenerative calcification of the mitral valve. The relationship between MAC and cardiovascular disease (CVD) risk factors is not well defined. Thus, we performed a cross-sectional study to determine which CVD risk factors are independently associated with MAC in the Multi-Ethnic Study of Atherosclerosis (MESA). Methods: MESA includes 6814 women and men ages 45–84 years old without apparent CVD in 4 ethnic groups (12% Chinese, 38% Caucasian, 22% Hispanic, and 28% African American). MAC was defined by presence of calcium in the mitral annulus by cardiac computed tomography at enrollment. Multivariable logistic regression was used to evaluate relationships between MAC and CVD risk factors. Results: The overall prevalence of MAC was 9%. The prevalence of MAC was highest in Caucasians (12%), followed by Hispanics (10%), African Americans (7%) and was lowest in Chinese (5%). Characteristics associated with MAC included age (p <0.01), female gender (p <0.01), increased body mass index (BMI) (p =0.03), and former smoking status (p <0.008). The MAC group had a higher prevalence of hypertension, diabetes mellitus (DM), and family history of heart attack (all p <0.001). After adjusting for all variables, age, female gender, diabetes mellitus, and increased BMI remained strongly associated with MAC. Conclusions: Age, female gender, DM, and increased BMI were significantly associated with MAC. Prevalence of MAC was strongly associated with female gender and increasing age in all ethnicities. [ABSTRACT FROM AUTHOR]

Decreased arterial distensibility is an early manifestation of adverse structural and functional changes within the vessel wall. Its correlation with thoracic aortic calcium (TAC), a marker of atherosclerosis, has not been well demonstrated. We tested the hypothesis that decreasing aortic compliance and increasing arterial stiffness would be independently associated with increased TAC. We included 3,540 subjects (61 ± 10 years, 46% men) from the Multi-ethnic Study of Atherosclerosis who had undergone an aortic distensibility (AD) assessment using magnetic resonance imaging. TAC was calculated using a modified Agatston algorithm on noncontrast cardiac computed tomographic scans. Multivariate regression models were calculated for the presence of TAC. Overall, 861 subjects (24%) had detectable TAC. Lower AD was observed among those with versus without TAC (2.02 ± 1.34 vs 1.28 ± 0.74, p <0.0001). The prevalence of TAC increased significantly across decreasing quartiles of AD (7%, 17%, 31%, and 42%, p <0.0001). Using multivariate analysis, TAC was independently associated with AD after adjusting for age, gender, ethnicity, and other covariates. In conclusion, our analysis has demonstrated that increased arterial stiffness is associated with increased TAC, independent of ethnicity and other atherosclerotic risk factors. [ABSTRACT FROM AUTHOR]

To date, sparse data are available with regard to gender differences in plaque morphology and composition. The aim of the present report was to assess the differences in coronary plaque burden and composition in a noninvasive manner between women and men using multidetector computed tomographic angiography. The study population consisted of 416 patients (61 ± 13 years), with 148 women (36%). A stenosis of ≥70% in at least one coronary segment was found in 11% of women compared to 25% of men (p <0.0001). Overall, women presented with a significantly lower mean number of segments containing calcified plaques (1.43 ± 2.04 vs 2.25 ± 2.30, p = 0.004) and mixed plaques (1.67 ± 1.23 vs 2.25 ± 2.30, p = 0.05). No such relation was seen with noncalcified plaques (0.72 ± 1.01 vs 0.86 ± 1.06, p = 0.21). In addition, the assessment of the overall proportion of the composition of plaque burden revealed relatively more noncalcified (40% vs 28%), less calcified (38% vs 43%), and mixed (23% vs 28%) plaques in women than in men (p <0.0001). On multivariate analysis of the total plaque burden, the women had a 19% (95% confidence interval 11% to 28%, p <0.0001) greater relative distribution of plaque that was noncalcified compared to the men, and the overall plaque burden was less likely to be calcified (p = 0.006) or mixed (p = 0.019). Similar results were seen in younger and older subjects. In conclusion, gender differences exist, not only in the atherosclerotic disease burden, but also in the underlying plaque composition. Women tended to have more exclusively noncalcified plaque and were less likely to have calcified or mixed plaques compared to men. Future studies are needed to elucidate whether these underlying differences in plaque composition might explain the reduced risk of cardiac events in women. [Copyright &y& Elsevier]

Abstract: Objective: Although prior studies have shown that traditional cardiovascular (CV) risk factors are associated with the burden of coronary atherosclerosis, less is known about the relationship of risk factors with coronary plaque sub-types. Coronary computed tomography angiography (CCTA) allows an assessment of both, total disease burden and plaque characteristics. In this study, we investigate the relationship between traditional CV risk factors and the presence and extent of coronary plaque sub-types in a large group of asymptomatic individuals. Methods: The study population consisted of 1015 asymptomatic Korean subjects (53±10 years; 64% were males) free of known CV disease who underwent 64-slice CCTA as part of a health screening evaluation. We analyzed plaque characteristics on a per-segment basis according to the modified American Heart Association classification. Plaques in which calcified tissue occupied more than 50% of the plaque area were classified as calcified (CAP), <50% calcified area as mixed (MCAP), and plaques without any calcium as non-calcified (NCAP). Results: A total of 215 (21%) subjects had coronary plaque while 800 (79%) had no identifiable disease. Multivariate regression analysis demonstrated that increased age (per decade) and gender are the strongest predictors for the presence of any coronary plaque or the presence of at least one segment of CAP and MCAP (any plaque—age: OR 2.89; 95% CI 2.34, 3.56; male gender: OR 5.21; 95% CI 3.20, 8.49; CAP—age: OR 2.75; 95% CI 2.12, 3.58; male gender: 4.78; 95% CI 2.48, 9.23; MCAP—age: OR 2.62; 95% CI 2.02, 3.39; male gender: OR 4.15; 95% CI 2.17, 7.94). The strongest predictors for the presence of any NCAP were gender (OR 3.56; 95% CI 1.96–6.55) and diabetes mellitus (OR 2.87; 95% CI 1.63–5.08). When looking at the multivariate association between the presence of ≥2 coronary segments with a plaque sub-type and CV risk factors, male gender was the strongest predictor for CAP (OR 7.31; 95% CI 2.12, 25.20) and MCAP (OR 5.54; 95% CI 1.84, 16.68). Alternatively, smoking was the strongest predictor for the presence of ≥2 coronary segments with NCAP (OR 4.86; 95% CI 1.68, 14.07). Low-density lipoprotein cholesterol (LDL-C) was only a predictor for the presence and extent of mixed coronary plaque. Conclusion: Age and gender are overall the strongest predictors of atherosclerosis as assessed by CCTA in this large asymptomatic Korean population and these two risk factors are not particularly associated with a specific coronary plaque sub-type. Smoking is a strong predictor of NCAP, which has been suggested by previous reports as a more vulnerable lesion. Whether a specific plaque sub-type is associated with a worse prognosis is yet to be determined by future prospective studies. [Copyright &y& Elsevier]

Abstract: Although atherosclerosis is associated with the elderly, young adults with hypercholesterolemia and other cardiovascular risk factors may have subclinical atherosclerotic disease. In many cases, when two or more risk factors are present, conventional risk assessment using the Framingham score, that was not designed to detect atherosclerotic plaques, may significantly underestimate the extent of atherosclerosis. Several non-invasive imaging technologies now make it possible to identify subclinical atherosclerosis before symptoms appear or major vascular events occur. These include B-mode ultrasound to measure carotid intima–media thickness, computed tomography to measure coronary artery calcification, and high-resolution magnetic resonance imaging to evaluate plaque size and composition. On the basis of available evidence, assessment of subclinical atherosclerosis should be considered in persons judged to be at intermediate risk by Framingham score, because test results may influence risk stratification and, consequently, the intensity of therapeutic intervention. Patients with significant subclinical atherosclerosis are at high risk and, like other high-risk individuals, should receive treatment designed to achieve aggressive low-density lipoprotein cholesterol targets. Clinical studies show that statin therapy may delay atherosclerosis progression and that intensive therapy with rosuvastatin may actually reverse the atherosclerotic process. [Copyright &y& Elsevier]

Thoracic aortic calcium (TAC) has been associated with a higher prevalence of coronary arterial calcium (CAC). The purpose of this study was to assess the relations between TAC and incident CAC and CAC progression in a cohort from the Multi-Ethnic Study of Atherosclerosis (MESA). MESA is a prospective cohort study of 6,814 participants free of clinical cardiovascular disease at entry who underwent noncontrast cardiac computed tomographic scanning at baseline examination and at a 2-year follow-up assessment. The independent associations between TAC and incident CAC in those without CAC at baseline and between TAC and CAC progression in those with CAC at baseline were investigated. The final study population consisted of 5,755 subjects (84%; mean age 62 ± 10 years, 48% men) who had follow-up CAC scores an average of 2.4 years later. Incident CAC was significantly higher in those with TAC compared with those without TAC at baseline (11 per 100 patient-years vs 6 per 100 patient-years). Similarly, TAC was associated with a higher CAC change (p <0.0001) in those with some CAC at baseline. In analysis adjusted for demographics and follow-up duration, TAC was associated with incident CAC (relative risk 1.72, p <0.0001) as well as with a greater CAC change (first quartile: relative risk 2.89, 95% confidence interval −3.16 to 8.95; fourth quartile: relative risk 24.21, 95% confidence interval 18.25 to 30.18). In conclusion, TAC is associated with the incidence and progression of CAC. The detection of TAC may improve risk stratification efforts. Future clinical outcomes studies are needed to support such an approach. [Copyright &y& Elsevier]

Abstract: Introduction/objectives: Cardiovascular disease is the leading cause of death for individuals with diabetes mellitus. Controversy exists regarding the screening of asymptomatic diabetics for occult coronary artery disease (CAD). The purpose of this study is to describe the prevalence of occult CAD in a group of asymptomatic subjects with diabetes using non-invasive coronary angiography, as well as to investigate the predictive accuracy of current guidelines with regards to their recommended criteria for further cardiac diagnostic testing in this patient population. Methods: We prospectively enrolled 217 asymptomatic Korean outpatients with type 2 diabetes who had no prior history of CAD. All underwent non-invasive coronary angiography using a 64-slice multi-detector computed tomography scanner. Results: The mean age of the study participants was 59±8 years; 66% were men. Diabetes duration was 7±7 years, mean Framingham risk score was 13%, and mean hemoglobin A1C level was 7%. Of the 217 outpatients, 138 (64%) had occult CAD based on cardiac computed tomography angiography (CCTA) findings. Thirty-six (36/138; 26%) had a significant stenosis on CCTA. Nearly half of the individuals (62/138; 45%) had a combination of non-calcified and calcified plaques. Only 5 out of 217 (2%) individuals with significant stenosis would have been missed using the American Diabetes Association (ADA) criteria for further cardiac testing. Conclusion: Almost two thirds of asymptomatic diabetics have occult CAD, including obstructive disease. Based on CCTA findings, the ADA criteria for further cardiac diagnostic testing would identify most individuals who have a significant coronary stenosis. [Copyright &y& Elsevier]

Objectives: In this study, we aimed to establish whether age-sex–specific percentiles of coronary artery calcium (CAC) predict cardiovascular outcomes better than the actual (absolute) CAC score. Background: The presence and extent of CAC correlates with the overall magnitude of coronary atherosclerotic plaque burden and with the development of subsequent coronary events. Methods: MESA (Multi-Ethnic Study of Atherosclerosis) is a prospective cohort study of 6,814 asymptomatic participants followed for coronary heart disease (CHD) events including myocardial infarction, angina, resuscitated cardiac arrest, or CHD death. Time to incident CHD was modeled with Cox regression, and we compared models with percentiles based on age, sex, and/or race/ethnicity to categories commonly used (0, 1 to 100, 101 to 400, 400+ Agatston units). Results: There were 163 (2.4%) incident CHD events (median follow-up 3.75 years). Expressing CAC in terms of age- and sex-specific percentiles had significantly lower area under the receiver-operating characteristic curve (AUC) than when using absolute scores (women: AUC 0.73 versus 0.76, p = 0.044; men: AUC 0.73 versus 0.77, p < 0.001). Akaike''s information criterion indicated better model fit with the overall score. Both methods robustly predicted events (>90th percentile associated with a hazard ratio [HR] of 16.4, 95% confidence interval [CI]: 9.30 to 28.9, and score >400 associated with HR of 20.6, 95% CI: 11.8 to 36.0). Within groups based on age-, sex-, and race/ethnicity-specific percentiles there remains a clear trend of increasing risk across levels of the absolute CAC groups. In contrast, once absolute CAC category is fixed, there is no increasing trend across levels of age-, sex-, and race/ethnicity-specific categories. Patients with low absolute scores are low-risk, regardless of age-, sex-, and race/ethnicity-specific percentile rank. Persons with an absolute CAC score of >400 are high risk, regardless of percentile rank. Conclusions: Using absolute CAC in standard groups performed better than age-, sex-, and race/ethnicity-specific percentiles in terms of model fit and discrimination. We recommend using cut points based on the absolute CAC amount, and the common CAC cut points of 100 and 400 seem to perform well. [Copyright &y& Elsevier]

It has been proposed that coronary artery calcium (CAC) can be used to estimate arterial age in adults. Supporting this concept is that chronologic age, as used in cardiovascular risk assessment, is a surrogate for atherosclerotic burden. This measure can provide patients with a more understandable version of their CAC scores (e.g., “You are 55 years old, but your arteries are more consistent with an arterial age of 65 years”). The aim of this study was to describe a method of calculating arterial age by equating estimated coronary heart disease (CHD) risk for observed age and CAC. Arterial age is then the risk equivalent of CAC. Data from the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort study of 6,814 participants free of clinical cardiovascular disease and followed for an average of 4 years, were used. Estimated arterial age was obtained as a simple linear function of log-transformed CAC. In a model for incident CHD risk controlling for age and arterial age, only arterial age was significant, indicating that observed age does not provide additional information after controlling for arterial age. Framingham risk calculated using this arterial age was more predictive of short-term incident coronary events than Framingham risk on the basis of observed age (area under the receiver-operating characteristic curve 0.75 for Framingham risk on the basis of observed age and 0.79 using arterial age, p = 0.006). In conclusion, arterial age provides a convenient transformation of CAC from Agatston units to a scale more easily appreciated by patients and treating physicians. [Copyright &y& Elsevier]

Abstract: Background: Growing evidence shows that non-high-density lipoprotein cholesterol (Non-HDL-C) is a strong and independent predictor of cardiovascular disease (CVD). Few studies have assessed the association between traditional lipid measures and subclinical end points. In this study we analyzed the association of Non-HDL-C, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) with coronary artery calcium (CAC), a marker of subclinical atherosclerosis. Methods: The study population consisted of 1611 consecutive asymptomatic individuals (67% men, mean age: 53±10 years) referred to a single electron beam tomography (EBT) facility for CAC screening. Multivariate logistic regression was used to test the association between increasing quartiles of lipid levels and presence of CAC score (CACS)>0 and CACS≥100, with the lowest levels (first quartile) of lipid values as reference. Results: Overall CACS of 0, 1–99, 100–399 and ≥400, were observed in 35%, 44%, 12% and 9% of the study subjects, respectively. The prevalence of CAC increased significantly across increasing quartiles of LDL-C, TG and Non-HDL-C (all p <0.0001), whereas CACS was significantly lower across increasing quartiles of HDL-C (p <0.001). In a multivariate model controlling for age, gender, race, cigarette smoking, hypertension, family history of coronary artery disease and obesity, there was a significant increase in the prevalence of CAC with increasing values of each lipid variable. In a multivariate model simultaneously controlling for increasing quartiles of the remaining lipid variables, only the association of Non-HDL-C with CACS>0 remained statistically significant (p =0.002). Similar results were observed with CACS≥100 (p =0.038). Conclusion: In this study Non-HDL-C was more strongly associated with subclinical atherosclerosis than all other conventional lipid values. These data suggests that Non-HDL-C may be an important treatment target in primary prevention. [Copyright &y& Elsevier]

Abstract: We sought to evaluate this “response-to-injury” hypothesis of atherosclerosis by studying the interaction between systolic blood pressure (SBP) and LDL- cholesterol (LDL-C) in predicting the presence of coronary artery calcification (CAC) in asymptomatic men. We studied 526 men (46±7 years of age) referred for electron-beam tomography (EBT) exam. The prevalence of CAC was determined across LDL-C tertiles (low: <115mg/dl; middle: 115–139mg/dl; high: ≥140mg/dl) within tertiles of SBP (low: <121mmHg; middle: 121–130mmHg; high: ≥131mmHg). CAC was found in 220 (42%) men. There was no linear trend in the presence of CAC across LDL-C tertiles in the low (p =0.6 for trend) and middle (p =0.3 for trend) SBP tertile groups, respectively. In contrast, there was a significant trend for increasing CAC with increasing LDL-C (1st: 44%; 2nd: 49%; 3rd: 83%; p <0.0001 for trend) in the high SBP tertile group. In multivariate logistic analyses (adjusting for age, smoking, triglyceride levels, HDL-cholesterol levels, body mass index, and fasting glucose levels), the odds ratio for any CAC associated with increasing LDL-C was significantly higher in those with highest SBP levels, whereas no such relationship was observed among men with SBP in the lower two tertiles. An interaction term (LDL-C×SBP) incorporated in the multivariate analyses was statistically significant (p =0.038). The finding of an interaction between SBP and LDL-C relation to CAC in asymptomatic men support the response-to-injury model of atherogenesis. [Copyright &y& Elsevier]

Abstract: Background: Emerging evidence indicates that calcifications in valvular and thoracic aorta are manifestations of generalized atherosclerosis. Assessing the presence and extent of extra-coronary atherosclerosis may further improve prognostic information in subjects who are at risk for cardiovascular disease. The aim of the study is to determine the relative prevalence and quantity of extra-coronary calcifications across ethnic groups in a multi-ethnic population based cohort of asymptomatic individuals. Methods and results: The ethnic differences associated with aortic valve calcification (AVC), mitral valve calcification (MVC), aortic valve root calcification (AVRC) and thoracic aortic wall calcification (TAC) were assessed in 6814 asymptomatic individuals in the multi-ethnic study of atherosclerosis (MESA) study. The overall prevalence of AVC, MVC, AVRC and TAC was 13, 10, 34 and 28%, respectively). As far as the valvular calcifications (AVC, MVC, AVRC) are concerned, the highest prevalence was observed in the Whites, followed by Hispanics and African-Americans with the lowest levels of calcification among the Chinese (all p <0.001). On the other hand, the Chinese along with Whites had the highest prevalence of TAC (p <0.001). After adjustment for traditional CVD risk factors and coronary artery calcification, the relative risk of AVC compared with Whites was 0.72 in Blacks (95% CI 0.59–0.90), 1.03 in Hispanics (95% CI 0.82–1.28) and 0.56 in Chinese (95% CI 0.40–0.80). Similar associations were observed for the presence of MVC and AVRC. However, as compared to Whites, the relative risk for presence of TAC was not significantly lower among Hispanics (RR: 0.83, 95% CI: 0.68–1.01) and Chinese Americans (RR: 1.24, 95% CI: 0.95–0.1.62); however Blacks had a significantly lower risk of TAC (RR: 0.50, 95% CI: 0.41–0.60), respectively. Conclusions: Racial differences exist in the prevalence of extra-coronary calcification in a large multi-ethnic population of asymptomatic individuals, thus underscoring the need for developing population specific nomograms to identify overall atherosclerotic burden in a more accurate manner in different ethnic groups. Further studies are needed to assess prognostic potential of each of these new measures of extra-coronary calcification in predicting subsequent cardiovascular events, independently and incrementally above known cardiovascular risk factors and the amount of calcified coronary plaque. [Copyright &y& Elsevier]

Despite convincing data demonstrating the benefits of aspirin (ASA), exercise, and dietary changes for both primary and secondary prevention of coronary heart disease, they remain underused. In this study, we assess whether higher coronary artery calcium (CAC) scores determined by electron beam computed tomography (EBCT) are associated with beneficial lifestyle behaviors in asymptomatic individuals. A total of 980 asymptomatic patients referred for EBCT risk assessment by their primary physician were sent a survey questioning them about health behaviors. We evaluated long-term ASA utilization, exercise, and dietary changes based on CAC using multivariable analysis. The study population consisted of 980 individuals (78% men, mean age 60 ± 8 years) who were followed for a mean of 3 ± 2 years after an initial EBCT scan. Overall, ASA initiation was lowest (29%) among those with CAC = 0, and gradually increased with higher CAC scores (1 to 99, 55%; 100 to 399, 61%; ≥400, 63%; p <0.001 for trend). Similarly, dietary changes and exercise were lowest (33% and 44%, respectively) among those with CAC = 0 and gradually increased with higher CAC scores (1 to 99, 40%; 100 to 399, 58%; ≥400, 56%; p <0.001 for trend for dietary changes; and 1 to 99, 62%; 100 to 399, 63%; ≥400, 67%; p <0.001 for trend for exercise). In multivariable analysis, greater baseline CAC was strongly associated with initiation of ASA therapy, dietary changes, and increased exercise. In conclusion, in addition to risk stratification of asymptomatic individuals, determination of CAC may also improve utilization of ASA therapy and behavioral modification. [Copyright &y& Elsevier]

Recent studies have shown that elevated white blood cell (WBC) counts independently predict adverse cardiovascular disease (CVD) outcomes. The metabolic syndrome (MS) is known to be associated with a higher degree of inflammation and increased CVD risk. It is unclear, however, whether MS provides incremental information to the Framingham risk score (FRS). The authors studied 458 asymptomatic men, of whom 112 had MS. WBC count was used as a marker of inflammation. The odds ratio (OR) for presence of WBCs in the highest quartile vs the lower 3 quartiles was 2.2; 95% confidence interval (CI), 1.39–3.40 for MS. After further adjustment for the FRS, the relationship remained significant (OR, 1.97; 95% CI, 1.25–3.13). The ability to identify higher levels of WBCs with MS was especially important in the low-risk men (OR, 2.66; 95% CI, 1.39–5.07). The study findings suggest that MS adds value to the FRS in identifying those with higher degrees of inflammation, especially among those classified as low-risk by the FRS. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large, ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality. Background: Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than non-Hispanic whites (NHW). Some of this variability may be due to differing pathophysiological mechanisms and effects of underlying atherosclerosis. Methods: Ten-year death rates from all causes (total deaths = 505) were compared using risk-adjusted Cox proportional hazards models in AA (n = 637), Hispanic (HS, n = 1,334), Asian (AS, n = 1,065), and NHW (n = 11,776) populations. Results: Ethnic minority patients were generally younger (0.3 to 4 years), more often persons with diabetes (p < 0.0001), hypertensive (p < 0.0001), and female (p < 0.0001). The prevalence of CAC scores ≥100 was highest in NHW (31%) and lowest for HS (18%) (p < 0.0001). Overall survival was 96%, 93%, and 92% for AS, NHW, and HS, respectively, as compared with 83% for AA (p < 0.0001). When comparing prognosis by CAC scores in ethnic minorities as compared with NHW, relative risk ratios were highest for AA with CAC scores ≥400 exceeding 16.1 (p < 0.0001). Hispanics with CAC scores ≥400 had relative risk ratios from 7.9 to 9.0, whereas AS with CAC scores ≥1,000 had relative risk ratios 6.6-fold higher than NHW (p < 0.0001). Conclusions: Consistent with population evidence, AA with increasing burden of subclinical coronary artery disease were the highest-risk ethnic minority population. These data support a growing body of evidence noting substantial differences in cardiovascular risk by ethnicity. [Copyright &y& Elsevier]

High low-density lipoprotein (LDL) cholesterol and the presence of metabolic syndrome (MS) are established risk factors for clinical and subclinical cardiovascular disease (CVD). However, the relative contribution to CVD risk of MS and high LDL cholesterol is not well defined. Therefore, the aim was assess the relative risk for the presence of coronary artery calcification (CAC) with metabolic syndrome (MS) compared with that of moderate or high LDL cholesterol. A total of 440 consecutive asymptomatic men (mean age 46 ± 7 years, range 29 to 65) presenting for CVD risk stratification were studied. MS was defined using National Cholesterol Education Program Adult Treatment Panel III criteria (n = 112; 24%). Moderate LDL cholesterol was defined as 130 to 159 mg/dl, and high LDL cholesterol as ≥160 mg/dl (n = 76; 17%). Overall, CAC was observed in 190 men (40%). The prevalence of CAC >0 was lowest in MS-negative men with LDL cholesterol <130 (35%) or 130 to 159 mg/dl (34%) and highest in MS-positive men with LDL cholesterol ≥160 mg/dl (80%). MS-positive men with LDL cholesterol of 130 to 159 mg/dl had CAC prevalence similar to that of MS-negative men with LDL cholesterol ≥160 mg/dl (54% vs 57%, respectively). This relation persisted with additional adjustment for age, smoking status, and cholesterol-lowering medication. In logistic regression analyses, the odds ratio for CAC >0 was highest in MS-positive men combined with high LDL cholesterol. In conclusion, these results suggest that the risk of CAC in asymptomatic men with moderate or high LDL cholesterol is magnified in persons with MS. [Copyright &y& Elsevier]

There is a growing body of evidence indicating that high triglyceride levels are an independent risk factor for cardiovascular disease (CVD) events. In this study we compared the association of fasting levels of non–high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, HDL cholesterol, and triglycerides with white blood cell (WBC) count, an inflammatory marker associated with an adverse CVD prognosis. We studied 458 asymptomatic men (46.0 ± 7.0 years old) who presented for CVD risk stratification. WBC count (×109 cells/L) increased significantly across increasing tertiles of triglyceride level (tertile 1, 6.04 ± 1.49; tertile 2 6.21 ± 1.44; tertile 3 6.78 ± 1.73, p <0.0001), whereas a trend of lower WBC counts was observed across increasing tertiles of HDL cholesterol (tertile 1, 6.52 ± 1.62; tertile 2, 6.24 ± 1.50; tertile 3, 6.21 ± 1.61, p = 0.08). In models adjusted for age, gender, and CVD risk factor, the odds ratio for a high WBC count (quartile ≥4 vs lower 3 quartiles) was significantly higher with increasing levels of triglyceride (2.4, 95% confidence interval 1.3 to 4.8, p = 0.02). When all lipid variables were introduced in the models in addition to traditional CVD risk factors, the association between plasma triglyceride level and WBC count persisted (p = 0.04), which was not found for other lipid parameters. In conclusion, in our study, only plasma triglyceride level was independently associated with a higher WBC count. [Copyright &y& Elsevier]

Abstract: Accurate risk assessment may be helpful in decreasing cardiovascular events through more appropriate targeting of preventive measures. Traditional risk assessment may be refined with the selective use of coronary artery calcium score (CACS) or other methods of subclinical atherosclerosis measurement. This article reviews information pertaining to the clinical use of CACS for assessing coronary atherosclerosis as a useful predictor of coronary artery disease (CAD) in certain population of patients. Coronary calcification is a marker of atherosclerosis that can be quantified with the use of cardiac CT and it is proportional to the extent and severity of atherosclerotic disease. The published studies demonstrate a high sensitivity of CACS for the presence of coronary artery disease but a much lower specificity for obstructive CAD depending on the magnitude of the CACS. Several large clinical trials have found clear, incremental predictive value of CACS over the Framingham risk score when used in asymptomatic patients. However, early detection of CAD by Electron Beam Tomography (EBT) screening has not convincingly demonstrated a reduction in mortality and morbidity. Nevertheless, relevant prognostic information obtained may be useful to initiate or intensify appropriate treatment strategies to slow the progression of existing atherosclerotic vascular disease. Current data suggest intermediate-risk patients may benefit most from further risk stratification with cardiac CT, as CAC testing is effective at identifying increased risk and in one study motivating effective behavioral changes. Randomized clinical trials will help determine if selective use of cardiac CT in the intermediate-risk patient would lead to more appropriate use of pharmacologic therapy and improved clinical outcomes. [Copyright &y& Elsevier]

Abstract: Background: A review of existing literature shows that for individuals with initial coronary calcium scores (CCS) of zero it would be reasonable to consider follow-up scanning no sooner than 3 years from the initial evaluation, however the data is very limited. In this study, we sought to determine the rate of new calcifications in patients initially presenting with a zero initial score on electron beam tomography (EBT). Methods and results: We evaluated 710 physician-referred participants (253 women and 448 men, mean age=56±9 years [range=29 to 93]) with no coronary artery calcium (CAC) at baseline electron beam tomography (EBT) scan. The participants underwent a follow-up scan at least 12 months apart. In our study, 248 (35%) were followed for 1–3 years, 256 (36%) for 3–5 years and 204 (29%) for >5 years, respectively. Overall, more than half of the individuals (62%) did not develop any CAC (score remained zero) in the interim period, whereas only 2% had CAC progression >50 during the follow-up. The overall median (interquartile range) and mean±S.D. change/year in these individuals was 0 (0–0.8) and 1±3, respectively. Only 11 (2%) had CAC progression/year of 11–50, whereas 3 (1%) had CAC change/year >50. It is interesting to note that even among individuals with long-term follow-up (>5 years), very few individuals (2%) had CAC progression >50. Individuals with follow-up 3–5 years did not have a significantly higher odds ratio for CAC change >10 (p =0.17) as compared to the reference group (follow-up of 1–3 years). All the other individuals who had a longer follow-up (>5 years) had a significantly higher likelihood of CAC progression >10 (OR=6.6, 95% CI=2.6–16.9, p <0.0001) compared to the reference group. Conclusion: In individuals with no detectable coronary calcium on an initial EBT scan, a repeat scan can be recommended no sooner than 5 years. [Copyright &y& Elsevier]

The objective of this study was to evaluate whether uric acid (UA) levels were associated with coronary artery calcium (CAC) in white men asymptomatic for coronary heart disease. We also evaluated whether this relation was dependent or not on the presence of the metabolic syndrome (MS). The study population consisted of 371 asymptomatic Brazilian men (48 ± 7 years of age) who underwent a routine evaluation. The average 10-year total risk of coronary heart disease calculated by Framingham risk score was 10.8 ± 7.8%. The age-adjusted prevalence of CAC in patients with a high UA level (fourth quartile ≥7.1 mg/dl, n = 91) was significantly higher than that in those with a normal UA level (58% vs 44%, p = 0.02). With respect to age, smoking, physical activity, and components of MS-adjusted analyses, a high UA level was independently associated with the presence of CAC (p = 0.043) and with increasing levels of CAC (p = 0.028). Prevalence of MS showed a graded increase according to serum UA values. In patients with the MS, after adjusting for age, smoking, physical activity, and white blood cell count, high levels of UA were strongly associated with the presence of any CAC (odds ratio 3.47, 95% confidence interval 1.26 to 9.53, p = 0.01) and with increasing levels of CAC (odds ratio 2.74, 95% confidence interval 1.15 to 6.50, p = 0.02). Conversely, there was no significant association of high UA levels in patients without the MS. However, the interaction between high UA level and the MS did not achieve statistical significance for the presence of CAC (p = 0.11) or higher levels of CAC (p = 0.16). In conclusion, our study suggests that, among asymptomatic moderate-risk men, high UA levels were independently associated with CAC in subjects with the MS. [Copyright &y& Elsevier]

Abstract: We utilized coronary artery calcium scores (CACS) to assess differences in atherosclerosis burden between asymptomatic White populations living in continents with different cardiovascular disease rates. The similarities in the genetic pool between Brazilian and Portuguese Caucasian subjects offered an opportunity to assess the influence of environmnetal factors on the development of atherosclerosis. We reviewed CACS data from 17,563 individuals (12,378 men and 5169 women) collected in the USA (74% of the subjects), Brazil (15% of the subjects) and Portugal (11% of the subjects). CACS was absent in 80 and 88% of Portuguese men and women, compared with 46 and 62% and 33 and 59% of Brazilian and US counterparts (p <0.0001). Although the US subjects showed the lowest prevalence of risk factors they had a higher median (interquartile range) CACS than the Brazilian and the Portuguese cohorts: 4 (0;87), 1 (0;68) and 0 (0;0), respectively (p <0.0001). After adjusting for differences in age and cardiovascular risk factors, US men showed higher relative risk ratios of having any CACS than either Brazilian or Portuguese men. Brazilian and US women did not differ as far as risk of CACS although they demonstrated a greater risk than Portuguese women. In this study, significant differences in CACS were detected among three nations in different continents. The CACS differences paralleled the respective cardiovascular mortality rates. [Copyright &y& Elsevier]

Abstract: Background: Although cardiovascular risk factor levels are substantially different in Caucasians, African-American, Hispanics, and Asians, the relative rates of coronary heart disease in these groups are not consistent with these differences. The objective of the study is to assess the differences in the prevalence and severity of coronary artery calcification, as a measure of atherosclerosis, in these different ethnic groups. Methods: Electron-beam tomography was performed in 16,560 asymptomatic men and women (Asians=1336, African-Americans=610, Hispanics=1256) aged ≥35 years referred by their physician for cardiovascular risk evaluation. The study population encompassed 70% males, aged 52±8 years. Results: Caucasians were more likely to present with dyslipidemia (p <0.0001), while African-Americans and Hispanics had a higher prevalence of smoking, diabetes, and hypertension (all p <0.001). After adjustment for age, gender, risk factors, and treatment for hypercholesterolemia, compared with Caucasians, the relative risks for men having coronary calcification were 0.64 (95% CI: 0.48–0.86) in African-Americans, 0.88 (95% CI: 0.67–1.15) in Hispanics, and 0.66 (95% CI: 0.55–0.80) in Asians. After similar adjustments, the relative risks for women having coronary calcification, were 1.58 (95% CI: 1.13–2.19) for African-Americans, 0.84 (95% CI: 0.66–1.06) in Hispanics, and 0.71 (95% CI: 0.56–0.89) in Asian women. After adjusting for age and risk factors using multivariable analysis, African-American men were least likely to have any coronary calcium while African-American women had significantly higher OR of any calcification. Asian men and women had significantly lower OR of any calcification. There was no significant difference in prevalence or severity of atherosclerosis between Hispanics and Caucasians, in men or women. Conclusions: Our study results demonstrate significant difference in the presence as well as severity of calcification according to ethnicity, independent of atherosclerotic risk factors. Results from this study (physician referred) closely parallel the results from MESA (population based, measured risk factors). Ethnic specific data on the predictive value of differing coronary calcium scores are needed. [Copyright &y& Elsevier]

Abstract: Objective: The presence of metabolic syndrome is associated with a higher degree of inflammation. We sought to assess whether the higher levels of cardiorespiratory fitness attenuate the levels of inflammation in people with metabolic syndrome. Research design and methods: We studied 449 consecutive asymptomatic men (47±7 years) who underwent a maximal treadmill exercise test according to the Bruce protocol. Cardiorespiratory fitness was divided into tertiles based on metabolic equivalents (METs). White blood cells (WBC) (×109 cells/L) count was used as marker of inflammation. Results: In our study population, 23% of the participants had the metabolic syndrome. The WBC count increased (p <0.0001 for trend) with increasing number of risk factors for metabolic syndrome; however there was an inverse relationship (p <0.0001 for trend) with increasing tertiles of fitness (6.47 cells×109 cells/L for lowest tertile and 5.7×109 cells/L for highest tertile). Multiple linear regression analyses demonstrated that as compared to individuals with no MS risk factor, the WBC count remained significantly higher in men with metabolic syndrome in first tertile (regression coefficient: 1.2, 95% CI 0.4–2.0, p =0.003) and second tertile (regression coefficient: 0.61, 95% CI 0.4–2.0, p =0.02) of cardiorespiratory fitness, respectively. However, in the highest tertile of fitness no increase in level of WBC count was observed with increasing metabolic syndrome risk factors. Conclusion: Our findings suggest that in people with metabolic syndrome an increased level of physical fitness might exert its beneficial effect via attenuating inflammation. [Copyright &y& Elsevier]

Abstract: Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of morbidity. Coronary heart disease (CHD) accounts for nearly half of all CVD deaths. Currently estimation of risk in primary prevention is based on the Framingham risk equations, which inputs traditional risk factors and is helpful in predicting the development of CHD in asymptomatic individuals. However many individuals suffer events in the absence of established risk factors for atherosclerosis and broad based population risk estimations may have little precision when applied to a given individual. To meet the challenge of CHD risk assessment, several tools have been developed to identify atherosclerotic disease in its preclinical stages. This paper aims to incorporate information from coronary artery calcification (CAC) scoring from a computed tomographic “heartscan” (using Electron Beam Tomography (EBT) as the validated prototype) along with current Framingham risk profiling in order to refine risk on an absolute scale by combining imaging and clinical data to affect a more comprehensive calculation of absolute risk in a given individual. For CAC scores above the 75th percentile but <90th percentile, 10 years is added to chronological age, and for CAC scores above the 90th percentile, 20 years is added to current chronological age. Among those in whom a positive CAC score is the norm such as older individuals (men≥55 years, women≥65 years) a CAC=0 will result in an age point score corresponding to the age-group whose median CAC score is zero i.e., 40–44 years for men and 55–59 years for women. The utilization of CAC scores allows the inclusion of sub-clinical disease definition into the context of modifiable risk factors as well as identifies high-risk individuals requiring aggressive treatment. [Copyright &y& Elsevier]