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Ciccarone Articles

Ciccarone Center Research


Journal of the American College of Cardiology

Landmark Articles

Caveat emptor: the coronary calcium warranty.
By: McEvoy JW, Blaha MJ, Blumenthal RS.
It would be beneficial for clinicians to have the “warranty period” of a zero coronary calcium score stratified by baseline risk group (<10% and 10% to 20%). It may even be prudent to stratify further, as some have advocated for CAC testing in an expanded intermediate-risk group of 6% to 20% (e.g., <6%, 6% to 10%, and 10% to 20%). The investigators may have been overly prudent to suggest that “caution should be applied to interpreting our results among patients who are not receiving lipid-lowering therapy.” Although they express concern that the 756 patients on statin therapy (72%) may have had retarded CAC progression, randomized trials to date have not shown that statin therapy can achieve this. CAC = 0 has enormous potential for ruling out important coronary artery disease in asymptomatic patients. The duration and application of the “warranty period” remains an important topic for further research.
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Zero coronary calcium and Bayes’ theorem.
By: Blaha MJ, Blumenthal RS, Nasir K.
It is important to note that the conclusion in the editorial that the Gottlieb et al. paper presents a “starkly contrasting picture” to a prior systematic review is based on a statistical error.Once again, Bayes’ theorem is critical. Although CAC = 0 may not definitively exclude important coronary artery disease (CAD) in patients referred for coronary angiography, there may be potential applications in lower-risk patients presenting with atypical chest pain features.
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What is the prognostic value of a zero calcium score? Ask Bayes!
By: McEvoy JW.
The role of calcium scoring (CS), if any, appears to be in the reclassification of asymptomatic patients at intermediate risk for CAD by traditional risk factor models. This has led to a Class IIb recommendation by the American Heart Association for the use of CS in these patients. Further research is ongoing to study the effect of such reclassification.
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Screening for cardiovascular risk in asymptomatic patients.
By: Berger JS, Jordan CO, Lloyd-Jones D, Blumenthal RS.
We describe 6 risk algorithms (Framingham Risk Score for coronary heart disease events and for cardiovascular events, Adult Treatment Panel III, SCORE [Systematic Coronary Risk Evaluation] project, Reynolds Risk Score, ASSIGN [Assessing Cardiovascular Risk to Scottish Intercollegiate Guidelines Network/SIGN to Assign Preventative Treatment], and QRISK [QRESEARCH Cardiovascular Risk Algorithm]) for outcomes, population derived/validated, receiver-operating characteristic, variables included, and limitations. Areas of uncertainty include 10-year versus lifetime risk, prediction of CVD or coronary heart disease end points, nonlaboratory-based risk scores, age at which to start, race and sex differences, and whether a risk score should guide therapy. We believe that the best high-risk approach to CVD evaluation and prevention lies in routine testing for cardiovascular risk factors and risk score assessment. We recommend that health care providers discuss the global cardiovascular risk and lifetime cardiovascular risk score assessment with each patient.
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A randomized, double-blind, placebo-controlled, dose-escalation study of intravenous adult human mesenchymal stem cells (prochymal) after acute myocardial infarction.
By: Hare JM, Traverse JH, Henry TD, Dib N, Strumpf RK, Schulman SP, Gerstenblith G, DeMaria AN, Denktas AE, Gammon RS, Hermiller JB Jr, Reisman MA, Schaer GL, Sherman W.
Bone marrow-derived hMSCs may ameliorate consequences of MI, and have the advantages of preparation ease, allogeneic use due to immunoprivilege, capacity to home to injured tissue, and extensive pre-clinical support.
Intravenous allogeneic hMSCs are safe in patients after acute MI.  This trial provides pivotal safety and provisional efficacy data for an allogeneic bone marrow-derived stem cell in post-infarction patients. (Safety Study of Adult Mesenchymal Stem Cells [MSC] to Treat Acute Myocardial Infarction; NCT00114452). 
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ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and...
By: Bairey Merz CN, Alberts MJ, Balady GJ, Ballantyne CM, Berra K, Black HR, Blumenthal RS, Davidson MH, Fazio SB, Ferdinand KC, Fine LJ, Fonseca V, Franklin BA, McBride PE, Mensah GA, Merli GJ, O’Gara PT, Thompson PD, Underberg JA.

The prevention of cardiovascular morbidity and mortality is a shared responsibility among all health professionals involved in the care of people at risk of developing CVD. This document is directed at those individuals seeking expertise at a leadership level in this field, and includes opportunities for formal training and alternative routes to competence and maintenance of competence in prevention of CVD and educational resources for acquisition and maintenance of competence in the prevention of CVD. To address the expanding fund of knowledge in the area and to ensure that an adequately trained force of preventive cardiovascular leaders will be available to primary care providers, as well as to provide a pool of providers with expertise in running rehabilitation and other programs designed to address the ongoing issue of adherence, the formulation of clinical competency criteria for the cardiovascular preventive specialist is needed. Cardiovascular preventive specialists will have varying areas of expertise and will not necessarily achieve all of the outlined areas of competencies. These clinical competency criteria in the area of specialty treatment and prevention of CVD are needed, given the current setting of a rapidly growing field of knowledge, ranging from molecular and cellular mechanisms to clinical outcomes, in order to translate this into improved patient care.

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