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Ciccarone Articles

Ciccarone Center Research

Year

2010

Landmark Articles

  • Baseline CAC accurately identifies coronary atherosclerosis and improves prediction of future cardiac events. However, whether knowledge of progression of CAC scores over time further improves risk prediction is unclear. We conducted a comprehensive review of published reports on CAC progression and found that CAC progression correlates with worsening atherosclerosis and may facilitate prediction of future cardiac events. These findings support the notion that slowing CAC progression with therapeutic interventions might provide prognostic benefit. However, despite promising early data, such interventions (most notably with statin therapy) have not been shown to slow the progression of CAC in any randomized controlled trial to date, outside of post hoc subgroup analyses. Thus, routine quantification of CAC progression cannot currently be recommended in clinical practice.
    Read on Pubmed
  • 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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  • In this observational study, we examined whether high baseline CACS were associated with the initiation as well continuation of new lipid-lowering medication (LLM), blood pressure-lowering medication (BPLM), and regular aspirin (ASA) use in a multi-ethnic population-based cohort. Findings indicate that CACS >400 was associated with a higher likelihood of initiation and continuation of LLM, BPLM, and ASA. The association was weaker for continuation than for initiation of these preventive therapies.
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  • 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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Abdominal obesity in rheumatoid arthritis: association with cardiometabolic risk factors and disease characteristics.
By: Giles JT, Allison M, Blumenthal RS, Post W, Gelber AC, Petri M, Tracy R, Szklo M, Bathon JM.
Abdominal adiposity, especially visceral adiposity, is emerging as a recognized cardiometabolic risk factor. This study was undertaken to investigate how abdominal fat is distributed in rheumatoid arthritis (RA), and its RA-related determinants. We compared men and women with RA with non-RA controls from MESA. The distribution of abdominal fat differs significantly by RA status. Higher VFA in men with RA, and the more potent association of VFA with cardiometabolic risk factors in men and women with RA, may contribute to cardiovascular risk in RA populations.
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Incidence of subclinical coronary atherosclerosis in patients with suspected embolic stroke using cardiac computed tomography.
By: Yoon YE, Chang HJ, Cho I, Jeon KH, Chun EJ, Choi SI, Bae HJ, Rivera JJ, Nasir K, Blumenthal RS, Lim TH.
The purpose of this study was to investigate the incidence of subclinical CAD in patients with suspected acute embolic stroke or transient ischemic attack (TIA) using 64-row multi-slice computed tomography (MSCT) and to examine its association with conventional risk stratification. In logistic regression analysis, only CACS independently predicted the presence ?50% occult CAD evidenced by CCTA. Subclinical CAD, including ?50% stenotic disease, is highly prevalent in patients who had suffered a suspected embolic stroke. The current guideline for further cardiac testing may have limited value to identify patients with ?50% CAD in this patient population, which can be improved by adopting CACS.
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Coronary artery calcium progression: an important clinical measurement? A review of published reports.
By: McEvoy JW, Blaha MJ, Defilippis AP, Budoff MJ, Nasir K, Blumenthal RS, Jones SR.
Baseline CAC accurately identifies coronary atherosclerosis and improves prediction of future cardiac events. However, whether knowledge of progression of CAC scores over time further improves risk prediction is unclear. We conducted a comprehensive review of published reports on CAC progression and found that CAC progression correlates with worsening atherosclerosis and may facilitate prediction of future cardiac events. These findings support the notion that slowing CAC progression with therapeutic interventions might provide prognostic benefit. However, despite promising early data, such interventions (most notably with statin therapy) have not been shown to slow the progression of CAC in any randomized controlled trial to date, outside of post hoc subgroup analyses. Thus, routine quantification of CAC progression cannot currently be recommended in clinical practice.
Read on Pubmed
Coronary artery calcium progression — an important clinical measurement? (State of the Art Paper)
By: McEvoy JW, Blaha M, DeFilippis A, Budoff M, Nasir K, Blumenthal RS, Jones SR.

Baseline coronary artery calcification (CAC) accurately identifies coronary atherosclerosis and might improve prediction of future cardiac events. Serial assessment of CAC scores has been proposed for monitoring atherosclerosis progression and for assessing the effectiveness of medical therapies aimed at reducing cardiac risk. However, whether knowledge of progression of CAC scores over time further improves risk prediction is unclear. Several trials relating medical therapies to CAC progression have been performed without any formal guidelines on the definition of CAC progression and how it is best quantified. We conducted a comprehensive review of published reports on CAC progression. Increased CAC progression is associated with many known cardiac risk factors. We found that CAC progression correlates with worsening atherosclerosis and may facilitate prediction of future cardiac events. These findings support the notion that slowing CAC progression with therapeutic interventions might provide prognostic benefit. However, despite promising early data, such interventions (most notably with statin therapy) have not been shown to slow the progression of CAC in any randomized controlled trial to date, outside of post hoc subgroup analyses. Thus, routine quantification of CAC progression cannot currently be recommended in clinical practice. First, standards of how CAC progression should be defined and assessed need to be developed. In addition, there remains a need for further studies analyzing the effect of other cardiac therapies on CAC progression and cardiac outcomes.

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Noninvasive visualization of coronary artery endothelial function in healthy subjects and in patients with coronary artery disease.
By: Hays AG, Hirsch GA, Kelle S, Gerstenblith G, Weiss RG, Stuber M.
The goal was to test 2 hypotheses: first, that coronary endothelial function can be measured non-invasively and abnormal function detected using clinical 3.0-T magnetic resonance imaging (MRI); and second, that the extent of local CAD, in a given patient, is related to the degree of local abnormal coronary endothelial function. We concluded that endothelial-dependent coronary artery dilation and increased blood flow in healthy subjects, and their absence in CAD patients, can now be directly visualized and quantified non-invasively. Local coronary endothelial function differs between severely and mildly diseased arteries in a given CAD patient. This novel, safe method may offer new insights regarding the importance of local coronary endothelial function and improved risk stratification in patients at risk for and with known CAD.
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Familial defective ApoB-100 is a major cause of increased LDL-cholesterol and coronary artery calcification in the old order Amish.
By: Shen H, Damcott CM, Rampersaud E, Pollin TI, Bielak LF, Post WS, Chang Y-PC, Rumberger JA, Shuldiner AR, Mitchell BD.

Elevated low-density lipoprotein cholesterol (LDL-C) levels are a major cardiovascular disease risk factor. Genetic factors are an important determinant of LDL-C levels. The R3500Q mutation in APOB is a major determinant of LDL-C levels and CAC in the Amish.

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Familial defective apolipoprotein B-100 and increased low-density lipoprotein cholesterol and coronary artery calcification in the old order amish.
By: Shen H, Damcott CM, Rampersaud E, Pollin TI, Horenstein RB, McArdle PF, Peyser PA, Bielak LF, Post WS, Chang YP, Ryan KA, Miller M, Rumberger JA, Sheedy PF 2nd, Shelton J, O’Connell JR, Shuldiner AR, Mitchell BD.
Elevated LDL-C levels are a major CVD risk factor. Genetic factors are an important determinant of LDL-C levels. To identify single nucleotide polymorphisms associated with LDL-C and subclinical coronary atherosclerosis, we performed a genome-wide association study of LDL-C in 841 asymptomatic Amish individuals aged 20 to 80 years, with replication in a second sample of 663 Amish individuals. We also performed scanning for CAC in 1,018 of these individuals. We concluded that the presence of R3500Q, the mutation responsible for familial defective apolipoprotein B-100, is a major determinant of LDL-C levels and CAC in the Amish.
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Risk factor differences for aortic vs. coronary calcified atherosclerosis: MESA.
By: Criqui MH, Kamineni A, Allison MA, Ix JH, Carr JJ, Cushman M, Detrano R, Post W, Wong ND.

The goal of this study was to compare and contrast coronary artery calcium (CAC) with abdominal aortic calcium (AAC) in terms of their associations with traditional and novel cardiovascular disease (CVD) risk factors. AAC showed stronger correlations with most CVD risk factors than did CAC. The predictive value of AAC compared with CAC for incident CVD events remains to be evaluated.

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Statin therapy in primary prevention: New insights regarding women and the elderly.
By: Harrington C, Horne A Jr., Hasan R, Blumenthal RS.

Cardiovascular disease (CVD) remains the leading cause of death in men and women in the United States and is a leading cause of disability. Advances in pharmacotherapy and revascularization strategies have resulted in a decrease in mortality and an improvement of quality of life. The emphasis on primary and secondary prevention is imperative to provide high-quality and cost-effective medical care that will improve survival and quality of life.

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Prevention strategies for coronary heart disease.
By: Blaha MJ, Ketlogetswe KS, Ndumele CE, Gluckman TJ, Blumenthal RS.
This state-of-the-art examination of comprehensive primary and secondary prevention strategies is a superb discussion of the impact of clinical trials and epidemiologic studies on our current national guidelines.