Showing papers by "Leslee J. Shaw published in 2020"
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Stanford University1, New York University2, Duke University3, Boston University4, Saint Louis University5, Imperial College London6, Northwick Park Hospital7, Hospital Universitario La Paz8, Durham University9, NewYork–Presbyterian Hospital10, Albany Medical College11, St. Michael's Hospital12, Montreal Heart Institute13, Auckland City Hospital14, All India Institute of Medical Sciences15, University of British Columbia16, Cedars-Sinai Medical Center17, Harvard University18, Brigham and Women's Hospital19, Saint Francis University20, Columbia University Medical Center21, University of Missouri–Kansas City22, Government Medical College, Thiruvananthapuram23, Sri Jayadeva Institute of Cardiovascular Sciences and Research24, University of São Paulo25, Veterans Health Administration26, Emory University27, Mayo Clinic28, Semmelweis University29, Flinders Medical Centre30, Université Paris-Saclay31, Uppsala University Hospital32, Uppsala University33, Keio University34, National Institutes of Health35, Vanderbilt University36, East Carolina University37, Icahn School of Medicine at Mount Sinai38
TL;DR: Evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years is not found.
Abstract: Background Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical ther...
1,324 citations
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TL;DR: In patients presenting with stable chest pain, low-attenuation plaque burden is the strongest predictor of fatal or nonfatal myocardial infarction, challenging the current perception of the supremacy of current classical risk predictors for myocardials.
Abstract: Background: The future risk of myocardial infarction is commonly assessed using cardiovascular risk scores, coronary artery calcium score, or coronary artery stenosis severity. We assessed whether ...
260 citations
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NewYork–Presbyterian Hospital1, Houston Methodist Hospital2, Leiden University Medical Center3, Cedars-Sinai Medical Center4, Los Angeles Biomedical Research Institute5, University Health System6, Beaumont Hospital7, University of Ottawa8, Innsbruck Medical University9, Ludwig Maximilian University of Munich10, University of Zurich11, Seoul National University Hospital12, University of British Columbia13, Unica Corporation14, Technion – Israel Institute of Technology15, University of Virginia Health System16
TL;DR: A ML model incorporating clinical features in addition to CACS can accurately estimate the pretest likelihood of obstructive CAD on CCTA and could improve risk stratification and help guide downstream management.
Abstract: AIMS: Symptom-based pretest probability scores that estimate the likelihood of obstructive coronary artery disease (CAD) in stable chest pain have moderate accuracy. We sought to develop a machine learning (ML) model, utilizing clinical factors and the coronary artery calcium score (CACS), to predict the presence of obstructive CAD on coronary computed tomography angiography (CCTA).
METHODS AND RESULTS: The study screened 35 281 participants enrolled in the CONFIRM registry, who underwent ≥64 detector row CCTA evaluation because of either suspected or previously established CAD. A boosted ensemble algorithm (XGBoost) was used, with data split into a training set (80%) on which 10-fold cross-validation was done and a test set (20%). Performance was assessed of the (1) ML model (using 25 clinical and demographic features), (2) ML + CACS, (3) CAD consortium clinical score, (4) CAD consortium clinical score + CACS, and (5) updated Diamond-Forrester (UDF) score. The study population comprised of 13 054 patients, of whom 2380 (18.2%) had obstructive CAD (≥50% stenosis). Machine learning with CACS produced the best performance [area under the curve (AUC) of 0.881] compared with ML alone (AUC of 0.773), CAD consortium clinical score (AUC of 0.734), and with CACS (AUC of 0.866) and UDF (AUC of 0.682), P < 0.05 for all comparisons. CACS, age, and gender were the highest ranking features.
CONCLUSION: A ML model incorporating clinical features in addition to CACS can accurately estimate the pretest likelihood of obstructive CAD on CCTA. In clinical practice, the utilization of such an approach could improve risk stratification and help guide downstream management.
128 citations
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TL;DR: Evidence increasingly supports the clinical utility of CCTA across various stages of CAD, from the detection of early subclinical disease to the assessment of acute chest pain, and it can be used to noninvasively quantify plaque burden and identify high-risk plaque, aiding in diagnosis, prognosis, and treatment.
115 citations
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TL;DR: There appears to be a stepwise increase in the presence of coronary artery calcium and the risk of incident ASCVD with increasing SBP levels, highlighting the importance of primordial prevention for SBP level increase and other traditional ASCVD risk factors, which generally seem to have similar trajectories of graded increase in risk within values traditionally considered to be normal.
Abstract: Importance The risk of atherosclerotic cardiovascular disease (ASCVD) at currently defined normal systolic blood pressure (SBP) levels in persons without ASCVD risk factors based on current definitions is not well defined. Objective To examine the association of SBP levels with coronary artery calcium and ASCVD in persons without hypertension or other traditional ASCVD risk factors based on current definitions. Design, Setting, and Participants A cohort of 1457 participants free of ASCVD from the Multi-Ethnic Study of Atherosclerosis who were without dyslipidemia (low-density lipoprotein cholesterol level ≥160 mg/dL or high-density lipoprotein cholesterol level Exposures Systolic blood pressure. Main Outcomes and Measures Presence or absence of coronary artery calcium and incident ASCVD events. Results Of the 1457 participants, 894 were women (61.4%); mean (SD) age was 58.1 (9.8) years and mean (SD) follow-up was 14.5 (3.9) years. There was an increase in traditional ASCVD risk factors, coronary artery calcium, and incident ASCVD events with increasing SBP levels. The aHR for ASCVD was 1.53 (95% CI, 1.17-1.99) for every 10-mm Hg increase in SBP levels. Compared with persons with SBP levels 90 to 99 mm Hg, the aHR for ASCVD risk was 3.00 (95% CI, 1.01-8.88) for SBP levels 100 to 109 mm Hg, 3.10 (95% CI, 1.03-9.28) for SBP levels 110 to 119 mm Hg, and 4.58 (95% CI, 1.47-14.27) for SBP levels 120 to 129 mm Hg. Conclusions and Relevance Beginning at an SBP level as low as 90 mm Hg, there appears to be a stepwise increase in the presence of coronary artery calcium and the risk of incident ASCVD with increasing SBP levels. These results highlight the importance of primordial prevention for SBP level increase and other traditional ASCVD risk factors, which generally seem to have similar trajectories of graded increase in risk within values traditionally considered to be normal.
106 citations
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TL;DR: Adverse RV remodeling predicts mortality in COVID-19 independent of standard clinical and biomarker-based assessment.
87 citations
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Leiden University Medical Center1, NewYork–Presbyterian Hospital2, Icahn School of Medicine at Mount Sinai3, Yonsei University4, University of Milan5, Beaumont Hospital6, University of Ottawa7, Innsbruck Medical University8, Seoul National University Hospital9, University of British Columbia10, Unica Corporation11, Chung-Ang University12, VU University Medical Center13, University of Ulsan14, Mayo Clinic15, Cedars-Sinai Medical Center16, Emory University17, Brigham and Women's Hospital18, Los Angeles Biomedical Research Institute19
TL;DR: Results of this study suggest that, on a per-patient and per-lesion basis, 1K plaque was associated with a lower risk for future ACS and that measurement of1K plaque may improve risk stratification beyond plaque burden.
Abstract: Importance: Plaque morphologic measures on coronary computed tomography angiography (CCTA) have been associated with future acute coronary syndrome (ACS). However, the evolution of calcified coronary plaques by noninvasive imaging is not known. Objective: To ascertain whether the increasing density in calcified coronary plaque is associated with risk for ACS. Design, Setting, and Participants: This multicenter case-control cohort study included individuals enrolled in ICONIC (Incident Coronary Syndromes Identified by Computed Tomography), a nested case-control study of patients drawn from the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry, which included 13 study sites in 8 countries. Patients who experienced core laboratory-verified ACS after baseline CCTA (n = 189) and control individuals who did not experience ACS after baseline CCTA (n = 189) were included. Patients and controls were matched 1:1 by propensity scores for age; male sex; presence of hypertension, hyperlipidemia, and diabetes; family history of premature coronary artery disease (CAD); current smoking status; and CAD severity. Data were analyzed from November 2018 to March 2019. Exposures: Whole-heart atherosclerotic plaque volume was quantitated from all coronary vessels and their branches. For patients who underwent invasive angiography at the time of ACS, culprit lesions were coregistered to baseline CCTA lesions by a blinded independent reader. Low-density plaque was defined as having less than 130 Hounsfield units (HU); calcified plaque, as having more than 350 HU and subcategorized on a voxel-level basis into 3 strata: 351 to 700 HU, 701 to 1000 HU, and more than 1000 HU (termed 1K plaque). Main Outcomes and Measures: Association between calcium density and future ACS risk. Results: A total of 189 patients and 189 matched controls (mean [SD] age of 59.9 [9.8] years; 247 [65.3%] were male) were included in the analysis and were monitored during a mean (SD) follow-up period of 3.9 (2.5) years. The overall mean (SD) calcified plaque volume (>350 HU) was similar between patients and controls (76.4 [101.6] mm3 vs 99.0 [156.1] mm3; P =.32), but patients who experienced ACS exhibited less 1K plaque (>1000 HU) compared with controls (3.9 [8.3] mm3 vs 9.4 [23.2] mm3; P =.02). Individuals within the highest quartile of 1K plaque exhibited less low-density plaque, as a percentage of total plaque, when compared with patients within the lower 3 quartiles (12.6% [10.4%] vs 24.9% [20.6%]; P <.001). For 93 culprit precursor lesions detected by CCTA, the volume of 1K plaque was lower compared with the maximally stenotic lesion in controls (2.6 [7.2] mm3 vs 7.6 [20.3] mm3; P =.01). The per-patient and per-lesion results were similar between the 2 groups when restricted to myocardial infarction cases. Conclusions and Relevance: Results of this study suggest that, on a per-patient and per-lesion basis, 1K plaque was associated with a lower risk for future ACS and that measurement of 1K plaque may improve risk stratification beyond plaque burden.
79 citations
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Cornell University1, University of Missouri–Kansas City2, Saint Louis University3, Cedars-Sinai Medical Center4, Harvard University5, Brigham and Women's Hospital6, Durham University7, Hospital Universitario La Paz8, Uppsala University9, Northwick Park Hospital10, Montreal Heart Institute11, Government Medical College, Thiruvananthapuram12, Guangdong General Hospital13, All India Institute of Medical Sciences14, Wrocław Medical University15, University of Hull16, Stanford University17
TL;DR: Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men, which may have implications for testing and treatment of patients with suspected stable ischemic heart disease.
Abstract: Importance While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. Objective To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. Design, Setting, and Participants This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. Interventions CCTA and angina assessment. Main Outcomes and Measures Sex differences in stress test, CCTA findings, and symptom severity. Results Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD ( Conclusions and Relevance Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease. Trial Registration ClinicalTrials.gov Identifier:NCT01471522
78 citations
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University Health System1, Houston Methodist Hospital2, Los Angeles Biomedical Research Institute3, Beaumont Hospital4, Pusan National University5, Seoul National University Bundang Hospital6, Seoul National University Hospital7, Yonsei University8, University of British Columbia9, Unica Corporation10, Ewha Womans University11, Brigham and Women's Hospital12, Emory University13, Icahn School of Medicine at Mount Sinai14, Cedars-Sinai Medical Center15, NewYork–Presbyterian Hospital16, Leiden University Medical Center17
TL;DR: Baseline PAV, not the presence of HRP features, was the most important predictor of lesions developing into obstructive lesions, and the pattern of individual coronary atherosclerotic plaque progression differed according to the presenceof HRP.
Abstract: Objectives This study explored whether the pattern of nonobstructive lesion progression into obstructive lesions would differ according to the presence of high-risk plaque (HRP). Background It is still debatable whether HRP simply represents a certain phase during the natural history of coronary atherosclerotic plaques or if disease progression would differ according to the presence of HRP. Methods Patients with nonobstructive coronary artery disease, defined as percent diameter stenosis (%DS) Results A total of 3,049 nonobstructive lesions were identified from 1,297 patients (mean age 60.3 ± 9.3 years; 56.8% men). There were 2,624 non-HRP and 425 HRP lesions. HRP lesions had a greater total PAV and all noncalcified components of PAV and %DS at baseline compared with non-HRP lesions. However, the annualized total PAV changes were greater in non-HRP lesions than in HRP lesions. On multivariate analysis adjusted for clinical risk factors, drug use, change in lipid level, total PAV, %DS, and HRP, only the baseline total PAV and %DS independently predicted the development of obstructive lesions (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.02 to 1.07, and HR: 1.07; 95% CI: 1.04 to 1.10, respectively, all p 0.05). Conclusions The pattern of individual coronary atherosclerotic plaque progression differed according to the presence of HRP. Baseline PAV, not the presence of HRP features, was the most important predictor of lesions developing into obstructive lesions. (Progression of Atherosclerotic Plaque Determined By Computed Tomographic Angiography Imaging [PARADIGM]; NCT02803411)
60 citations
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University Health System1, NewYork–Presbyterian Hospital2, Cedars-Sinai Medical Center3, Los Angeles Biomedical Research Institute4, Beaumont Hospital5, Pusan National University6, Unica Corporation7, University of British Columbia8, Ewha Womans University9, Seoul National University Hospital10, Yonsei University11, Seoul National University Bundang Hospital12, Emory University13, Brigham and Women's Hospital14, Icahn School of Medicine at Mount Sinai15, Leiden University Medical Center16
TL;DR: Based on a ML framework, quantitative atherosclerosis characterization has been shown to be the most important feature when compared with clinical, laboratory, and qualitative measures in identifying patients at risk of RPP.
Abstract: Background Rapid coronary plaque progression (RPP) is associated with incident cardiovascular events. To date, no method exists for the identification of individuals at risk of RPP at a single point in time. This study integrated coronary computed tomography angiography-determined qualitative and quantitative plaque features within a machine learning (ML) framework to determine its performance for predicting RPP. Methods and Results Qualitative and quantitative coronary computed tomography angiography plaque characterization was performed in 1083 patients who underwent serial coronary computed tomography angiography from the PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) registry. RPP was defined as an annual progression of percentage atheroma volume ≥1.0%. We employed the following ML models: model 1, clinical variables; model 2, model 1 plus qualitative plaque features; model 3, model 2 plus quantitative plaque features. ML models were compared with the atherosclerotic cardiovascular disease risk score, Duke coronary artery disease score, and a logistic regression statistical model. 224 patients (21%) were identified as RPP. Feature selection in ML identifies that quantitative computed tomography variables were higher-ranking features, followed by qualitative computed tomography variables and clinical/laboratory variables. ML model 3 exhibited the highest discriminatory performance to identify individuals who would experience RPP when compared with atherosclerotic cardiovascular disease risk score, the other ML models, and the statistical model (area under the receiver operating characteristic curve in ML model 3, 0.83 [95% CI 0.78-0.89], versus atherosclerotic cardiovascular disease risk score, 0.60 [0.52-0.67]; Duke coronary artery disease score, 0.74 [0.68-0.79]; ML model 1, 0.62 [0.55-0.69]; ML model 2, 0.73 [0.67-0.80]; all P<0.001; statistical model, 0.81 [0.75-0.87], P=0.128). Conclusions Based on a ML framework, quantitative atherosclerosis characterization has been shown to be the most important feature when compared with clinical, laboratory, and qualitative measures in identifying patients at risk of RPP.
57 citations
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NewYork–Presbyterian Hospital1, VU University Medical Center2, Leiden University Medical Center3, University Health System4, University of Pavia5, Pusan National University6, Inje University7, Kangwon National University8, Seoul National University Hospital9, Keimyung University10, Kwandong University11, Ewha Womans University12, Houston Methodist Hospital13, Medical University of South Carolina14, Kaiser Permanente15, St Mary's Hospital16, Morristown Medical Center17, Cedars-Sinai Medical Center18, Icahn School of Medicine at Mount Sinai19
TL;DR: A comprehensive anatomic interpretation with CCTA, including quantification of obstructive and nonobstructive atherosclerotic plaque, was superior to functional imaging in the diagnosis of invasive FFR.
Abstract: Importance Stress imaging has been the standard for diagnosing functionally significant coronary artery disease. It is unknown whether novel, atherosclerotic plaque measures improve accuracy beyond coronary stenosis for diagnosing invasive fractional flow reserve (FFR) measurement. Objective To compare the diagnostic accuracy of comprehensive anatomic (obstructive and nonobstructive atherosclerotic plaque) vs functional imaging measures for estimating vessel-specific FFR. Design, Setting, and Participants Controlled clinical trial of diagnostic accuracy with a multicenter derivation-validation cohort of patients referred for nonemergent invasive coronary angiography. A total of 612 patients (64 [10] years; 30% women) with signs and symptoms suggestive of myocardial ischemia from 23 sites were included. Patients were recruited from 2014 to 2017. Data analysis began in August 2018. Interventions Patients underwent invasive coronary angiography with measurement of invasive FFR, coronary computed tomographic angiography (CCTA) quantification of atherosclerotic plaque and FFR by CT (FFR-CT), and semiquantitative scoring of rest/stress myocardial perfusion imaging (by magnetic resonance, positron emission tomography, or single photon emission CT). Multivariable generalized linear mixed models were derived and validated calculating the area under the receiver operating characteristics curve. Main Outcomes and Measures The primary end point was invasive FFR of 0.80 or less. Results Of the 612 patients, the mean (SD) age was 64 (10) years, and 426 (69.9%) were men. An invasive FFR of 0.80 or less was measured in 26.5% of 1727 vessels. In the derivation cohort, CCTA vessel-specific factors associated with FFR 0.80 or less were stenosis severity, percentage of noncalcified atheroma volume, lumen volume, the number of lesions with high-risk plaque (≥2 of low attenuation plaque, positive remodeling, napkin ring sign, or spotty calcification), and the number of lesions with stenosis greater than 30%. Fractional flow reserve–CT was not additive to this model including stenosis and atherosclerotic plaque. Significant myocardial perfusion imaging predictors were the summed rest and difference scores. In the validation cohort, the areas under the receiver operating characteristic curve were 0.81 for CCTA vs 0.67 for myocardial perfusion imaging (P Conclusions and Relevance A comprehensive anatomic interpretation with CCTA, including quantification of obstructive and nonobstructive atherosclerotic plaque, was superior to functional imaging in the diagnosis of invasive FFR. Comprehensive CCTA measures improve prediction of vessel-specific coronary physiology more so than stress-induced alterations in myocardial perfusion. Trial Registration ClinicalTrials.gov Identifier:NCT02173275.
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Houston Methodist Hospital1, Brigham and Women's Hospital2, George Washington University3, University of Maryland, Baltimore4, Uppsala University5, Mayo Clinic6, Scott & White Hospital7, Harvard University8, University of British Columbia9, Baker IDI Heart and Diabetes Institute10, Stanford University11, Indiana University12, University of Virginia Health System13, West Virginia University14, NewYork–Presbyterian Hospital15, University of Minnesota16
TL;DR: The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented disruption to routine patient care and health care professionals scrambled within weeks to attend to the surge of affected individuals.
Abstract: The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented disruption to routine patient care ([1][1]). Health care professionals scrambled within weeks to attend to the surge of affected individuals amid concerns of hospital capacity and scarcity of personal protective equipment (PPE
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TL;DR: Across the spectrum of RF burden, a higher CAC score was strongly associated with long-term, all-cause mortality and a greater proportion of deaths due to CVD and CHD and across RF strata, CAC added prognostic information.
Abstract: Objectives This study sought to evaluate the association and burden of coronary artery calcium (CAC) with long-term, cause-specific mortality across the spectrum of baseline risk. Background Although CAC is a known predictor of short-term, all-cause mortality, data on long-term and cause-specific mortality are inadequate. Methods The CAC Consortium cohort is a multicenter cohort of 66,636 participants without coronary heart disease (CHD) who underwent CAC testing. The following risk factors (RFs) were considered: 1) current cigarette smoking; 2) dyslipidemia; 3) diabetes mellitus; 4) hypertension; and 5) family history of CHD. Results During the 12.5-years median follow-up, 3,158 (4.7%) deaths occurred; 32% were cardiovascular disease (CVD) deaths. Participants with CAC scores ≥400 had a significantly increased risk for CHD and CVD mortality (hazard ratio [HR]: 5.44; 95% confidence interval [CI]: 3.88 to 7.62; and HR: 4.15; 95% CI: 3.29 to 5.22, respectively) compared with CAC of 0. Participants with ≥3 RFs had a smaller increased risk for CHD and CVD mortality (HR: 2.09; 95% CI: 1.52 to 2.85; and HR: 1.84; 95% CI: 1.46 to 2.31, respectively) compared with those without RFs. Across RF strata, CAC added prognostic information. For example, participants without RFs but with CAC ≥400 had significantly higher all-cause, non-CVD, CVD, and CHD mortality rates compared with participants with ≥3 RFs and CAC of 0. Conclusions Across the spectrum of RF burden, a higher CAC score was strongly associated with long-term, all-cause mortality and a greater proportion of deaths due to CVD and CHD. Absence of CAC identified people with a low risk over 12 years of follow-up, with most deaths being non-CVD in nature, regardless of RF burden.
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TL;DR: A U-Net-inspired, deep-learning model rapidly segmented and quantified cardiac structures with high accuracy on a pixel level, with good agreement with manual annotation, facilitating its expansion into areas of research and clinical import.
Abstract: Objectives This study designed and evaluated an end-to-end deep learning solution for cardiac segmentation and quantification. Background Segmentation of cardiac structures from coronary computed tomography angiography (CCTA) images is laborious. We designed an end-to-end deep-learning solution. Methods Scans were obtained from multicenter registries of 166 patients who underwent clinically indicated CCTA. Left ventricular volume (LVV) and right ventricular volume (RVV), left atrial volume (LAV) and right atrial volume (RAV), and left ventricular myocardial mass (LVM) were manually annotated as ground truth. A U-Net-inspired, deep-learning model was trained, validated, and tested in a 70:20:10 split. Results Mean age was 61.1 ± 8.4 years, and 49% were women. A combined overall median Dice score of 0.9246 (interquartile range: 0.8870 to 0.9475) was achieved. The median Dice scores for LVV, RVV, LAV, RAV, and LVM were 0.938 (interquartile range: 0.887 to 0.958), 0.927 (interquartile range: 0.916 to 0.946), 0.934 (interquartile range: 0.899 to 0.950), 0.915 (interquartile range: 0.890 to 0.920), and 0.920 (interquartile range: 0.811 to 0.944), respectively. Model prediction correlated and agreed well with manual annotation for LVV (r = 0.98), RVV (r = 0.97), LAV (r = 0.78), RAV (r = 0.97), and LVM (r = 0.94) (p Conclusions A deep-learning model rapidly segmented and quantified cardiac structures. This was done with high accuracy on a pixel level, with good agreement with manual annotation, facilitating its expansion into areas of research and clinical import.
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TL;DR: The results support the emerging consensus that CAC = 0 represents a unique population with favorable all-cause prognosis who may be considered for more flexible treatment goals in primary prevention.
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University of British Columbia1, University of Cambridge2, Seoul National University Hospital3, UCLA Medical Center4, Yonsei University5, Seoul National University Bundang Hospital6, Unica Corporation7, Nova Southeastern University8, Pusan National University9, Emory University10, Brigham and Women's Hospital11, Cedars-Sinai Medical Center12, Icahn School of Medicine at Mount Sinai13, Leiden University Medical Center14, Beaumont Hospital15, King Saud bin Abdulaziz University for Health Sciences16, NewYork–Presbyterian Hospital17, University Health System18
TL;DR: Calcified plaque is a marker for risk of adverse events and disease progression due to its strong association with the total plaque burden, and increasing PCPV is a markers of plaque stability and reduced risk at both a lesion and patient level.
Abstract: Objectives The aim of the current study was to explore the impact of plaque calcification in terms of absolute calcified plaque volume (CPV) and in the context of its percentage of the total plaque volume at a lesion and patient level on the progression of coronary artery disease. Background Coronary artery calcification is an established marker of risk of future cardiovascular events. Despite this, plaque calcification is also considered a marker of plaque stability, and it increases in response to medical therapy. Methods This analysis included 925 patients with 2,568 lesions from the PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) registry, in which patients underwent clinically indicated serial coronary computed tomography angiography. Plaque calcification was examined by using CPV and percent CPV (PCPV), calculated as (CPV/plaque volume) × 100 at a per-plaque and per-patient level (summation of all individual plaques). Results CPV was strongly correlated with plaque volume (r = 0.780; p Conclusions Calcified plaque is a marker for risk of adverse events and disease progression due to its strong association with the total plaque burden. When considered as a percentage of the total plaque volume, increasing PCPV is a marker of plaque stability and reduced risk at both a lesion and patient level. (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging [PARADIGM]; NCT02803411 )
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University Health System1, University of Ulsan2, Yonsei University3, Kwandong University4, Hanyang University5, Ewha Womans University6, Mayo Clinic7, NewYork–Presbyterian Hospital8, Seoul National University Hospital9, Los Angeles Biomedical Research Institute10, Seoul National University Bundang Hospital11, Unica Corporation12, University of British Columbia13, Emory University14, Beaumont Hospital15, Brigham and Women's Hospital16, Cedars-Sinai Medical Center17, Icahn School of Medicine at Mount Sinai18, Cardiovascular Institute of the South19, Leiden University Medical Center20
TL;DR: TyG index had a positive and significant association with an increased risk of PP and rapid PP after adjusting for confounding factors and is an independent predictive marker for the progression of coronary atherosclerosis.
Abstract: The association between triglyceride glucose (TyG) index and coronary atherosclerotic change remains unclear. We aimed to evaluate the association between TyG index and coronary plaque progression (PP) using serial coronary computed tomography angiography (CCTA). A total of 1143 subjects (aged 60.7 ± 9.3 years, 54.6% male) who underwent serial CCTA with available data on TyG index and diabetic status were analyzed from The Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry. PP was defined as plaque volume (PV) (mm3) at follow-up minus PV at index > 0. Annual change of PV (mm3/year) was defined as PV change divided by inter-scan period. Rapid PP was defined as the progression of percent atheroma volume (PV divided by vessel volume multiplied by 100) ≥ 1.0%/year. The median inter-scan period was 3.2 (range 2.6–4.4) years. All participants were stratified into three groups based on TyG index tertiles. The overall incidence of PP was 77.3%. Baseline total PV (group I [lowest]: 30.8 (0.0–117.7), group II: 47.2 (6.2–160.4), and group III [highest]: 57.5 (8.4–154.3); P < 0.001) and the annual change of total PV (group I: 5.7 (0.0–20.2), group II: 7.6 (0.5–23.5), and group III: 9.4 (1.4–27.7); P = 0.010) were different among all groups. The risk of PP (odds ratio [OR] 1.648; 95% confidence interval [CI] 1.167–2.327; P = 0.005) and rapid PP (OR 1.777; 95% CI 1.288–2.451; P < 0.001) was increased in group III compared to that in group I. TyG index had a positive and significant association with an increased risk of PP and rapid PP after adjusting for confounding factors. TyG index is an independent predictive marker for the progression of coronary atherosclerosis. Clinical registration ClinicalTrials.gov NCT02803411
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Leiden University Medical Center1, NewYork–Presbyterian Hospital2, University of Erlangen-Nuremberg3, Houston Methodist Hospital4, Cedars-Sinai Medical Center5, Los Angeles Biomedical Research Institute6, University Health System7, Beaumont Hospital8, University of Ottawa9, Innsbruck Medical University10, Ludwig Maximilian University of Munich11, University of Zurich12, Seoul National University Hospital13, University of British Columbia14, Unica Corporation15, Technion – Israel Institute of Technology16, University of Virginia Health System17
TL;DR: Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors, suggesting synergistic effects of both.
Abstract: AIMS: In patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent.
METHODS AND RESULTS: Patients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3-4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3-2.2) and 1.4 (95% CI 1.1-1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004).
CONCLUSION: Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both.
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TL;DR: In the United States, functional imaging is the most commonly used method to diagnose potentially obstructive coronary artery disease in patients with stable chest pain, but evidence from several contemporary randomized clinical trials may advocate a new paradigm of imaging for detecting CAD.
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TL;DR: The CAC-DRS system, combining the Agatston score and the number of vessels with CAC provides better stratification of risk for CHD, CVD, and all-cause death than the Ag atston score alone.
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University of Arkansas for Medical Sciences1, GlaxoSmithKline2, NewYork–Presbyterian Hospital3, Leiden University4, Beaumont Hospital5, University of Ottawa6, Baptist Memorial Hospital-Memphis7, Innsbruck Medical University8, Seoul National University9, Yonsei University10, University of British Columbia11, University of Virginia12, Chung-Ang University13, VU University Medical Center14, Hanyang University15, Myongji University16, Mayo Clinic17, Cedars-Sinai Medical Center18, Los Angeles Biomedical Research Institute19, Emory University20, Harvard University21, Icahn School of Medicine at Mount Sinai22
TL;DR: In a high-risk cohort, a boosted ensemble algorithm can be used to predict CL from non-CL precursors on coronary CTA, and this model demonstrated significantly higher area under the receiver-operating characteristic curve for discriminating CL precursor.
Abstract: Objectives This study sought to identify culprit lesion (CL) precursors among acute coronary syndrome (ACS) patients based on qualitative and quantitative computed tomography–based plaque characteristics. Background Coronary computed tomography angiography (CTA) has been validated for patient-level prediction of ACS. However, the applicability of coronary CTA to CL assessment is not known. Methods Utilizing the ICONIC (Incident COroNary Syndromes Identified by Computed Tomography) study, a nested case-control study of 468 patients with baseline coronary CTA, the study included ACS patients with invasive coronary angiography–adjudicated CLs that could be aligned to CL precursors on baseline coronary CTA. Separate blinded core laboratories adjudicated CLs and performed atherosclerotic plaque evaluation. Thereafter, the study used a boosted ensemble algorithm (XGBoost) to develop a predictive model of CLs. Data were randomly split into a training set (80%) and a test set (20%). The area under the receiver-operating characteristic curve of this model was compared with that of diameter stenosis (model 1), high-risk plaque features (model 2), and lesion-level features of CL precursors from the ICONIC study (model 3). Thereafter, the machine learning (ML) model was applied to 234 non-ACS patients with 864 lesions to determine model performance for CL exclusion. Results CL precursors were identified by both coronary angiography and baseline coronary CTA in 124 of 234 (53.0%) patients, with a total of 582 lesions (containing 124 CLs) included in the analysis. The ML model demonstrated significantly higher area under the receiver-operating characteristic curve for discriminating CL precursors (0.774; 95% confidence interval [CI]: 0.758 to 0.790) compared with model 1 (0.599; 95% CI: 0.599 to 0.599; p Conclusions In a high-risk cohort, a boosted ensemble algorithm can be used to predict CL from non-CL precursors on coronary CTA.
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Leiden University Medical Center1, NewYork–Presbyterian Hospital2, Houston Methodist Hospital3, Los Angeles Biomedical Research Institute4, Beaumont Hospital5, Pusan National University6, Unica Corporation7, University of British Columbia8, Ewha Womans University9, Seoul National University Hospital10, Yonsei University11, Seoul National University Bundang Hospital12, University Health System13, Cedars-Sinai Medical Center14, Emory University15, Brigham and Women's Hospital16, Icahn School of Medicine at Mount Sinai17
TL;DR: PAV was less affected by patient's body surface area then PV and TAVnorm and may be the preferred method to report coronary atherosclerotic burden.
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University Health System1, Houston Methodist Hospital2, Los Angeles Biomedical Research Institute3, Beaumont Hospital4, Pusan National University5, Seoul National University Bundang Hospital6, Seoul National University Hospital7, Yonsei University8, University of British Columbia9, Unica Corporation10, Ewha Womans University11, Brigham and Women's Hospital12, Emory University13, Icahn School of Medicine at Mount Sinai14, Cedars-Sinai Medical Center15, NewYork–Presbyterian Hospital16, Leiden University Medical Center17
TL;DR: The compositional PV progression differed according tosex, suggesting that comprehensive plaque evaluation may contribute to further refining of risk stratification according to sex.
Abstract: OBJECTIVES: This study sought to explore sex-based differences in total and compositional plaque volume (PV) progression.
BACKGROUND: It is unclear whether sex has an impact on PV progression in patients with coronary artery disease (CAD).
METHODS: The study analyzed a prospective multinational registry of consecutive patients with suspected CAD who underwent 2 or more clinically indicated coronary computed tomography angiography (CTA) at ≥2-year intervals. Total and compositional PV at baseline and follow-up were quantitatively analyzed and normalized using the analyzed total vessel length. Multivariate linear regression models were constructed.
RESULTS: Of the 1,255 patients included (median coronary CTA interval 3.8 years), 543 were women and 712 were men. Women were older (62 ± 9 years of age vs. 59 ± 9 years of age; p 0.05). At baseline, men possessed greater total PV (31.3 mm3 [interquartile range (IQR): 0 to 121.8 mm3] vs. 56.7 mm3 [IQR: 6.8 to 152.1 mm3] p = 0.005), and there was an approximately 9-year delay in women in developing total PV than in men. The prevalence of high-risk plaques was greater in men than women (31% vs. 20%; p < 0.001). In multivariate analysis, after adjusting for age, clinical risk factors, medication use, and total PV at baseline, despite similar total PV progression rates, female sex was associated with greater calcified PV progression (β = 2.83; p = 0.004) but slower noncalcified PV progression (β = -3.39; p = 0.008) and less development of high-risk plaques (β = -0.18; p = 0.049) than in men.
CONCLUSIONS: The compositional PV progression differed according to sex, suggesting that comprehensive plaque evaluation may contribute to further refining of risk stratification according to sex. (NCT02803411).
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TL;DR: CAC predicts CHD, CVD, and all-cause mortality in patients with diabetes; however, greater CAC predicts CVD and total mortality more strongly in women.
Abstract: OBJECTIVE While diabetes has been previously noted to be a stronger risk factor for cardiovascular disease (CVD) in women compared with men, whether this is still the case is not clear. Coronary artery calcium (CAC) predicts coronary heart disease (CHD) and CVD in people with diabetes; however, its sex-specific impact is less defined. We compared the relation of CAC in women versus men with diabetes for total, CVD, and CHD mortality. RESEARCH DESIGN AND METHODS We studied adults with diabetes from a large registry of patients with CAC scanning with mortality follow-up over 11.5 years. Cox regression examined the relation of CAC with mortality end points. RESULTS Among 4,503 adults with diabetes (32.5% women) aged 21–93 years, 61.2% of women and 80.4% of men had CAC >0. Total, CVD, and CHD mortality rates were directly related to CAC; women had higher total and CVD death rates than men when CAC >100. Age- and risk factor-adjusted hazard ratios (HRs) per log unit CAC were higher among women versus men for total (1.28 vs. 1.18) (interaction P = 0.01) and CVD mortality (1.47 vs. 1.27) (interaction P = 0.04) but were similar for CHD mortality (1.53 and 1.48). For CVD mortality, HRs with CAC scores of 101–400 and >400 were 3.67 and 6.27, respectively, for women and 1.63 and 3.48, respectively, for men (interaction P = 0.04). For total mortality, HRs were 2.56 and 4.05 for women, respectively, and 1.88 and 2.66 for men, respectively (interaction P = 0.01). CONCLUSIONS CAC predicts CHD, CVD, and all-cause mortality in patients with diabetes; however, greater CAC predicts CVD and total mortality more strongly in women.
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University Health System1, Cedars-Sinai Medical Center2, University of Calgary3, Los Angeles Biomedical Research Institute4, Beaumont Hospital5, Pusan National University6, Unica Corporation7, University of British Columbia8, Ewha Womans University9, Seoul National University Hospital10, Yonsei University11, Seoul National University Bundang Hospital12, Emory University13, Brigham and Women's Hospital14, Icahn School of Medicine at Mount Sinai15, Leiden University Medical Center16, NewYork–Presbyterian Hospital17
TL;DR: The study findings suggest that the overall cardiovascular disease risk burden is associated with the progression of coronary atherosclerosis; the progress of fibrofatty plaque and low-attenuation plaque and the development of adverse plaque characteristics appear to be accelerated in patients with a high risk of atherosclerotic cardiovascular disease.
Abstract: Importance Several studies have reported that the progression of coronary atherosclerosis, as measured by serial coronary computed tomographic (CT) angiography, is associated with the risk of future cardiovascular events. However, the cumulative consequences of multiple risk factors for plaque progression and the development of adverse plaque characteristics have not been well characterized. Objectives To examine the association of cardiovascular risk factor burden, as assessed by atherosclerotic cardiovascular disease (ASCVD) risk score, with the progression of coronary atherosclerosis and the development of adverse plaque characteristics. Design, Setting, and Participants This cohort study is a subgroup analysis of participant data from the prospective observational Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging (PARADIGM) study, which evaluated the association between serial coronary CT angiography findings and clinical presentation. The PARADIGM international multicenter registry, which includes 13 centers in 7 countries (Brazil, Canada, Germany, Italy, Portugal, South Korea, and the US), was used to identify 1005 adult patients without known coronary artery disease who underwent serial coronary CT angiography scans (median interscan interval, 3.3 years; interquartile range [IQR], 2.6-4.8 years) between December 24, 2003, and December 16, 2015. Based on the 10-year ASCVD risk score, the cardiovascular risk factor burden was classified as low ( 20.0%). Data were analyzed from February 8, 2019, to April 17, 2020. Exposures Association of baseline ASCVD risk burden with plaque progression. Main Outcomes and Measures Noncalcified plaque, calcified plaque, and total plaque volumes (mm3) were measured. Noncalcified plaque was subclassified using predefined Hounsfield unit thresholds for fibrous, fibrofatty, and low-attenuation plaque. The percent atheroma volume (PAV) was defined as plaque volume divided by vessel volume. Adverse plaque characteristics were defined as the presence of positive remodeling, low-attenuation plaque, or spotty calcification. Results In total, 1005 patients (mean [SD] age, 60 [8] years; 575 men [57.2%]) were included in the analysis. Of those, 463 patients (46.1%) had a low 10-year ASCVD risk score (low-risk group), 373 patients (37.1%) had an intermediate ASCVD risk score (intermediate-risk group), and 169 patients (16.8%) had a high ASCVD risk score (high-risk group). The annualized progression rate of PAV for total plaque, calcified plaque, and noncalcified plaque was associated with increasing ASCVD risk (r = 0.26 for total plaque,r = 0.23 for calcified plaque, andr = 0.11 for noncalcified plaque;P Conclusions and Relevance Progression of coronary atherosclerosis occurred across all ASCVD risk groups and was associated with an increase in 10-year ASCVD risk. The progression of fibrofatty and low-attenuation plaques and the development of adverse plaque characteristics was greater in patients with a high risk of ASCVD.
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NewYork–Presbyterian Hospital1, Cornell University2, Yonsei University3, Ewha Womans University4, Seoul National University Hospital5, Seoul National University Bundang Hospital6, Unica Corporation7, Pusan National University8, Beaumont Hospital9, Los Angeles Biomedical Research Institute10, University of British Columbia11, Emory University12, Brigham and Women's Hospital13, Cedars-Sinai Medical Center14, Icahn School of Medicine at Mount Sinai15, Leiden University Medical Center16
TL;DR: An automated deep learning model demonstrated segmentation of multiple cardiovascular structures from CCTA images with reasonable overall accuracy when evaluated on a pixel level.
Abstract: OBJECTIVES: To develop, demonstrate and evaluate an automated deep learning method for multiple cardiovascular structure segmentation.
BACKGROUND: Segmentation of cardiovascular images is resource-intensive. We design an automated deep learning method for the segmentation of multiple structures from Coronary Computed Tomography Angiography (CCTA) images.
METHODS: Images from a multicenter registry of patients that underwent clinically-indicated CCTA were used. The proximal ascending and descending aorta (PAA, DA), superior and inferior vena cavae (SVC, IVC), pulmonary artery (PA), coronary sinus (CS), right ventricular wall (RVW) and left atrial wall (LAW) were annotated as ground truth. The U-net-derived deep learning model was trained, validated and tested in a 70:20:10 split.
RESULTS: The dataset comprised 206 patients, with 5.130 billion pixels. Mean age was 59.9 ± 9.4 yrs., and was 42.7% female. An overall median Dice score of 0.820 (0.782, 0.843) was achieved. Median Dice scores for PAA, DA, SVC, IVC, PA, CS, RVW and LAW were 0.969 (0.979, 0.988), 0.953 (0.955, 0.983), 0.937 (0.934, 0.965), 0.903 (0.897, 0.948), 0.775 (0.724, 0.925), 0.720 (0.642, 0.809), 0.685 (0.631, 0.761) and 0.625 (0.596, 0.749) respectively. Apart from the CS, there were no significant differences in performance between sexes or age groups.
CONCLUSIONS: An automated deep learning model demonstrated segmentation of multiple cardiovascular structures from CCTA images with reasonable overall accuracy when evaluated on a pixel level.
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NewYork–Presbyterian Hospital1, Leiden University Medical Center2, Houston Methodist Hospital3, Beaumont Hospital4, University of Ottawa5, Innsbruck Medical University6, Unica Corporation7, Seoul National University Hospital8, University of British Columbia9, University of Virginia Health System10, University Health System11, Yonsei University12, Chung-Ang University13, University of Amsterdam14, Cedars-Sinai Medical Center15, Los Angeles Biomedical Research Institute16, Emory University17, Brigham and Women's Hospital18, Icahn School of Medicine at Mount Sinai19, Leiden University20
TL;DR: While HRP is more prevalent among obstructives lesions, non-obstructive HRP lesions outnumber those that are obstructive and confer risk clinically approaching that of obstructive lesions without HRP.
Abstract: Author(s): Ferraro, Richard A; van Rosendael, Alexander R; Lu, Yao; Andreini, Daniele; Al-Mallah, Mouaz H; Cademartiri, Filippo; Chinnaiyan, Kavitha; Chow, Benjamin JW; Conte, Edoardo; Cury, Ricardo C; Feuchtner, Gudrun; de Araujo Goncalves, Pedro; Hadamitzky, Martin; Kim, Yong-Jin; Leipsic, Jonathon; Maffei, Erica; Marques, Hugo; Plank, Fabian; Pontone, Gianluca; Raff, Gilbert L; Villines, Todd C; Lee, Sang-Eun; Al'Aref, Subhi J; Baskaran, Lohendran; Cho, Iksung; Danad, Ibrahim; Gransar, Heidi; Budoff, Matthew J; Samady, Habib; Stone, Peter H; Virmani, Renu; Narula, Jagat; Berman, Daniel S; Chang, Hyuk-Jae; Bax, Jeroen J; Min, James K; Shaw, Leslee J; Lin, Fay Y | Abstract: AimsHigh-risk plaque (HRP) and non-obstructive coronary artery disease independently predict adverse events, but their importance to future culprit lesions has not been resolved. We sought to determine in patients prior to confirmed acute coronary syndrome (ACS) the association between lesion percent diameter stenosis (%DS), and the absolute number and prevalence of HRP. The secondary objective was to examine the relative importance of non-obstructive HRP in future culprit lesions.Methods and resultsWithin the ICONIC study, a nested case-control study of patients undergoing coronary computed tomographic angiography (coronary CT), we included ACS cases with culprit lesions confirmed by invasive coronary angiography and coregistered to baseline coronary CT. Quantitative CT was used to evaluate obstructive (≥50%) and non-obstructive (l50%) diameter stenosis, with HRP defined as ≥2 features of spotty calcification, positive remodelling, or low-attenuation plaque at baseline. A total of 234 patients with downstream ACS over 54 (interquartile range 5-525.5) days exhibited 198/898 plaques with HRP on coronary CT. While HRP was less prevalent in non-obstructive (19.7%, 161/819) than obstructive lesions (46.8%, 37/79, P l 0.001), non-obstructive plaque comprised 81.3% (161/198) of HRP lesions overall. Among the 128 patients with identifiable culprit lesion precursors, the adjusted hazard ratio (HR) was 1.85 [95% confidence interval (CI) 1.26-2.72] for HRP, with no interaction between %DS and HRP (P = 0.82). Compared to non-obstructive HRP lesions, obstructive lesions without HRP exhibited a non-significant HR of 1.41 (95% CI 0.61-3.25, P = 0.42).ConclusionsWhile HRP is more prevalent among obstructive lesions, non-obstructive HRP lesions outnumber those that are obstructive and confer risk clinically approaching that of obstructive lesions without HRP.
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TL;DR: This study demonstrates the non-negligible prevalence of CAC among very high-risk young US adults, reinforcing the critical importance of traditional risk factors in the earliest development of detectable subclinical ASCVD.
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NewYork–Presbyterian Hospital1, Brigham and Women's Hospital2, University of Virginia Health System3, Harvard University4, University of Maryland, Baltimore5, Uppsala University6, Scott & White Hospital7, University of British Columbia8, Baker IDI Heart and Diabetes Institute9, Stanford University10, Indiana University11, West Virginia University12, Houston Methodist Hospital13, Mayo Clinic14, Duke University15, University of Missouri–Kansas City16, Riverside Methodist Hospital17, University of Pittsburgh18, University of Ottawa19, Christiana Care Health System20, Baptist Health21, Northside Hospital22, University of California, San Diego23, University of Bristol24, University of Leeds25, Golden Jubilee National Hospital26, Northwestern University27, National Institutes of Health28, University of Michigan29, University of Minnesota30
TL;DR: The highly anticipated ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial is conducted to assess for the incremental clinical benefits of an initial invasive management strategy over an initial medical therapy.
Abstract: The highly anticipated ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, the largest study to-date conducted to assess for the incremental clinical benefits of an initial invasive management strategy over an initial medical therapy
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TL;DR: This review summarizes key concepts, clinical limitations, and important opportunities for research about biomarker- and imaging-based tests in older adults with cardiovascular disease.