Association of coronary artery calcification and thoracic aortic calcification with incident peripheral arterial disease in the Multi-Ethnic Study of Atherosclerosis (MESA).

AIMS: The association of subclinical atherosclerotic disease in the coronary arteries and thoracic aorta with incident peripheral arterial disease (PAD) is unknown. We investigated the association between coronary artery calcium score (CACs) and thoracic aortic calcium score (TACs) with incident clinical and subclinical PAD. METHODS AND RESULTS: The Multi-Ethnic Study of Atherosclerosis (MESA) recruited 6814 men and women aged 45-84 from four ethnic groups who were free of clinical cardiovascular disease at enrolment. Coronary artery calcium score and thoracic aortic calcium score were measured from computed tomography scans. Participants with a baseline ankle-brachial index (ABI) ≤0.90 or >1.4 were excluded. Abnormal ABI was defined as ABI ≤0.9 or >1.4 at follow-up exam. Multivariable logistic regression and Cox proportional hazards models were used to test the associations between baseline CACs and TACs with incident abnormal ABI and clinical PAD, respectively. A total of 6409 participants (female: 52.8%) with a mean age of 61 years were analysed. Over a median follow-up of 16.7 years, 91 participants developed clinical PAD. In multivariable analysis, each unit increase in log (CACS + 1) and log (TACs + 1) were associated with 23% and 13% (P < 0.01for both) higher risk of incident clinical PAD, respectively. In 5725 (female: 52.6%) participants with an available follow-up ABI over median 9.2 years, each 1-unit increase in log (CACs + 1) and log (TACs + 1) were independently associated with 1.15-fold and 1.07-fold (P < 0.01for both) higher odds of incident abnormal ABI, respectively. CONCLUSION: Higher baseline CACs and TACs predict abnormal ABI and clinical PAD independent of traditional cardiovascular risk factors and baseline ABI.

Association of soluble interleukin-2 receptor α and tumour necrosis factor receptor 1 with heart failure: The Multi-Ethnic Study of Atherosclerosis.

AIMS: Soluble tumour necrosis factor-α receptor 1 (sTNF-αR1) and interleukin-2 receptor α (sIL-2Rα) predict incident heart failure (HF) in the elderly population. However, the association of these biomarkers with HF in a multi-ethnic asymptomatic population is unclear. We aimed to investigate the association of sTNF-αR1 and sIL-2Rα with incident HF in a multi-ethnic population of middle age and older participants. METHODS AND RESULTS: The multi-ethnic study of atherosclerosis is a prospective population-based study of 6814 participants aged 45-84 years who were free of clinical cardiovascular disease at enrolment. We included 2869 participants with available sTNF-αR1 or sIL-2Rα level measurement at baseline multi-ethnic study of atherosclerosis exam (2000-2002). We used Cox proportional-hazards model to investigate the association between sTNF-αR1 and sIL-2Rα with incident HF after adjusting for traditional cardiovascular risk factors and coronary artery calcium score measured by cardiac computed tomography. Among the included participants, the mean (standard deviation) age was 61.6 (10.2) years and 46.7% were men. The median (interquartile range) sTNF-αR1 and sIL-2Rα were 1293 (1107-1547) and 901 (727-1154) pg/mL. During a median follow-up of 14.2 (interquartile range: 11.7-14.8) years, 130 participants developed HF. In multivariable analysis, the hazard ratio (95% confidence interval, P value) of incident HF for each standard deviation increment of log-transformed sTNF-αR1 and sIL-2Rα was 1.43 (1.21-1.7, P ≤ 0.001) and 1.26 (1.04-1.53, P = 0.02), respectively. Excluding participants with interim coronary heart disease, we found a statistically significant association between sTNF-αR1 and HF with hazard ratio of 1.39 (95% confidence interval: 1.11 to 1.74, P = 0.005) and sIL-2Rα and HF showing a hazard ratio of 1.39 (95% confidence interval: 1.09 to 1.76, P = 0.007). CONCLUSIONS: sTNF-αR1 and sIL-2Rα are associated with a higher risk of incident HF in a multi-ethnic cohort without a previous history of cardiovascular disease.

Valvular calcification and risk of peripheral artery disease: the Multi-Ethnic Study of Atherosclerosis (MESA).

AIMS: The detection of cardiac valvular calcification on routine imaging may provide an opportunity to identify individuals at increased risk for peripheral artery disease (PAD). We investigated the associations of aortic valvular calcification (AVC) and mitral annular calcification (MAC) with risk of developing clinical PAD or a low ankle-brachial index (ABI). METHODS AND RESULTS: AVC and MAC were measured on cardiac computed tomography in 6778 Multi-Ethnic Study of Atherosclerosis participants without baseline PAD between 2000 and 2002. Clinical PAD was ascertained through 2015. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15, was assessed among 5762 individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Adjusted Cox proportional hazards and Poisson regression modelling were used to determine the association of valvular calcification with clinical PAD and low ABI, respectively. There were 117 clinical PAD and 198 low ABI events that occurred over a median follow-up of 14 years and 9.2 years, respectively. The presence of MAC was associated with an increased risk of clinical PAD [hazard ratio 1.79; 95% confidence interval (CI) 1.04-3.05] but not a low ABI (rate ratio 1.28; 95% CI 0.75-2.19). No significant associations were noted for the presence of AVC and risk of either clinical PAD. CONCLUSION: MAC is associated with an increased risk of developing clinical PAD. Future studies are needed to corroborate our findings and better understand whether MAC holds any predictive value as a risk marker for PAD.

Comparative Effectiveness of CT-Derived Atherosclerotic Plaque Metrics for Predicting Myocardial Ischemia.

OBJECTIVES: This study sought to investigate the performance of various cardiac computed tomography (CT)-derived atherosclerotic plaque metrics for predicting provocable myocardial ischemia. BACKGROUND: The association of coronary arterial diameter stenosis with myocardial ischemia is only modest, but cardiac CT provides several other, readily available atherosclerosis metrics, which may have incremental value. METHODS: The study analyzed 873 nonstented coronary arteries and their myocardial perfusion territories in 356 patients (mean 62 years of age) enrolled in the CORE320 (Coronary Artery Evaluation using 320-row Multidetector Computed Tomography Angiography and Myocardial Perfusion) study. Myocardial perfusion defects in static CT perfusion imaging were graded at rest and after adenosine in 13 myocardial segments using a 4-point scale. The summed difference score was calculated by subtracting the summed rest score from the summed stress score. Reversible ischemia was defined as summed difference score ≥1. In a sensitivity analysis, results were also provided using single-photon emission computed tomography (SPECT) as the reference standard. Vessel based predictor variables included maximum percent diameter stenosis, lesion length, coronary calcium score, maximum cross-sectional calcium arc, percent atheroma volume (PAV), low-attenuation atheroma volume, positive (external) vascular remodeling, and subjective impression of "vulnerable plaque." The study used logistic regression models to assess the association of plaque metrics with myocardial ischemia. RESULTS: In univariate analysis, all plaque metrics were associated with reversible ischemia. In the adjusted logistic model, only maximum percent diameter stenosis (1.26; 95% confidence interval: 1.15 to 1.38) remained an independent predictor. With SPECT as outcome variable, PAV and "vulnerable" plaque remained predictive after adjustment. In vessels with intermediate stenosis (40% to 70%), no single metric had clinically meaningful incremental value. CONCLUSIONS: Various plaque metrics obtained by cardiac CT predict provocable myocardial ischemia by CT perfusion imaging through their association with maximum percent stenosis, while none had significant incremental value. With SPECT as reference standard, PAV and "vulnerable plaque" remained predictors of ischemia after adjustment but the predictive value added to stenosis assessment alone was small.

Thrombus entrapped in patent foramen ovale: a rare form of thrombus in transit.

In rare cases, thrombus in transit can be entrapped in a patent foramen ovale (PFO). A patient with this condition is at high risk of embolic stroke and death. Early diagnosis and treatment is essential to help prevent stroke and death in these cases. There is no universal management guideline for this rare condition. The decision between medical versus surgical treatment should be made individually for each patient. We present a case of thrombus in transit entrapped in a PFO that was treated medically by lifelong anticoagulation.