Detection of urinary tract stones on submillisievert abdominopelvic CT imaging with deep-learning image reconstruction algorithm (DLIR).

PURPOSE: Urolithiasis is a chronic condition that leads to repeated CT scans throughout the patient's life. The goal was to assess the diagnostic performance and image quality of submillisievert abdominopelvic computed tomography (CT) using deep learning-based image reconstruction (DLIR) in urolithiasis. METHODS: 57 patients with suspected urolithiasis underwent both non-contrast low-dose (LD) and ULD abdominopelvic CT. Raw image data of ULD CT were reconstructed using hybrid iterative reconstruction (ASIR-V 70%) and high-strength-level DLIR (DLIR-H). The performance of ULD CT for the detection of urinary stones was assessed by two readers and compared with LD CT with ASIR-V 70% as a reference standard. Image quality was assessed subjectively and objectively. RESULTS: 266 stones were detected in 38 patients. Mean effective dose was 0.59 mSv for ULD CT and 1.96 mSv for LD CT. For diagnostic performance, sensitivity and specificity were 89% and 94%, respectively, for ULDCT with DLIR-H. There was an almost perfect intra-observer concordance on ULD CT with DLIR-H versus LDCT with ASIR-V 70% (ICC = 0.90 and 0.90 for the two readers). Image noise was significantly lower and signal-to-noise ratio significantly higher with DLIR-H compared to ASIR-V 70%. Subjective image quality was also significantly better with ULDCT with DLIR-H. CONCLUSION: ULD CT with Deep Learning Image Reconstruction maintains a good diagnostic performance in urolithiasis, with better image quality than hybrid iterative reconstruction and a significant radiation dose reduction.

Prospective Comparison of Free-Breathing Accelerated Cine Deep Learning Reconstruction Versus Standard Breath-Hold Cardiac MRI Sequences in Patients With Ischemic Heart Disease.

BACKGROUND. Cine cardiac MRI sequences require repeated breath-holds, which can be difficult for patients with ischemic heart disease (IHD). OBJECTIVE. The purpose of the study was to compare a free-breathing accelerated cine sequence using deep learning (DL) reconstruction and a standard breath-hold cine sequence in terms of image quality and left ventricular (LV) measurements in patients with IHD undergoing cardiac MRI. METHODS. This prospective study included patients undergoing 1.5- or 3-T cardiac MRI for evaluation of IHD between March 15, 2023, and June 21, 2023. Examinations included an investigational free-breathing cine short-axis sequence with DL reconstruction (hereafter, cine-DL sequence). Two radiologists (reader 1 [R1] and reader 2 [R2]), in blinded fashion, independently assessed left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and subjective image quality for the cine-DL sequence and a standard breath-hold balanced SSFP sequence; R1 assessed artifacts. RESULTS. The analysis included 26 patients (mean age, 64.3 ± 11.7 [SD] years; 14 men, 12 women). Acquisition was shorter for the cine-DL sequence than the standard sequence (mean ± SD, 0.6 ± 0.1 vs 2.4 ± 0.6 minutes; p < .001). The cine-DL sequence, in comparison with the standard sequence, showed no significant difference for LVEF for R1 (mean ± SD, 51.7% ± 14.3% vs 51.3% ± 14.7%; p = .56) or R2 (53.4% ± 14.9% vs 52.8% ± 14.6%; p = .53); significantly greater LVEDV for R2 (mean ± SD, 171.9 ± 51.9 vs 160.6 ± 49.4 mL; p = .01) but not R1 (171.8 ± 53.7 vs 165.5 ± 52.4 mL; p = .16); and no significant difference in LVESV for R1 (mean ± SD, 88.1 ± 49.3 vs 86.0 ± 50.5 mL; p = .45) or R2 (85.2 ± 48.1 vs 81.3 ± 48.2 mL; p = .10). The mean bias between the cine-DL and standard sequences by LV measurement was as follows: LVEF, 0.4% for R1 and 0.7% for R2; LVEDV, 6.3 mL for R1 and 11.3 mL for R2; and LVESV, 2.1 mL for R1 and 3.9 mL for R2. Subjective image quality was better for cine-DL sequence than the standard sequence for R1 (mean ± SD, 2.3 ± 0.5 vs 1.9 ± 0.8; p = .02) and R2 (2.2 ± 0.4 vs 1.9 ± 0.7; p = .02). R1 reported no significant difference between the cine-DL and standard sequences for off-resonance artifacts (3.8% vs 23.1% examinations; p = .10) and parallel imaging artifacts (3.8% vs 19.2%; p = .19); blurring artifacts were more frequent for the cine-DL sequence than the standard sequence (42.3% vs 7.7% examinations; p = .008). CONCLUSION. A free-breathing cine-DL sequence, in comparison with a standard breath-hold cine sequence, showed very small bias for LVEF measurements and better subjective quality. The cine-DL sequence yielded greater LV volumes than the standard sequence. CLINICAL IMPACT. A free-breathing cine-DL sequence may yield reliable LVEF measurements in patients with IHD unable to repeatedly breath-hold. TRIAL REGISTRATION. ClinicalTrials.gov NCT05105984.

The evolving role of cardiovascular magnetic resonance in the assessment of mitral valve prolapse.

Mitral valve prolapse (MVP), characterized by a displacement > 2 mm above the mitral annulus of one or both bileaflets, with or without leaflet thickening, is a common valvular heart disease, with a prevalence of approximately 2% in western countries. Although this population has a generally good overall prognosis, MVP can be associated with mitral regurgitation (MR), left ventricular (LV) remodeling leading to heart failure, ventricular arrhythmia, and, the most devastating complication, sudden cardiac death, especially in myxomatous bileaflet prolapse (Barlow's disease). Among several prognostic factors reported in the literature, LV fibrosis and mitral annular disjunction may act as an arrhythmogenic substrate in this population. Cardiac magnetic resonance (CMR) has emerged as a reliable tool for assessing MVP, MR severity, LV remodeling, and fibrosis. Indeed, CMR is the gold standard imaging modality to assess ventricular volume, function, and wall motion abnormalities; it allows accurate calculation of the regurgitant volume and regurgitant fraction in MR using a combination of LV volumetric measurement and aortic flow quantification, independent of regurgitant jet morphology and valid in cases of multiple valvulopathies. Moreover, CMR is a unique imaging modality that can assess non-invasively focal and diffuse fibrosis using late gadolinium enhancement sequences and, more recently, T1 mapping. This review describes the use of CMR in patients with MVP and its role in identifying patients at high risk of ventricular arrhythmia.

Is the Calcium Score Useful for Rheumatoid Arthritis Patients at Low or Intermediate Cardiovascular Risk?

Cardiovascular disease, particularly myocardial infarction, is the leading cause of death of rheumatoid arthritis (RA) patients. The usefulness of the coronary artery calcification score (CACS), determined using cardiac computed-tomography (CT)-scan images, was assessed as a part of a cardiovascular work-up of RA patients at low or intermediate cardiovascular disease risk. This descriptive, cross-sectional, single-center study was conducted on patients with stable RA or that which is in remission. Each patient's work-up included a collection of cardiovascular risk factors, laboratory analyses, an electrocardiogram, a supra-aortic trunks (SATs) echo-Doppler test and a cardiac CT scan. The primary endpoint was to determine the frequency of patients with a CACS > 100, indicating notable atherosclerosis. Fifty patients were analyzed: mean ± standard deviation age was 53.7 ± 7.5 years, 82% women. The CACS exceeded 100 in 12 (24%) patients (11 were at intermediate risk) and 2 of them underwent angioplasty for silent myocardial ischemia. Cardiovascular risk was reclassified from intermediate to high for 5 patients. Age according to sex and smoking status were significantly associated with that increase; no association was found with RA characteristics or treatments.

Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery.

Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.

Clinical and Cardiovascular Magnetic Resonance Predictors of Early and Long-Term Clinical Outcome in Acute Myocarditis.

Introduction: The natural history of acute myocarditis (AM) remains partially unknown and predictors of outcome are debated. We sought to assess the impact of various cardiac magnetic resonance (CMR) parameters on early and long-term prognosis in a population of patients with AM. Materials and Methods: In a two-center longitudinal study, we included consecutive patients with diagnosis of AM based on CMR and without hemodynamic compromise. The primary endpoint was the occurrence of an event in the acute phase (≤15 days). Secondary endpoints were the occurrence of major adverse cardiac events (MACE) and recurrence of AM during follow-up. Results: Three hundred and eighty-eight patients were included [mean age 38.5 years, 77.3% male, mean ejection fraction (EF):56%] of which 82% (317) presented with chest pain. CMR was performed 4 ± 2 days after index presentation. Overall, 38 patients (9.8%) had an event at the acute phase, 41 (10.6%) presented at least one MACE during follow-up (median 7.5 years, 6.6-8.9) and 30 (7.7%) experienced a recurrence of AM. By multivariate analysis, the independent predictors of initial complications were absence of chest pain (OR [95%CI] = 0.35 [0.15-0.82]), presence of syncope/pre-syncope (OR [95%CI] = 3.56 [1.26-10.02]), lower EF (OR [95%CI] = 0.94 [0.91-0.98] per%), myocardial extent of late gadolinium enhancement (LGE) (OR [95%CI] = 1.05 [1.002-1.100] per%) and absence of edema (OR [95%CI] = 0.44 [0.19-0.97]). Only age (HR [95%CI] = 1.021 [1.001-1.041] per year) and an initial alteration of EF (HR [95%CI] = 0.94 [0.91-0.97] per%) were associated with MACE during follow-up. Factors independently associated with AM recurrence were myocarditis prior to the index episodes (HR [95%CI] = 5.74 [1.72-19.22]) and viral syndrome at the index episode (HR [95%CI] = 4.21 [1.91-9.28]). Conclusion: In routine consecutive hemodynamically stable patients with diagnosis of AM based on CMR, absence of edema, reduced EF, and extent of LGE were associated with early adverse outcome. Only age and EF were associated with long-term events.

Pulmonary emphysema quantification at low dose chest CT using Deep Learning image reconstruction.

PURPOSE: Quantitative analysis of emphysema volume is affected by the radiation dose and the CT reconstruction technique. We aim to evaluate the influence of a commercially available deep learning image reconstruction algorithm (DLIR) on the quantification of pulmonary emphysema in low-dose chest CT. METHODS: We performed a retrospective study of low dose chest CT scans in 54 patients with chronic obstructive pulmonary disease (COPD). Raw data were reconstructed using FBP, iterative reconstruction (ASIR-V 70%) and deep learning based algorithms at high, medium and low-strength (DLIR -H, -M, -L). Filtered FBP images served as reference. Pulmonary emphysema volume (proportion of voxels below -950 UH) was measured on each reconstruction dataset and visually assessed by a chest radiologist. Quantitative image quality was assessed by placing 3 regions of interest in the trachea, in air and in a paraspinal muscle. Signal to noise ratio was also measured. RESULTS: The mean CDTIvol was 2.38 ± 0.68 mGy. Significant differences in emphysema volumes between the filtered FBP reference and ASIR-V, DLIR-H, DLIR-M or DLIR-L were observed, (p < 10-3) for all. A strong correlation between filtered FBP volumes and DLIR-H was reported (r = 0.999, p < 10-4), a 10% overestimation with DLIR-H being observed. Noise was significantly reduced in DLIR-H volumes compared to the other reconstruction methods. Signal to noise ratio was improved when using DLIR-H (p < 10-6). CONCLUSION: There are significant differences regarding emphysema volumes between FBP, iterative reconstruction or deep learning-based DLIR algorithm. DLIR-H shows the closest correlation to filtered FBP while increasing SNR.

Diagnostic performance and image quality of deep learning image reconstruction (DLIR) on unenhanced low-dose abdominal CT for urolithiasis.

BACKGROUND: Patients with urolithiasis undergo radiation overexposure from computed tomography (CT) scans. Improvement of image reconstruction is necessary for radiation dose reduction. PURPOSE: To evaluate a deep learning-based reconstruction algorithm for CT (DLIR) in the detection of urolithiasis at low-dose non-enhanced abdominopelvic CT. MATERIAL AND METHODS: A total of 75 patients who underwent low-dose abdominopelvic CT for urolithiasis were retrospectively included. Each examination included three reconstructions: DLIR; filtered back projection (FBP); and hybrid iterative reconstruction (IR; ASiR-V 70%). Image quality was subjectively and objectively assessed using attenuation and noise measurements in order to calculate the signal-to-noise ratio (SNR), absolute contrast, and contrast-to-noise ratio (CNR). Attenuation of the largest stones were also compared. Detectability of urinary stones was assessed by two observers. RESULTS: Image noise was significantly reduced with DLIR: 7.2 versus 17 and 22 for ASiR-V 70% and FBP, respectively. Similarly, SNR and CNR were also higher compared to the standard reconstructions. When the structures had close attenuation values, contrast was lower with DLIR compared to ASiR-V. Attenuation of stones was also lowered in the DLIR series. Subjective image quality was significantly higher with DLIR. The detectability of all stones and stones >3 mm was excellent with DLIR for the two observers (intraclass correlation [ICC] = 0.93 vs. 0.96 and 0.95 vs. 0.99). For smaller stones (<3 mm), results were different (ICC = 0.77 vs. 0.86). CONCLUSION: For low-dose abdominopelvic CT, DLIR reconstruction exhibited image quality superior to ASiR-V and FBP as well as an excellent detection of urinary stones.

MRI Assessment of Right Ventricular Volumes and Function in Patients With Repaired Tetralogy of Fallot Using kat-ARC Accelerated Sequences.

OBJECTIVE. The objective of our study was to assess the accuracy and reproducibility of right ventricular volumes and function measurements in patients with repaired tetralogy of Fallot using two k-adaptive-t autocalibrating reconstruction for cartesian sampling (kat-ARC) accelerated sequences: a morphologic 3D cine sequence and a functional free-breathing 4D flow sequence. SUBJECTS AND METHODS. Seventeen patients who underwent cardiac MRI with gadolinium injection as part of follow-up of repaired tetralogy of Fallot from March 2017 to July 2018 were prospectively included in the initial study population; the final study cohort was composed of 15 of the 17 patients. Ventricle volume measurements were performed on a 3D cine kat-ARC sequence, a 4D flow kat-ARC sequence, and a 2D cine balanced steady-state free precession (bSSFP) sequence. The 2D cine bSSFP sequence was the reference standard in cardiac assessment. Intertechnique and interobserver analyses were performed. Bland-Altman analysis and correlation tests were used to compare quantitative measurements. RESULTS. Ventricular end-diastolic volume (EDV) and end-systolic volume (ESV) values were well correlated in the right ventricle (r = 0.94-0.98) for both 3D and 4D sequences. Ejection fraction (EF) also showed good correlation for both 3D and 4D sequences (r = 0.79 and r = 0.92). Bland-Altman analysis showed good agreement between right and left ventricular volumes, with narrower limits of agreement in the left ventricle, and an intraclass correlation coefficient (ICC) of greater than 0.80. For the 4D flow sequence, ventricular volumes were overestimated, which led to underestimation of the EF (bias for EDV = -10.2 mL, bias for ESV = -22.7 mL, bias for EF = 6.4%). Interobserver agreement was excellent for the ventricular volumes (ICC, 0.93-0.99) and fair to excellent for the EFs (ICC, 0.59-0.83). CONCLUSION. Compared with the reference standard 2D bSSFP sequence, the 3D cine kat-ARC accelerated sequence showed good accuracy and reproducibility for right ventricular measurements in patients with repaired tetralogy of Fallot. The short duration of the 4D flow kat-ARC sequence appears promising for performing volumetric measurements.

Usefulness of Cardiac Magnetic Resonance Imaging in Aortic Stenosis.

The objective of this review is to provide an overview of the role of cardiac magnetic resonance (CMR) in aortic stenosis (AS). Although CMR is undeniably the gold standard for assessing left ventricular volume, mass, and function, the assessment of the left ventricular repercussions of AS by CMR is not routinely performed in clinical practice, and its role in evaluating and quantifying AS is not yet well established. CMR is an imaging modality integrating myocardial function and disease, which could be particularly useful in a pathology like AS that should be considered as a global myocardial disease rather than an isolated valve disease. In this review, we discuss the emerging potential of CMR for the diagnosis and prognosis of AS. We detail its utility for studying all aspects of AS, including valve anatomy, flow quantification, left ventricular volumes, mass, remodeling, and function, tissue mapping, and 4-dimensional flow magnetic resonance imaging. We also discuss different clinical situations where CMR could be useful in AS, for example, in low-flow low-gradient AS to confirm the low-flow state and to understand the reason for the left ventricular dysfunction or when there is a suspicion of associated cardiac amyloidosis.

Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: An echocardiographic and computed tomography study.

BACKGROUND: An increased acceleration time to ejection time (AT/ET) ratio is associated with increased mortality in patients with aortic stenosis (AS). AIM: To identify the factors associated with an increased AT/ET ratio. METHODS: The relationships between the AT/ET ratio and clinical and Doppler echocardiographic variables of interest in the setting of AS were analysed retrospectively in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (LVEF). The computed tomography aortic valve calcium (CT-AVC) score was studied in a subgroup of 342 patients. RESULTS: In the univariate analysis, the AT/ET ratio was found to correlate with peak aortic jet velocity (r=0.57; P<0.0001), mean pressure gradient (r=0.60; P<0.0001), aortic valve area (r=-0.50; P<0.0001) and CT-AVC score (r=0.24; P<0.0001). The AT/ET ratio had good accuracy in predicting a peak aortic jet velocity≥4 m/s, a mean pressure gradient≥40mmHg and an aortic valve area≤1.0cm2, with an optimal cut-off value of 0.34. Multivariable linear regression analysis showed that presence of AS-related symptoms, decreased LV stroke volume index, LVEF, absence of diabetes mellitus, systolic blood pressure, increased LV mass index, relative wall thickness and peak aortic jet velocity were independently associated with an increased AT/ET ratio (all P<0.05). In the subgroup of patients who underwent CT-AVC scoring, the CT-AVC score was independently associated with an increased AT/ET ratio (P<0.05). CONCLUSIONS: The AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond the haemodynamic and anatomical severity of AS influence the AT/ET ratio, including LV geometry, function and systolic blood pressure. These findings should be considered when assessing the AT/ET ratio in patients with AS and preserved LVEF.

Detection and Characterization of Atypical Renal Cysts and Solid Renal Masses in Kidney Transplant Patients by Use of Dual-Energy CT Iodine Maps.

OBJECTIVE. The purpose of this study was to evaluate whether dual-energy CT follow-up of kidney transplant recipients performed with only two contrast-enhanced phases and reconstructed material maps has the same diagnostic efficiency as triphasic conventional CT in detection and characterization of atypical renal cysts and renal masses. MATERIALS AND METHODS. In a retrospective study, 175 renal transplant patients underwent dual-energy CT as part of their follow-up (monoenergetic unenhanced, late contrast-enhanced, and tubular contrast-enhanced dual-energy phases). An unenhanced virtual series and material separation maps were reconstructed. ROIs were marked on theses lesions, the bladder, and the psoas muscle. Material suppressed iodine was used to record attenuation measurements on the unenhanced and virtual unenhanced series in the tubular and late phases, and material concentration measurements were obtained on the iodine density images. The delivered doses for each series were registered. RESULTS. One hundred one renal lesions (spontaneous attenuation > 20 HU, size > 10 mm) were detected. An iodine concentration threshold greater than 1500 µg/mL was associated with excellent diagnostic performance (sensitivity, 100%; specificity, 92.55%; positive predictive value, 50%; negative predictive value, 100%) for detection of suspect lesions (enhancement > 20 HU). The two lesions with an iodine concentration greater than 5000 µg/mL corresponded to the only two histologically proven cancers. CONCLUSION. Iodine concentration maps obtained with dual-energy CT perform as well as enhanced images obtained at conventional CT in the detection and characterization of tissue and atypical cystic renal lesions in kidney transplant recipients. Use of this method could reduce radiation dose, especially by avoiding the unenhanced series.

Biological scoring system for early prediction of acute bowel ischemia after cardiac surgery: the PALM score.

BACKGROUND: Bowel ischemia is a life-threatening emergency defined as an inadequate vascular perfusion leading to bowel inflammation resulting from impaired colonic/small bowel blood supply. Main issue for physicians regarding bowel ischemia diagnosis lies in the absence of informative and specific clinical or biological signs leading to delayed management, resulting in a poorer prognosis, especially after cardiac surgery. The aim of the present series was to propose a simple scoring system based on biological data for the diagnosis of bowel ischemia. METHODS: In a retrospective monocentric study, patients admitted in cardiac ICU, after cardiovascular surgery, were screened for inclusion. According to a 1:2 ratio (case-control), matching between two groups was based on sex, type of cardiovascular surgery, and the operative period (per month). Patients were divided into two groups: "ischemic group" which corresponds to patients with confirmed bowel ischemia and "non-ischemic group" which corresponds to patients without bowel ischemia. Primary objective was the conception of a scoring system for the diagnosis of bowel ischemia. Secondary objectives were to detail the postoperative morbidity and the diagnostic features for the distinction between acute mesenteric ischemia and ischemic colitis. RESULTS: Forty-eight patients (1.3%) had confirmed bowel ischemia ("ischemic group"). According to the 2:1 matching, 96 patients were included in the "non-ischemic group." Aspartate aminotransferase > 449 UI/L, lactate > 4 mmol/L, procalcitonin > 4.7 µg/L, and myoglobin > 1882 µg/L were found to be independently associated with bowel ischemia. Based on their respective odds ratios, points were assigned to each item ranging from 4 to 8. AUROCC [95% confidence interval] of the scoring system to diagnose bowel ischemia was 0.93 [0.91-0.95], p < 0.001. The optimal threshold after bootstrapping was ≥ 14 points; this yielded a sensitivity of 85.4%, a specificity of 94.8%, a positive likelihood ratio of 16.42, a negative likelihood ratio of 0.15, a Youden's index of 0.802, and a diagnostic odds ratio of 106.62. CONCLUSIONS: A biological scoring system based on PCT, ASAT, lactate, and myoglobin measurement allows the diagnosis of bowel ischemia after cardiac surgery with high accuracy. This score could help clinician to propose an early diagnosis and an early treatment in this high mortality disease.

Computed Tomography Aortic Valve Calcium Scoring in Patients With Aortic Stenosis.

BACKGROUND: Computed tomography aortic valve calcium scoring (CT-AVC) holds promise for the assessment of patients with aortic stenosis (AS). We sought to establish the clinical utility of CT-AVC in an international multicenter cohort of patients. METHODS AND RESULTS: Patients with AS who underwent ECG-gated CT-AVC within 3 months of echocardiography were entered into an international, multicenter, observational registry. Optimal CT-AVC thresholds for diagnosing severe AS were determined in patients with concordant echocardiographic assessments, before being used to arbitrate disease severity in those with discordant measurements. In patients with long-term follow-up, we assessed whether CT-AVC thresholds predicted aortic valve replacement and death. In 918 patients from 8 centers (age, 77±10 years; 60% men; peak velocity, 3.88±0.90 m/s), 708 (77%) patients had concordant echocardiographic assessments, in whom CT-AVC provided excellent discrimination for severe AS (C statistic: women 0.92, men 0.89). Our optimal sex-specific CT-AVC thresholds (women 1377 Agatston unit and men 2062 Agatston unit) were nearly identical to those previously reported (women 1274 Agatston unit and men 2065 Agatston unit). Clinical outcomes were available in 215 patients (follow-up 1029 [126-2251] days). Sex-specific CT-AVC thresholds independently predicted aortic valve replacement and death (hazard ratio, 3.90 [95% confidence interval, 2.19-6.78]; P<0.001) after adjustment for age, sex, peak velocity, and aortic valve area. Among 210 (23%) patients with discordant echocardiographic assessments, there was considerable heterogeneity in CT-AVC scores, which again were an independent predictor of clinical outcomes (hazard ratio, 3.67 [95% confidence interval, 1.39-9.73]; P=0.010). CONCLUSIONS: Sex-specific CT-AVC thresholds accurately identify severe AS and provide powerful prognostic information. These findings support their integration into routine clinical practice. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01358513, NCT02132026, NCT00338676, NCT00647088, NCT01679431.

The Addition of Vascular Calcification Scores to Traditional Risk Factors Improves Cardiovascular Risk Assessment in Patients with Chronic Kidney Disease.

BACKGROUND: Although a variety of non-invasive methods for measuring cardiovascular (CV) risk (such as carotid intima media thickness, pulse wave velocity (PWV), coronary artery and aortic calcification scores (measured either by CT scan or X-ray) and the ankle brachial index (ABI)) have been evaluated separately in chronic kidney disease (CKD) cohorts, few studies have evaluated these methods simultaneously. Here, we looked at whether the addition of non-invasive methods to traditional risk factors (TRFs) improves prediction of the CV risk in patients at different CKD stages. METHODS: We performed a prospective, observational study of the relationship between the outputs of non-invasive measurement methods on one hand and mortality and CV outcomes in 143 patients at different CKD stages on the other. During the follow-up period, 44 patients died and 30 CV events were recorded. We used Cox models to calculate the relative risk for outcomes. To assess the putative clinical value of each method, we also determined the categorical net reclassification improvement (NRI) and the integrated discrimination improvement. RESULTS: Vascular calcification, PWV and ABI predicted all-cause mortality and CV events in univariate analyses. However, after adjustment for TRFs, only aortic and coronary artery calcification scores were found to be significant, independent variables. Moreover, the addition of coronary artery calcification scores to TRFs improved the specificity of prediction by 20%. CONCLUSION: The addition of vascular calcification scores (especially the coronary artery calcification score) to TRFs appears to improve CV risk assessment in a CKD population.

Coronary and abdominal aorta calcification in rheumatoid arthritis: relationships with traditional cardiovascular risk factors, disease characteristics, and concomitant treatments.

OBJECTIVE: To assess the influence of traditional cardiovascular (CV) risk factors, disease characteristics, and concomitant treatments in patients with rheumatoid arthritis (RA) on coronary artery calcification (CAC) and abdominal aorta calcification (AAC). METHODS: In our cross-sectional study, 75 patients with RA were compared with 75 age-matched and sex-matched control participants. The CAC and AAC scores were measured by computed tomography in patients with no clinical evidence of coronary artery disease. The relationships between the presence or absence of CAC and AAC and traditional CV risk factors, disease characteristics, and concomitant treatments in patients with RA were assessed in a multiple logistic regression analysis. RESULTS: The RA and control groups did not differ significantly in terms of age, sex composition, or the prevalence of traditional CV risk factors. AAC and CAC were more prevalent and severe in patients with RA than in controls. Older age (OR=1.15, p<0.01) and hypertension (OR=3.77, p=0.04) were found to be independently associated with CAC, whereas current use of methotrexate (MTX; OR=0.12, p=0.01) was found to be associated with the absence of CAC. Older age (OR per yr=1.17, p<0.001) and erosive arthritis (OR=3.78, p=0.03) were found to be independently associated with AAC. CONCLUSION: Our study demonstrates that in patients with RA, (1) CAC and AAC are more prevalent and more severe compared with age-matched and sex-matched control participants, (2) current use of MTX is a major determinant of the absence of CAC, and (3) erosive arthritis is a major determinant of AAC.

Total calcium-sensing receptor expression in circulating monocytes is increased in rheumatoid arthritis patients with severe coronary artery calcification.

INTRODUCTION: Human circulating monocytes express the calcium-sensing receptor (CaSR) and are involved in atherosclerosis. This study investigated the potential association between vascular calcification in rheumatoid arthritis (RA) and CaSR expression in circulating monocytes. METHODS: In this cross-sectional study, 50 RA patients were compared to 25 control subjects matched for age and gender. Isolation of peripheral blood mononuclear cells and flow cytometry analysis were performed to study the surface and total CaSR expression in circulating monocytes. Coronary artery calcium (CAC) and abdominal aortic calcification (AAC) scores were evaluated by computed tomography and an association between these scores and the surface and/or total CaSR expression in circulating monocytes in RA patients was investigated. RESULTS: The two groups were similar in terms of age (RA: 60.9 ± 8.3 years, versus controls: 59.6 ± 5.3 years) and gender (RA: 74.0% females versus 72.0% females). We did not find a higher prevalence and greater burden of CAC or AAC in RA patients versus age- and gender-matched controls. When compared with control subjects, RA patients did not exhibit greater total CaSR (101.6% ± 28.8 vs. 99.9% ± 22.0) or surface CaSR (104.6% ± 20.4 vs. 99.9% ± 13.7) expression, but total CaSR expression in circulating monocytes was significantly higher in RA patients with severe CAC (Agatston score ≥ 200, n = 11) than in patients with mild-to-moderate CAC (1 to 199, n = 21) (P = 0.01). CONCLUSIONS: This study demonstrates for the first time that total CaSR expression in human circulating monocytes is increased in RA patients with severe coronary artery calcification.