Impact of Diabetes and Increasing Body Mass Index Category on Left Ventricular Systolic and Diastolic Function.

BACKGROUND: Diabetes and obesity are both worldwide growing epidemics, and both are independently associated with increased risk for heart failure and death. The aim of this study was to examine the additive detrimental effect of both diabetes and increasing body mass index (BMI) category on left ventricular (LV) myocardial systolic and diastolic function. METHODS: The present retrospective multicenter study included 653 patients (337 with type 2 diabetes and 316 without diabetes) of increasing BMI category. All patients had normal LV ejection fractions. LV myocardial systolic (peak systolic global longitudinal strain and peak systolic global longitudinal strain rate) and diastolic (average mitral annular e' velocity and early diastolic global longitudinal strain rate) function was quantified using echocardiography. RESULTS: Increasing BMI category was associated with progressively more impaired LV myocardial function in patients with diabetes (P < .001). Patients with diabetes had significantly more impaired LV myocardial function for all BMI categories compared with those without diabetes (P < .001). On multivariate analysis, both diabetes and obesity were independently associated with an additive detrimental effect on LV myocardial systolic and diastolic function. However, obesity was associated with greater LV myocardial dysfunction than diabetes. CONCLUSION: Both diabetes and increasing BMI category had an additive detrimental effect on LV myocardial systolic and diastolic function. Furthermore, increasing BMI category was associated with greater LV myocardial dysfunction than diabetes. As they frequently coexist together, future studies on patients with diabetes should also focus on obesity.

Prevalence by Computed Tomographic Angiography of Coronary Plaques in South Asian and White Patients With Type 2 Diabetes Mellitus at Low and High Risk Using Four Cardiovascular Risk Scores (UKPDS, FRS, ASCVD, and JBS3).

The aim of this study was to explore the association between various cardiovascular (CV) risk scores and coronary atherosclerotic burden on coronary computed tomography angiography (CTA) in South Asians with type 2 diabetes mellitus and matched whites. Asymptomatic type 2 diabetic South Asians and whites were matched for age, gender, body mass index, hypertension, and hypercholesterolemia. Ten-year CV risk was estimated using different risk scores (United Kingdom Prospective Diabetes Study [UKPDS], Framingham Risk Score [FRS], AtheroSclerotic CardioVascular Disease [ASCVD], and Joint British Societies for the prevention of CVD [JBS3]) and categorized into low- and high-risk groups. The presence of coronary artery calcium (CAC) and obstructive coronary artery disease (CAD; ≥50% stenosis) was assessed using coronary CTA. Finally, the relation between coronary atherosclerosis on CTA and the low- and high-risk groups was compared. UKPDS, FRS, and ASCVD showed no differences in estimated CV risk between 159 South Asians and 159 matched whites. JBS3 showed a significant greater absolute CV risk in South Asians (18.4% vs 14.2%, p <0.01). Higher presence of CAC score >0 (69% vs 55%, p <0.05) and obstructive CAD (39% vs 27%, p <0.05) was observed in South Asians. South Asians categorized as high risk, using UKPDS, FRS, and ASCVD, showed more CAC and CAD compared than whites. JBS3 showed no differences. In conclusion, asymptomatic South Asians with type 2 diabetes mellitus more frequently showed CAC and obstructive CAD than matched whites in the population categorized as high-risk patients using UKPDS, FRS, and ASCVD as risk estimators. However, JBS3 seems to correlate best to CAC and CAD in both ethnicity groups compared with the other risk scores.

Prognostic Value of Coronary Computed Tomography Imaging in Patients at High Risk Without Symptoms of Coronary Artery Disease.

At present, traditional risk factors are used to guide cardiovascular management of asymptomatic subjects. Intensified surveillance may be warranted in those identified as high risk of developing cardiovascular disease (CVD). This study aims to determine the prognostic value of coronary computed tomography (CT) angiography (CCTA) next to the coronary artery calcium score (CACS) in patients at high CVD risk without symptoms suspect for coronary artery disease (CAD). A total of 665 patients at high risk (mean age 56 ± 9 years, 417 men), having at least one important CVD risk factor (diabetes mellitus, familial hypercholesterolemia, peripheral artery disease, or severe hypertension) or a calculated European systematic coronary risk evaluation of >10% were included from outpatient clinics at 2 academic centers. Follow-up was performed for the occurrence of adverse events including all-cause mortality, nonfatal myocardial infarction, unstable angina, or coronary revascularization. During a median follow-up of 3.0 (interquartile range 1.3 to 4.1) years, adverse events occurred in 40 subjects (6.0%). By multivariate analysis, adjusted for age, gender, and CACS, obstructive CAD on CCTA (≥50% luminal stenosis) was a significant predictor of adverse events (hazard ratio 5.9 [CI 1.3 to 26.1]). Addition of CCTA to age, gender, plus CACS, increased the C statistic from 0.81 to 0.84 and resulted in a total net reclassification index of 0.19 (p <0.01). In conclusion, CCTA has incremental prognostic value and risk reclassification benefit beyond CACS in patients without CAD symptoms but with high risk of developing CVD.

Prognostic value of coronary computed tomography angiography in diabetic patients without chest pain syndrome.

AIMS: Diabetic patients with coronary artery disease (CAD) are often free of chest pain syndrome. A useful modality for non-invasive assessment of CAD is coronary computed tomography angiography (CTA). However, the prognostic value of CAD on coronary CTA in diabetic patients without chest pain syndrome is relatively unknown. Therefore, the aim was to investigate the long-term prognostic value of coronary CTA in a large population diabetic patients without chest pain syndrome. METHODS: Between 2005 and 2013, 525 diabetic patients without chest pain syndrome were prospectively included to undergo coronary artery calcium (CAC)-scoring followed by coronary CTA. During follow-up, the composite endpoint of all-cause mortality, non-fatal myocardial infarction (MI), and late revascularization (>90 days) was registered. RESULTS: In total, CAC-scoring was performed in 410 patients and coronary CTA in 444 patients (431 interpretable). After median follow-up of 5.0 (IQR 2.7-6.5) years, the composite endpoint occurred in 65 (14%) patients. Coronary CTA demonstrated a high prevalence of CAD (85%), mostly non-obstructive CAD (51%). Furthermore, patients with a normal CTA had an excellent prognosis (event-rate 3%). An incremental increase in event-rate was observed with increasing CAC-risk category or coronary stenosis severity. Finally, obstructive (50-70%) or severe CAD (>70%) was independently predictive of events (HR 11.10 [2.52;48.79] (P = .001), HR 15.16 [3.01;76.36] (P = .001)). Obstructive (50-70%) or severe CAD (>70%) provided increased value over baseline risk factors. CONCLUSION: Coronary CTA provided prognostic value in diabetic patients without chest pain syndrome. Most importantly, the prognosis of patients with a normal CTA was excellent.

Changes in ischaemia as assessed with single-photon emission computed tomography myocardial perfusion imaging in high-risk patients with diabetes without cardiac symptoms: relation with coronary atherosclerosis on computed tomography coronary angiography.

AIMS: The study aims (i) to evaluate changes in myocardial ischaemia on single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) after 2 years in a cohort of high-risk patients with diabetes without cardiac symptoms or known coronary artery disease (CAD) and (ii) to assess the value of baseline computed tomography coronary angiography (CTA)-derived coronary atherosclerosis parameters to predict changes in myocardial ischaemia. METHODS AND RESULTS: The population consisted of 100 high-risk patients with diabetes without cardiac symptoms referred for cardiovascular risk stratification. All patients underwent coronary artery calcium (CAC) scoring, CTA, and SPECT MPI. After 2 years of follow-up, SPECT MPI was repeated to evaluate potential progression of ischaemia.In total, 20% of patients presented with ischaemia at baseline. Of these 20 patients, 7 (35%) still had ischaemia at follow-up, whereas 13 (65%) showed resolution and 4 (20%) showed progression of ischaemia at follow-up. Of the 80 patients without ischaemia at baseline, 65 (81%) had a normal MPI at follow-up and 15 patients (19%) presented with new ischaemia. There were no significant differences in the CAC score or the extent, severity, and composition of CAD on CTA between patients with and without ischaemia at baseline. Similarly, no differences could be demonstrated between patients with and without ischaemia at follow-up or between patients with and without progression of ischaemia. CONCLUSION: The rate of progression of ischaemia in high-risk patients with diabetes without cardiac symptoms is limited. Few patients presented with new ischaemia, whereas some patients showed resolution of ischaemia. Atherosclerosis parameters on CTA were not predictive of new-onset ischaemia or progression of ischaemia.

New insights on Carpentier I mitral regurgitation from multidetector row computed tomography.

The underlying mechanism of mitral regurgitation (MR) because of isolated annulus dilation (Carpentier type I) remains controversial in patients with atrial fibrillation (AF). The present study evaluated changes in mitral valve geometry of patients with AF and structurally and functionally normal left ventricles and mitral leaflets. Grade of MR and left ventricular (LV) function was evaluated with echocardiography. Changes in mitral valve geometry were evaluated with multidetector row computed tomography (MDCT) performed before radiofrequency catheter ablation for AF. From a cohort of 480 patients with drug-refractory AF referred for catheter ablation, 170 patients (mean age 58 ± 10 years, 67% men) with structural and functional normal left ventricles and mitral leaflets were included. The intercommissural and anteroposterior diameter, perimeter, and area of the mitral annulus and left atrial volume were assessed with MDCT and correlated with the grade of MR as assessed with echocardiography. A total of 49 patients (29%) had MR ≥2+. These patients had larger mitral annulus area compared with patients with MR <2+ (665.0 ± 100.6 mm(2)/m(2) vs 530.5 ± 66.6 mm(2)/m(2), p <0.001), whereas LV size and function (ejection fraction 64.9 ± 6.3% vs 63.1 ± 5.7%, p = 0.08) were similar. After adjusting for age, type of AF, hypertension, left atrial volume, and LV end-systolic volume and ejection fraction, the mitral annulus dimensions remained independently correlated with MR ≥2+. In conclusion, in AF patients with structural and functional normal left ventricles and mitral leaflets, MDCT demonstrated that mitral annulus dilation is independently associated with type I MR.

Associations of atherosclerosis in the descending thoracic aorta on CTA with arterial stiffness and chronic kidney disease in asymptomatic patients with diabetes mellitus.

The relation between atherosclerosis in the descending thoracic aortic (DTA), arterial stiffness and chronic kidney disease (CKD) in patients with diabetes mellitus (DM) remains unclear. The current aim was to evaluate associations of DTA atherosclerosis with arterial stiffness and parameters of CKD in asymptomatic patients with DM. A total of 213 asymptomatic patients with diabetes (mean age 52 years, 56% men) underwent cardiovascular risk assessment including multi-slice computed tomography (for non-invasive coronary angiography, from which DTA atherosclerosis can be derived), non-invasive assessment of arterial stiffness with applanation tonometry and assessment of renal function. Measurements of DTA atherosclerosis included assessment of DTA thickening and calcium score. Arterial stiffness was determined by the carotid-femoral pulse wave velocity (PWV), parameters of CKD included estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR). DTA atherosclerosis was present in 180 (84%) patients. Patients with DTA atherosclerosis had increased arterial stiffness, lower eGFR and higher UACR values. After multivariate correction, DTA calcium score was independently associated with PWV (ß = 0.18, p = 0.04). Furthermore, both DTA maximal wall thickness and DTA calcium score were independently associated with eGFR (ß = -7.37, p < 0.001 and ß = -1.99, p < 0.003, respectively), but not with UACR. The increase in arterial stiffness by atherosclerosis seemed to be mediated by arterial calcification, while the DTA calcium score was independently associated with arterial stiffness, but not DTA maximal wall thickness. Furthermore, parameters of CKD in patients with DM had a distinct relationship with DTA atherosclerosis: DTA atherosclerosis was associated with eGFR but not with UACR.

Comparison by computed tomographic angiography-the presence and extent of coronary arterial atherosclerosis in South Asians versus Caucasians with diabetes mellitus.

South Asians in the Western world have a high prevalence of diabetes mellitus (DM) and an increased risk of coronary artery disease (CAD) and mortality compared with Caucasians. CAD in asymptomatic South Asian patients with type 2 DM has not been investigated. The aim of this observational cohort study was to investigate CAD in asymptomatic South Asian patients with type 2 DM and to compare with matched Caucasian patients. A total of 120 asymptomatic South Asian patients with type 2 DM and matched Caucasian patients (mean age 52 years, 55% men) were derived from an ongoing registry of cardiovascular risk stratification in asymptomatic patients with DM. Cardiovascular risk assessment included multidetector row coronary computed tomography angiography. CAD was assessed as the coronary artery calcium score and classified into no signs of atherosclerosis or minor wall irregularities <30%, nonsignificant CAD 30% to 50%, or significant CAD ≥50% stenosis. On a patient base, CAD was scored according to the severity and number of vessels and segments with significant CAD. Subsequently, CAD was assessed per coronary artery and per segment. Compared with Caucasian patients, South Asian patients had a significantly higher coronary artery calcium score and higher prevalence of significant CAD (41% vs 28%, respectively, p = 0.008), involving more coronary vessels and segments. Significant CAD was especially more frequent in the left anterior descending coronary artery. In conclusion, asymptomatic South Asian patients with type 2 DM have a higher prevalence and extent of CAD compared with matched Caucasian patients.

Changes in multidirectional LV strain in asymptomatic patients with type 2 diabetes mellitus: a 2-year follow-up study.

AIMS: Asymptomatic patients with diabetes mellitus (DM) and normal left ventricular (LV) ejection fraction (EF) may have LV dysfunction as assessed with speckle tracking echocardiography. Whether this subtle LV dysfunction may progress or not over time remains unknown. The present evaluation assessed changes in LV function with two-dimensional (2D) speckle tracking analysis in asymptomatic clinically stable patients with type 2 DM and normal LVEF after 2-year follow-up. METHODS AND RESULTS: A total of 112 asymptomatic patients with type 2 DM and normal LVEF (53 ± 10 years, 59% men) were evaluated. Patients remained clinically stable between baseline and follow-up echocardiography. Conventional and 2D speckle tracking echocardiographic measurements were performed. Circumferential strain (CS) and longitudinal strain (LS) were measured to assess systolic function and strain rate during isovolumetric relaxation time (SR IVR) and peak transmitral early diastolic inflow strain rate (SR E) to assess diastolic function. After 2-year follow-up, a significant increase in the LV mass index and significant decrease in the E/A ratio were observed. Left ventricular ejection fraction remained unchanged (59 to 60%, P = 0.4). In contrast, 2D speckle tracking analysis demonstrated a significant impairment in CS (-19.7 ± 4.0 to -18.9 ± 3.8%, P < 0.001), LS (-17.2 ± 2.3 to -16.9 ± 2.7%, P = 0.022), and SR E (from 1.02 ± 0.28 to 0.94 ± 0.25 S(-1), P < 0.001). After adjusting for changes in the LV mass index, only changes in CS and SR E remained significant (P < 0.001 and P = 0.013, respectively). CONCLUSION: Asymptomatic patients with type 2 DM and normal LVEF may show mild progression of subclinical LV function assessed with 2D speckle tracking echocardiography. The prognostic implications of these mild changes warrant prospective evaluation.

CT coronary angiography is feasible for the assessment of coronary artery disease in chronic dialysis patients, despite high average calcium scores.

PURPOSE: Significant obstructive coronary artery disease (CAD) is common in asymptomatic dialysis patients. Identifying these high risk patients is warranted and may improve the prognosis of this vulnerable patient group. Routine catheterization of incident dialysis patients has been proposed, but is considered too invasive. CT-angiography may therefore be more appropriate. However, extensive coronary calcification, often present in this patient group, might hamper adequate lumen evaluation. The objective of this study was to assess the feasibility of CT-angiography in this patient group. METHODS: For this analysis all patients currently participating in the ICD2 trial (ISRCTN20479861), with no history of PCI or CABG were included. The major epicardial vessels were evaluated on a segment basis (segment 1-3, 5-8, 11 and 13) by a team consisting of an interventional and an imaging specialist. Segments were scored as not significant, significant and not interpretable. RESULTS: A total of 70 dialysis patients, with a mean age of 66±8 yrs and predominantly male (70%) were included. The median calcium score was 623 [79, 1619]. Over 90% of the analyzed segments were considered interpretable. The incidence of significant CAD on CT was 43% and was associated with cardiovascular events during follow-up. The incidence of cardiovascular events after 2-years follow-up: 36% vs. 0% in patients with no significant CAD (p<0.01). CONCLUSION: Despite the high calcium scores CT-angiography is feasible for the evaluation of the extent of CAD in dialysis patients. Moreover the presence of significant CAD on CT was associated with events during follow-up.

Association of atherosclerosis in the descending thoracic aorta with coronary artery disease on multi detector row computed tomography coronary angiography in patients with suspected coronary artery disease.

The association between atherosclerosis in the descending thoracic aorta (DTA) visualized on computed tomography coronary angiography (CTA) and coronary artery disease (CAD) has not been extensively explored. Therefore, a comprehensive analysis of DTA atherosclerosis on CTA was performed and the association of DTA atherosclerosis with CAD was evaluated in patients with suspected CAD. A total of 344 patients (54 ± 12 years, 54% men) with suspected CAD underwent CTA. CTA were classified based on CAD severity in no signs of atherosclerosis or minor wall-irregularities <30%, non-significant CAD 30-50%, or significant CAD ≥50% stenosis. The DTA was divided in segments according the posterior intercostal arteries. Per segment the presence of atherosclerotic plaque (defined as ≥2 mm wall thickness) was determined and maximal wall thickness was measured. Plaque composition was scored as non-calcified or mixed and the percentage of DTA segments with atherosclerosis was calculated. Significant CAD was present in 152 (44%) patients and 278 (81%) had DTA atherosclerotic plaque. DTA maximal wall thickness and percentage of DTA segments with atherosclerosis were 2.7 ± 1 mm and 49 ± 36%. The presence, severity and extent of DTA atherosclerosis significantly increased with increasing CAD severity. Multivariate logistic regression analysis corrected for age and other risk factors demonstrated independent associations of DTA plaque (OR 6.56, 95% CI 1.78-24.19, p = 0.005) and maximal DTA wall thickness (OR 2.00, 95% CI 1.28-3.12, p = 0.002) with significant CAD. The presence and severity of DTA atherosclerosis were independently related with significant CAD on CTA in patients with suspected CAD.

Automatic quantification and characterization of coronary atherosclerosis with computed tomography coronary angiography: cross-correlation with intravascular ultrasound virtual histology.

Plaque constitution on computed tomography coronary angiography (CTA) is associated with prognosis. At present only visual assessment of plaque constitution is possible. An accurate automatic, quantitative approach for CTA plaque constitution assessment would improve reproducibility and allows higher accuracy. The present study assessed the feasibility of a fully automatic and quantitative analysis of atherosclerosis on CTA. Clinically derived CTA and intravascular ultrasound virtual histology (IVUS VH) datasets were used to investigate the correlation between quantitatively automatically derived CTA parameters and IVUS VH. A total of 57 patients underwent CTA prior to IVUS VH. First, quantitative CTA quantitative computed tomography (QCT) was performed. Per lesion stenosis parameters and plaque volumes were assessed. Using predefined HU thresholds, CTA plaque volume was differentiated in 4 different plaque types necrotic core (NC), dense calcium (DC), fibrotic (FI) and fibro-fatty tissue (FF). At the identical level of the coronary, the same parameters were derived from IVUS VH. Bland-Altman analyses were performed to assess the agreement between QCT and IVUS VH. Assessment of plaque volume using QCT in 108 lesions showed excellent correlation with IVUS VH (r = 0.928, p < 0.001) (Fig. 1). The correlation of both FF and FI volume on IVUS VH and QCT was good (r = 0.714, p < 0.001 and r = 0.695, p < 0.001 respectively) with corresponding bias and 95 % limits of agreement of 24 mm(3) (-42; 90) and 7.7 mm(3) (-54; 70). Furthermore, NC and DC were well-correlated in both modalities (r = 0.523, p < 0.001) and (r = 0.736, p < 0.001). Automatic, quantitative CTA tissue characterization is feasible using a dedicated software tool. Fig. 1 Schematic illustration of the characterization of coronary plaque on CTA: cross-correlation with IVUS VH. First, the 3-dimensional centerline was generated from the CTA data set using an automatic tree extraction algorithm (Panel I). Using a unique registration a complete pullback series of IVUS images was mapped on the CTA volume using true anatomical markers (Panel II). Fully automatic lumen and vessel wall contour detection was performed for both imaging modalities (Panel III). Finally, fusion-based quantification of atherosclerotic lesions was based on the lumen and vessel wall contours as well as the corresponding reference lines (estimate of normal tapering of the coronary artery), as shown in panel IV. At the level of the minimal lumen area (MLA) (yellow lines), stenosis parameters, could be calculated for both imaging techniques. Additionally, plaque volumes and plaque types were derived for the whole coronary artery lesion, ranging from the proximal to distal lesion marker (blue markers). Fibrotic tissue was labeled in dark green, Fibro-fatty tissue in light green, dense calcium in white and necrotic core was labeled in red.

Relationship between left ventricular diastolic function and arterial stiffness in asymptomatic patients with diabetes mellitus.

Left ventricular (LV) diastolic dysfunction and increased arterial stiffness are common in patients with diabetes mellitus (DM). However, the relation between these two pathophysiological factors remains unclear. The aim of this study was to investigate the relationship between LV diastolic function and arterial stiffness as assessed with applanation tonometry. In 142 asymptomatic patients with DM (mean age 48 years, 75 (53 %) men, 72 (51 %) patients with type 2 DM) LV diastolic function was assessed with echocardiography. Arterial stiffness was evaluated measuring the aortic pulse wave velocity (PWV) whereas wave reflection was assessed measuring central systolic blood pressure (cSBP), central pulse pressure (cPP), and augmentation index (AIx) with applanation tonometry. Mean E/A ratio, E' and E/E' ratio were 1.1 ± 0.3, 8.1 ± 2.3 and 9.2 ± 3.3 cm/s, respectively. Mean PWV, mean cSBP, median cPP and mean AIx were 7.9 ± 2.4 m/s, 122 ± 17 mmHg, 40 [35-51] mmHg and 17.9 ± 12.1 %, respectively. PWV was independently associated with LV diastolic dysfunction grade (ß = 0.76, p = 0.03). In contrast, measures of wave reflection, cPP, cSBP and AIx were independently related with E/A ratio, but not with the LV diastolic dysfunction grade. Parameters of arterial stiffness and wave reflection are associated with echocardiographic indices of LV diastolic function in asymptomatic patients with DM. Therapies that prevent progression of arterial stiffness and reduce late-systolic pressure overload may help to reduce the prevalence of LV diastolic dysfunction in this population.

Cardiovascular metabolic syndrome: mediators involved in the pathophysiology from obesity to coronary heart disease.

Patients with obesity and diabetes mellitus are at increased risk for cardiovascular events and have a higher cardiovascular morbidity and mortality. This worse prognosis is partly explained by the late recognition of coronary heart disease in these patients, due to the absence of symptoms. Early identification of coronary heart disease is vital, to initiate preventive medical therapy and improve prognosis. At present, with the use of cardiovascular risk models, the identification of coronary heart disease in these patients remains inadequate. To this end, biomarkers should improve the early identification of patients at increased cardiovascular risk. The first part of this review describes the pathophysiologic pathway from obesity to coronary heart disease. The second part evaluates several mediators from this pathophysiologic pathway for their applicability as biomarkers for the identification of coronary heart disease.

Relationship between vascular stiffness and stress myocardial perfusion imaging in asymptomatic patients with diabetes.

PURPOSE: Vascular stiffness may potentially be used as a screening tool to identify asymptomatic patients with diabetes with abnormal myocardial perfusion. The purpose of this study was therefore to determine the association between vascular stiffness, measured in term of pulse wave velocity (PWV) and augmentation index (AIx), and abnormal myocardial perfusion imaging (MPI) in asymptomatic patients with diabetes. METHODS: Prospectively, 160 asymptomatic patients with diabetes (mean age 51 years, 87 men) underwent MPI with adenosine stress. The summed stress score (SSS) was determined in each patient according to a 17-segment and five-point score. Abnormal MPI (SSS ≥ 3) was classified as moderate (SSS 3-7) or severe (SSS ≥ 8) MPI defects. Using applanation tonometry, the carotid-femoral PWV and the radial AIx corrected to 75 beats per minute were determined noninvasively. RESULTS: MPI was abnormal in 61 patients (38%), with severe MPI defects in 22 patients (14%). Mean PWV increased with deteriorating MPI from 8.4 ± 2.2 m/s in normal MPI to 9.0 ± 2.2 m/s in moderate MPI defects (p = 0.11) and to 11.1 ± 2.5 m/s in severe MPI defects (p < 0.01). Likewise, mean AIx increased from 18.4 ± 13.4% to 19.4 ± 10.7% (p = 0.66) and to 25.4 ± 9.0% (p = 0.03). After adjustment for age and other risk factors, PWV remained a significant predictor of severe MPI defects (p = 0.01, OR 1.50, 95% CI 1.11-2.00), whereas AIx was no longer significant (p = 0.20). CONCLUSION: Vascular stiffness measured by PWV is associated with severe MPI defects in asymptomatic patients with diabetes.

Prognostic value of renal dysfunction for the prediction of outcome versus results of computed tomographic coronary angiography.

Chronic kidney disease (CKD) is associated with cardiovascular (CV) events caused by advanced atherosclerosis. Computed tomographic coronary angiography (CTA) can accurately diagnose coronary artery disease (CAD) and predict CV outcomes. The aim of the present study was to evaluate whether moderate CKD provides prognostic information for CV events in patients undergoing CTA. In total 885 patients with suspected CAD underwent CTA and were stratified to moderate CKD (85 patients) or no CKD (770 patients) based on a cut-off estimated glomerular filtration rate of 60 ml/min/1.73 m(2). After 896 days of follow-up, 42 patients developed CV events. Annualized CV event rates were 1.2% in patients with no CKD and no CAD, 2.5% in patients with moderate CKD alone, 2.5% in patients with obstructive CAD alone, and 3.7% in those with moderate CKD and obstructive CAD. Multivariate models demonstrated that moderate CKD (hazard ratio 2.39, confidence interval 1.09 to 5.21, p = 0.03) and obstructive CAD (hazard ratio 2.76, confidence interval 1.40 to 5.44, p <0.01) were independent predictors of CV events. Importantly, moderate CKD provided incremental prognostic information in addition to clinical characteristics and obstructive CAD (chi-square 49.4, p = 0.04). In conclusion, moderate CKD was associated with CV events and provided incremental prognostic information.

Usefulness of hypertriglyceridemic waist phenotype in type 2 diabetes mellitus to predict the presence of coronary artery disease as assessed by computed tomographic coronary angiography.

The present study tested whether in patients with type 2 diabetes mellitus (DM) the combination of increased waist circumference and increased plasma triglyceride (TG) levels can predict the presence of coronary artery disease (CAD) as assessed by multidetector computed tomographic coronary angiography (CTA). In 202 patients with type 2 DM who were clinically referred for CTA, waist circumference and TG levels were measured. Patients were divided into 4 groups according to waist circumference measurements and TG levels. Increased waist circumference and TG levels (n = 61, 31%) indicated the presence of the hypertriglyceridemic waist phenotype. Patients with low waist circumference and TG (n = 49, 24%) were considered the reference group. Physical examination and blood measurements were performed. CTA was used to determine presence and severity of CAD. In addition, plaque type was evaluated. Plasma cholesterol levels were significantly increased in the group with increased TG levels and waist circumference, whereas high-density lipoprotein cholesterol was significantly lower than in the reference group. There was a significant increase in the presence of any CAD (odds ratio 3.3, confidence interval 1.31 to 8.13, p <0.05) and obstructive CAD (≥50%, odds ratio 2.9, confidence interval 1.16 to 7.28, p <0.05) in the group with increased TG level and waist circumference. In addition, a significantly larger number of noncalcified and mixed plaques was observed. In conclusion, in patients with type 2 DM, presence of the hypertriglyceridemic waist phenotype translated into a deteriorated blood lipid profile and more extensive CAD on CTA. Accordingly, the hypertriglyceridemic waist phenotype may serve as a practical clinical biomarker to improve risk stratification in patients with type 2 DM.

Function and anatomy: SPECT-MPI and MSCT coronary angiography.

For the diagnosis of coronary artery disease (CAD), non-invasive cardiac imaging is indispensable. Myocardial perfusion imaging (MPI) by single photon emission computed tomography (SPECT) investigates the pathophysiological consequences of luminal obstructive CAD, while multislice computed tomography coronary angiography (CTA) indicates the presence, extent and location of coronary atherosclerosis. The integration of CTA and SPECT data may provide important information which may be useful for patient management. In this manuscript the value of both techniques will be described. In addition, the feasibility and potential value of combined anatomic and functional imaging will be discussed.

Peri-coronary epicardial adipose tissue is related to cardiovascular risk factors and coronary artery calcification in post-menopausal women.

AIMS: To determine whether peri-coronary epicardial adipose tissue (EAT) is associated with vascular risk factors and coronary atherosclerosis. METHODS AND RESULTS: In this study, 573 healthy post-menopausal women underwent a cardiac CT scan to assess coronary calcification. Peri-coronary EAT thickness was measured in the areas of right coronary artery (RCA), left anterior descending (LAD) artery, and left circumflex (LCX) coronary artery. Average EAT thickness was 16.5 +/- 4.3 mm (range 5.9-34.6) in the RCA area, 6.4 +/- 2.2 mm (range 2.0-14.0) in the LAD area, and 10.8 +/- 3.0 mm (range 2.8-29.1) in the LCX area. Overall average thickness was 11.2 +/- 2.2 mm (range 5.4-19.1). EAT was positively related to age (P = 0.002). In age-adjusted linear regression models, EAT was positively related to weight (P< 0.001), waist circumference (P< 0.001), waist-to-hip ratio (P< 0.001), body mass index (P< 0.001), glucose (P< 0.001), triglycerides (P = 0.001), use of anti-hypertensive drugs (P = 0.007), and systolic blood pressure (P = 0.034), and inversely to HDL cholesterol (P = 0.005). In multivariable models, age, weight, waist circumference, smoking, and glucose were the main determinants of EAT. EAT showed a graded relation with coronary calcification (P = 0.026). CONCLUSION: EAT is strongly related to vascular risk factors and coronary calcification. Our findings support the hypothesis that EAT affects coronary atherosclerosis and possibly coronary risk.