Ronak Rajani

Increase in epicardial fat volume is associated with greater coronary artery calcification progression in subjects at intermediate risk by coronary calcium score: A serial study using non-contrast cardiac CT

OBJECTIVE Epicardial fat volume (EFV) is related to calcified coronary plaques. However, it is unknown whether baseline EFV or changes in EFV affect the progression of coronary artery calcification over time. METHODS We identified 375 consecutive asymptomatic subjects with an intermediate risk of developing coronary artery disease, who underwent serial non-contrast CT at least 3-5 years apart. Subjects were divided into tertiles of CCS progression (% increase) between the 2 scans. Subjects from the upper tertile (High Progressors) were matched by age and gender to 81 subjects from the lower tertile (Low Progressors). All subjects underwent serial measurements of CCS and EFV. Relationships between EFV and CCS progression, and change in plaque number were examined. RESULTS At baseline, there was no difference in EFV, and EFV indexed to body surface area (EFVi) between the groups. At follow-up, EFV, EFVi and percent increase in EFVi-change were higher in High Progressors than Low Progressors (EFV, 102 ± 38 cm(3) vs. 90 ± 35 cm(3), p=0.03; EFVi, 50 ± 16cm(3)/m(2) vs. 46 ± 15 cm(3)/m(2), p=0.03; percent increase in EFVi-change, 15 ± 22% vs. 7 ± 20%, p=0.02). On multivariate analysis, after adjusting for conventional risk factors, EFVi increase ≥15% [odds ratio (OR) 2.3, p<0.05], log (baseline CCS) [OR 0.3, p<0.0001] and scan interval time [p=0.003, OR 1.0] were predictive of being a High Progressor. EFVi increase ≥ 15% (β=3.0, p=0.02) and hypertension (β=3.1, p=0.01) were independent predictors of number of new calcified plaques on follow-up. CONCLUSION Increase in EFV is associated with greater progression of coronary artery calcification in intermediate-risk subjects.

Weight change modulates epicardial fat burden: A 4-year serial study with non-contrast computed tomography

INTRODUCTION Epicardial fat volume (EFV) is linked to cardiovascular event risk. We aimed to investigate the relationships between EFV and weight change. METHODS From the EISNER (Early Identification of Subclinical Atherosclerosis using Non-invasive Imaging Research) Registry with baseline and follow-up coronary calcium scans (1248 subjects), we selected a cohort of 374 asymptomatic subjects matched using age decade, gender and coronary calcium score (CCS) as a measure of subclinical cardiovascular risk, who underwent 2 scans at an interval of 4.1±0.4 years. Using semi-automated validated software, pericardial contours were generated on all slices by spline interpolation from 5 to 10 control points. EFV was computed as fat volume within the pericardial contours. Weight gain/loss was defined as >5% change. RESULTS At baseline, EFV was moderately correlated to weight, body mass index (BMI) and waist circumference (r=0.51, 0.41 and 0.50, p<0.0001). EFV change was weakly correlated to change in weight (r=0.37, p<0.0001), BMI (r=0.39, p<0.0001) and waist circumference (r=0.21, p=0.002). On multivariable linear regression analysis, weight change [β=1.2, 95% confidence interval (CI) 0.9-1.5, p<0.001], BMI change (β=1.2, 95% CI 0.9-1.5, p<0.001), gender (β=-6.4, 95% CI -10.9 to -1.8, p=0.006) and hypertension (β=4.7, 95% CI 0.5-9.0, p=0.03) predicted EFV change. EFV decreased in 54 subjects with weight loss and increased in 71 subjects with weight gain (-2.3±21.1% vs. 23.3±24.4%, p<0.001). CONCLUSIONS EFV is related to body weight, BMI and waist circumference. Reduction in weight may stabilize or reduce EFV, while weight gain may promote EFV increase.

Relation of Diagonal Ear Lobe Crease to the Presence, Extent, and Severity of Coronary Artery Disease Determined by Coronary Computed Tomography Angiography

Controversy exists concerning the relation between diagonal ear lobe crease (DELC) and coronary artery disease (CAD). We examined whether DELC is associated with CAD using coronary computed tomography (CT) angiography. We studied 430 consecutive patients without a history of coronary artery intervention who underwent CT angiography on a dual-source scanner. Presence of DELC was agreed by 2 blinded observers. Two blinded readers evaluated CT angiography images for presence of CAD and for significant CAD (≥50% stenosis). Chi-square and t tests were used to assess demographic differences between subgroups with and without DELC and the relation of DELC to 4 measurements of CAD: any CAD, significant CAD, multivessel disease (cutoff ≥2), and number of segments with plaque (cutoff ≥3). Multivariable logistic regression was performed to adjust for CAD confounders: age, gender, symptoms, and CAD risk factors. Mean age was 61 ± 13 and 61% were men. DELC was found in 71%, any CAD in 71%, and significant CAD in 17% of patients. After adjusting for confounders, DELC remained a significant predictor of all 4 measurements of CAD (odds ratio 1.8 to 3.3, p = 0.002 to 0.017). Sensitivity, specificity, and positive and negative predictive values for DELC in detecting any CAD were 78%, 43%, 77%, and 45%. Test accuracy was calculated at 67%. Area under the receiver operator characteristic curve was 61% (p = 0.001). In conclusion, in this study of patients imaged with CT angiography, finding DELC was independently and significantly associated with increased prevalence, extent, and severity of CAD.

Threshold for the Upper Normal Limit of Indexed Epicardial Fat Volume: Derivation in a Healthy Population and Validation in an Outcome-Based Study

Epicardial fat volume (EFV) quantified on noncontrast cardiac computed tomography relates to cardiovascular prognosis. We sought to define the upper normal limit of body surface area (BSA)-indexed EFV (EFVi) in a healthy population and to validate it as a predictor of major adverse cardiovascular events (MACE). We analyzed noncontrast cardiac computed tomography scans of 226 healthy subjects with a low Framingham Risk Score (FRS; ≤6%) performed for coronary calcium scoring (CCS). EFV was quantified using validated software and indexed to BSA. We defined the 95th percentile as the upper normal limit. Subsequently, we reanalyzed a separate cohort of 232 participants from a previously published case-control study with 4-year follow-up and 58 cases of MACE to test the additive value of an abnormally high EFVi for predicting MACE. Of the 226 healthy participants 51% were men (mean age 52 ± 9 years). EFV correlated to BSA (r = 0.373, p <0.0001). Median, range, and 25th and 75th percentiles of the non-normally distributed EFVi were 33.3, 10.8 to 96.6, and 24.5 and 45.5 cm(3)/m(2). The 95th percentile definition of the upper normal limit of EFVi was 68.1 cm(3)/m(2). For prediction of MACE, EFVi values higher than the newly defined threshold emerged as a significant and independent predictor after controlling for confounders (odds ratio 2.8, 95% confidence interval 1.3 to 6.4, p = 0.012) and trended in its additive value to the combination of CCS ≥400 and FRS (area under the receiver operating characteristic curve 0.714 vs 0.675, p = 0.1277). In conclusion, in a healthy population we determined 68.1 cm(3)/m(2) as the 95th percentile threshold for abnormally high EFVi. EFVi exceeding this value independently predicted MACE and trended to add to CCS and FRS in this prediction.

Myocardial bridging on coronary CTA: An innocent bystander or a culprit in myocardial infarction?

Myocardial bridging describes the clinical entity whereby a segment of coronary artery is either partially or completely covered by surrounding myocardium. It represents the most frequent congenital coronary anomaly and has an estimated prevalence of ≤13% on angiographic series. With the emergence of cardiac computed tomography and its ability to simultaneously image the coronary arteries and also the myocardium, there has been an apparent increase in the detection rates of myocardial bridges (prevalence as high as 44%). It has now become important to evaluate their clinical significance. Myocardial bridging is generally considered a benign entity with survival rates of 97% at 5 years; however, there is now emerging evidence that certain myocardial bridge characteristics may be associated with cardiovascular morbidity. The length and depth of myocardial bridges have been associated with increased atherosclerosis, whereas the degree of systolic compression has been associated with ischemia on myocardial perfusion single-photon emission tomography. On the basis of current evidence, it appears that limiting further testing for ischemia to symptomatic patients with long and/or deep myocardial brides would be appropriate.

The relationship between epicardial fat volume and incident coronary artery calcium.

BACKGROUND Epicardial fat volume (EFV) has been associated with prevalent but not incident coronary artery calcium. However, the relationship between EFV and development of incident coronary calcium (incCC) has not been reported. OBJECTIVE We evaluated the relationship between epicardial fat volume and the development of coronary artery calcium over 3-5 years. METHODS From 1248 subjects who underwent 2 serial noncontrast cardiac CT scans 3-5 years (median, 4 years) apart to measure coronary calcium score of 0 who subsequently developed incident coronary calcium (incCC(+)) were matched to 106 controls in whom coronary calcium score remained 0 (incCC(-)). EFV was calculated by determination of the pericardial contour, followed by identification of fat voxels with the use of validated software (QFAT). Baseline EFV and EFV indexed to body surface area (EFVi) and subsequent EFV and EFVi changes were compared between incCC(-) and incCC(+) populations. A significant EFV increase was defined as a ≥10% and ≥25% increase from the baseline value. RESULTS Baseline EFVi was similar between the 2 groups [EFVi, 40.9 ± 17.9 cm³ (median, 38.3 cm³) in incCC(-) vs 40.3 ± 16.3 cm³ (median, 37.0 cm³) in incCC(+); P = 0.96]. On the follow-up CT, EFVi increased in 74.5% of incCC(-) and in 76.4% of incCC(+) (P = 0.75). EFVi changes between the 2 groups were similar [4.9 ± 8.9 cm³ (median, 4.9 cm³) in incCC(-) vs 4.2 ± 8.0 cm³) (median, 3.5 cm³) in incCC(+); P = 0.67]. On multivariate analysis, after adjusting for cardiovascular risk factors, incCC was not related to an increase in EFVi at a 10% or 25% level. CONCLUSIONS In very low-risk subjects with a coronary calcium score of 0, baseline EFVi and change in EFVi after 3-5 years were not related to the development of incidental coronary artery calcium.

Social Networks are they Good for Your Health ? The Era of Facebook and Twitter

Sir, Since its introduction in 2005, the social networking web site Facebook has grown at an unprecedented rate, to over 500 million active users. This and other networking web sites (e.g. Twitter and MySpace) have heralded a new era in how individuals socially interact. Indeed, in 2010 alone there were two major film productions (‘The Social Network’ and ‘Catfish’) highlighting the ever-growing fascination and popularity of social networking. However, despite the now ubiquitous use of social networking web sites, there has been little consideration as to how this use may impact human health. There is good reason to examine how social phenomena impact health. Having satisfying social interaction is an innate psychological need. Meeting our social needs produces vitality, whereas chronic social disconnectedness is pathophysiologically damaging, both in humans and animals.1–3 The effects are not dissimilar to that …

INCREASED PERICARDIAL FAT ACCUMULATION IS ASSOCIATED WITH INCREASED INTRAMYOCARDIAL LIPID CONTENT AND DURATION OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY EXPOSURE IN PATIENTS INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS

Our aim was to examine whether the use of highly active antiretroviral therapy (HAART) in patients with HIV is associated with changes in pericardial fat and myocardial lipid content measured from cardiac magnetic resonance imaging (CMR). We prospectively compared 27 HIV seropositive (+) male

If at first you do not succeed: try another phase! Rescue reconstruction of an anomalous coronary artery in a patient with atrial fibrillation

An 81-year-old woman with a background history of hypertension, hypercholesterolaemia, and diabetes mellitus presented with exertional dyspnoea and was referred for coronary computed tomography angiography (CTA). At coronary CTA, the woman was incidentally found to be in atrial fibrillation with a heart rate ranging from 50 to 88 bpm. The CTA was performed on a dual-source scanner with full tube current throughout the entire cardiac cycle to permit unlimited reconstructions (total radiation dose 20.3 mSv). Standard reconstructions at the 65–80% phases of the R–R interval rendered the womans coronary CTA scan uninterpretable for the exclusion of significant coronary artery disease ( Figure 1 A – C ). Subsequent manual …

Multiple myocardial crypts on cardiac CT angiography in a symptomatic patient with troponin elevation

A 57-year-old Middle Eastern woman presented to the emergencydepartment(ED)withleftarmandchestdiscomfortwhichdevelopedwhile driving her car. The discomfort lasted for a few minutes andresolved spontaneously. Past medical history was remarkable forknown LVH by ECG, severe concentric LVH by echocardiography andno coronary heart disease risk factors. ECG in the ED showed LVH andST segment depression in leads V4 through V6 and was unchangedfrom prior ECG done 1 year before. Serum troponin I was elevated at0.16 ng/ml (normal b0.05 ng/ml). Based on the clinical history,abnormal ECG and elevated troponin levels, the ED physicianconsidered the diagnosis of an acute coronary syndrome, adminis-teredaspirinandclopidogrelandrecommendedadmissionforfurtherobservation and management. Cardiology consultation was thensought in the ED, and in view of previously known diagnosis ofhypertrophic cardiomyopathy, immediate coronary CT angiography(CCTA) was recommended to rule out obstructive coronary arterydisease.Low dose CCTA (4.9 mSv) was performed using a 64 slice dual-source CT scanner (Somatom, Siemens Medical Solutions, Forchheim,Germany).CCTArevealednoevidenceforcoronaryplaqueorstenosis.Despite the positive troponin and the abnormal ECG, a diagnosis ofacute coronary syndrome was excluded, and the patient wasdischarged from the ED.Non-coronary assessment of the CCTA confirmed severe asym-metric septal hypertrophy and demonstrated an unusual finding ofthree thin crypts in the left ventricle. The largest crypt was 12 mm inlength in the superior mid septum at the junction of the left and rightventricles with a 2 mm separation from the right ventricle (Fig. 1 a