Tochi M. Okwuosa

Distribution of coronary artery calcium scores by Framingham 10-year risk strata in the MESA (Multi-Ethnic Study of Atherosclerosis) potential implications for coronary risk assessment.

OBJECTIVES By examining the distribution of coronary artery calcium (CAC) levels across Framingham risk score (FRS) strata in a large, multiethnic, community-based sample of men and women, we sought to determine if lower-risk persons could benefit from CAC screening. BACKGROUND The 10-year FRS and CAC levels are predictors of coronary heart disease. A CAC level of 300 or more is associated with the highest risk for coronary heart disease even in low-risk persons (FRS, <10%); however, expert groups have suggested CAC screening only in intermediate-risk groups (FRS, 10% to 20%). METHODS We included 5,660 Multi-Ethnic Study of Atherosclerosis participants. The number needed to screen (number of people that need to be screened to detect 1 person with CAC level above the specified cutoff point) was used to assess the yield of screening for CAC. CAC prevalence was compared across FRS strata using chi-square tests. RESULTS CAC levels of more than 0, of 100 or more, and of 300 or more were present in 46.4%, 20.6%, and 10.1% of participants, respectively. The prevalence and amount of CAC increased with higher FRS. A CAC level of 300 or more was observed in 1.7% and 4.4% of those with FRS of 0% to 2.5% and of 2.6% to 5%, respectively (number needed to screen, 59.7 and 22.7, respectively). Likewise, a CAC level of 300 or more was observed in 24% and 30% of those with FRS of 15.1% to 20% and more than 20%, respectively (number needed to screen, 4.2 and 3.3, respectively). Trends were similar when stratified by age, sex, and race or ethnicity. CONCLUSIONS Our study suggests that in very low-risk individuals (FRS ≤5%), the yield of screening and probability of identifying persons with clinically significant levels of CAC is low, but becomes greater in low- and intermediate-risk persons (FRS 5.1% to 20%).

Cardiovascular Health of Patients With Cancer and Cancer Survivors : A Roadmap to the Next Level

Many existing and emerging cancer therapies have a significant effect on the cardiovascular health of patients with cancer and cancer survivors. This paper examines current aspects of interdisciplinary cardio-oncology clinical care delivery and education in the United States and outlines how these data provide a platform for future development of the field. We present the results of the nationwide survey on cardio-oncology services, practices, and opinions, conducted among chiefs of cardiology and program directors, which demonstrate ranges of clinical activities and identify significant interest for increased educational opportunities and expert training of cardiovascular physicians in this field. The survey respondents recognized clinical relevance but emphasized lack of national guidelines, lack of funds, and limited awareness and infrastructure as the main challenges for development and growth of cardio-oncology. We discuss potential solutions to unmet needs through interdisciplinary collaboration and the active roles of professional societies and other stakeholders.

Yield of screening for coronary artery calcium in early middle-age adults based on the 10-year Framingham Risk Score: the CARDIA study.

OBJECTIVES The purpose of this study was to assess the prevalence and distribution of coronary artery calcium (CAC) across Framingham Risk Score (FRS) strata and therefore determine FRS levels at which asymptomatic, young to early middle-age individuals could potentially benefit from CAC screening. BACKGROUND High CAC burden is associated with increased risk of coronary events beyond the FRS. Expert panel recommendations for CAC screening are based on data obtained in middle-age and older individuals. METHODS We included 2,831 CARDIA (Coronary Artery Risk Development in Young Adults) study participants with an age range of 33 to 45 years. The number needed to screen ([NNS] number of people in each FRS stratum who need to be screened to detect 1 person with a CAC score above the specified cut point) was used to assess the yield of screening for CAC. CAC prevalence was compared across FRS strata using a chi-square test. RESULTS CAC scores >0 and ≥100 were present in 9.9% and 1.8% of participants, respectively. CAC prevalence and amount increased across higher FRS strata. A CAC score >0 was observed in 7.3%, 20.2%, 19.1%, and 44.8% of individuals with FRSs of 0 to 2.5%, 2.6% to 5%, 5.1% to 10%, and >10%, respectively (NNS = 14, 5, 5, and 2, respectively). A CAC score of ≥100 was observed in 1.3%, 2.4%, and 3.5% of those with FRSs of 0 to 2.5%, 2.6% to 5%, and 5.1% to 10%, respectively (NNS = 79, 41, and 29, respectively), but in 17.2% of those with an FRS >10% (NNS = 6). Similar trends were observed when findings were stratified by sex and race. CONCLUSIONS In this young to early middle-age cohort, we observed concordance between CAC prevalence/amount and FRS strata. Within this group, the yield of screening and possibility of identifying those with a high CAC burden (CAC score of ≥100) is low in those with an FRS of ≤10%, but considerable in those with an FRS >10%.

Burgeoning Cardio-Oncology Programs: Challenges and Opportunities for Early Career Cardiologists/Faculty Directors

From 1935 to 2013, cardiovascular diseases and cancer have been the 2 leading causes of death such that, in 2010, heart disease and cancer accounted for 46% of all deaths in the United States [(1)][1]. Notwithstanding, owing to the success gained in finding treatments and cures for various cancers,

Prediction of Coronary Artery Calcium Progression in Individuals With Low Framingham Risk Score: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVES This study sought to determine whether novel markers not involving ionizing radiation could predict coronary artery calcium (CAC) progression in a low-risk population. BACKGROUND Increase in CAC scores over time (CAC progression) improves prediction of coronary heart disease (CHD) events. Due to radiation exposure, CAC measurement represents an undesirable method for repeated risk assessment, particularly in individuals with low predicted risk (Framingham Risk Score [FRS] <10%). METHODS From 6,814 participants in MESA (Multi-Ethnic Study of Atherosclerosis), 2,620 individuals were classified as low risk for CHD events (FRS <10%) and had follow-up CAC measurement. In addition to traditional risk factors (RFs), various combinations of novel marker models were selected on the basis of data-driven, clinical, or backward stepwise selection techniques. RESULTS Mean follow-up was 2.5 years. CAC progression occurred in 574 participants (22% overall; 214 of 1,830 with baseline CAC = 0 and 360 of 790 with baseline CAC >0). Addition of various combinations of novel markers to the base model (c statistic = 0.711) revealed improvements in discrimination of approximately only 0.005 each (c statistics 0.7158, 0.7160, and 0.7164) for the best-fit models. All 3 best-fit novel marker models calibrated well but were similar to the base model in predicting individual risk probabilities for CAC progression. The highest prevalence of CAC progression occurred in the highest compared with the lowest probability quartile groups (39.2% to 40.3% vs. 6.4% to 7.1%). CONCLUSIONS In individuals at low predicted risk according to FRS, traditional risk factors predicted CAC progression in the short term with good discrimination and calibration. Prediction improved minimally when various novel markers were added to the model.

Factors associated with presence and extent of coronary calcium in those predicted to be at low risk according to Framingham risk score (from the Multi-Ethnic Study of Atherosclerosis).

Even among asymptomatic persons at low risk (<10%) according to the Framingham risk score, high coronary artery calcium (CAC) scores signify a greater predicted risk of coronary heart disease events. We sought to determine the noninvasive factors (without radiation exposure) significantly associated with CAC in low-risk, asymptomatic persons. In a cross-sectional analysis, we studied 3,046 participants from the Multi-Ethnic Study of Atherosclerosis at a low 10-year predicted risk (Framingham risk score <10%) of coronary heart disease events. Multivariate logistic regression analysis was used to assess the association of novel markers with the presence of any CAC (CAC >0) and advanced CAC (CAC ≥ 300). A CAC level of >0 and of ≥ 300 was present in 30% and 3.5% of participants, respectively. Factor VIIIc, fibrinogen, and soluble intercellular adhesion molecule were each associated with the presence of CAC (p ≤ 0.02), and C-reactive protein, D-dimer, and the carotid intima-media thickness with advanced CAC (p ≤ 0.03). The base model combining the traditional risk factors had excellent discrimination for advanced CAC (C-statistic 0.808). The addition of the 2 best-fit models combining the biomarkers with or without carotid intima-media thickness improved the c-statistic to 0.822 and 0.820, respectively. All 3 models calibrated well but were similar in estimating the individual risk probabilities for advanced CAC (prevalence 9.97%, 10.63%, and 10.10% in the greatest quartiles of predicted probabilities vs 0.26%, 0.26%, and 0.26% in the lowest quartiles, respectively). In conclusion, in low-risk persons, the traditional risk factors alone predicted advanced CAC with high discrimination and calibration. The biomarker combinations with and without carotid intima-media thickness were also significantly associated with advanced CAC; however, the improvement in the prediction and estimation of the clinical risk were modest compared to the traditional risk factors alone.

Changes in procoagulants track longitudinally with insulin resistance: findings from the coronary artery risk development in young adults (CARDIA) study.

To examine the association between changes in procoagulants (fibrinogen factors VII and VIII and von Willebrand factor) and the risk of insulin resistance.

Cardiovascular disease in cancer survivors

Certain cancer therapies, including radiation therapy and some types of chemotherapies, are associated with increased risk of cardiovascular disease (CVD) and events. Some of these effects such as those presented by anthracyclines, radiation therapy, cisplatin, as well as those presented by hormone therapy for breast cancer—usually taken for many years for some breast and prostate cancers—are long-lasting and associated with cardiovascular events risk more than 20 years after cancer treatment. Cardiovascular testing, diagnostic assessment of suspected cardiovascular symptomatology, as well as laboratory tests for CVD risk factors are imperative. The early recognition and treatment of CVD processes that arise in survivorship years is pivotal, with specific attention to some CVD processes with specific suggested treatment modalities. Preventive measures include adequate screening, the use of medications such as ACE inhibitors/angiotensin receptor blockers and/or beta blockers, statin therapy and aspirin in persons who warrant these medications, as well as therapeutic lifestyle modifications such as exercise/physical activity, weight loss and appropriate diet for a healthy lifestyle. Periodic follow-up with a good primary care physician who understands the risks associated with cancer therapy is important, and referral to onco-cardiology for further management of cardiovascular risk in these survivors is based on a patients cardiovascular risk level and the type, amount and duration of cancer therapies received during the patients lifetime.

Building a cardio-oncology program in a small- to medium-sized, nonprimary cancer center, academic hospital in the USA: challenges and pitfalls.

10.2217/FCA.15.43

Haemodynamic instability secondary to cardiac involvement by lymphoma

Cardiac involvement in lymphomas is not uncommon, but it is often missed due to the variability in its presentation. We present a case of bradycardia and complete heart block resulting in haemodynamic instability in a patient with recurrent diffuse large B-cell lymphoma. Timely diagnosis and appropriate management of such patients is crucial and requires a high index of suspicion. Our patient required temporary pacemaker implantation and intravenous corticosteroid therapy. His complete heart block and bradycardia eventually resolved after a course of radiation therapy.