Patrick Campbell

(Editor’s note: This article has been adapted from its original publication on our sister site 

Cardiac computed tomography (CT) may provide a safer option than coronary angiography for assessing patients with stable chest pain and suspected coronary artery disease (CAD), according to 

In the randomized multicenter DISCHARGE trial, which involved over 3,500 patients with stable chest pain, researchers found that initial cardiac CT and coronary angiography had similar cardiovascular risks, but the 

use of CT had a significantly lower risk of major, procedure-related complications

“The trial confirmed that the CT-based examination is safe in patients with stable chest pain and suspected coronary artery disease,” said Marc Dewey, MD, head of the Department of Radiology on Campus Charité Mitte. “Among the patients referred for cardiac catheterization and included in this trial, the risk of major cardiovascular events was found to be similar in both the CT and catheterization groups, occurring in 2.1% and 3.0% of patients, respectively. The incidence of major, procedure-related complications was found to be lower in patients managed with an initial CT strategy.”

Conducted across 26 European medical centers from October 3, 2015 to April 12, 2019, the DISCHARGE trial enrolled 3,667 patients who were randomized in a 1:1 ratio to undergo CT or invasive coronary angiography. Of the 3,667 enrolled, 3,561 were included in a modified intention-to-treat analysis.

To be considered eligible for the study, patients needed to be at least 30 years of age and referred for invasive coronary angiography at a study site because of stable chest pain with an intermediate pretest probability of obstructive CAD. Investigators noted a web-based system was used to ensure concealment of group assignments after eligibility criteria had been checked.

As part of the study protocol, it was recommended that patients in either arm without obstructive CAD be discharged from the trial center back to their referring physician for further treatment while those with obstructive CAD were treated according to guidelines.

The primary outcome of interest for the study was incidence of major adverse cardiovascular events, which was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke. Secondary outcomes of interest included major procedure-related complications occurring during or within the first 48 hours after CT or invasive coronary angiography.

Of the 3,561 people included in the intention-to-treat analysis, 1,808 represented the CT group and 1,753 patients were in the invasive coronary angiography group. Baseline characteristics of patients were similar between the study groups and the median follow-up time was 3.5 (IQR, 2.9-4.2) years.

During the follow-up period, a total of 90 major adverse cardiovascular events occurred among the study cohort, with events occurring among 2.1% in the CT group and 3.0% in the invasive coronary angiography group (HR, 0.70 [95% CI, 0.46-1.07]; 

=.10). When assessing major procedure-related complications, 42 such events were identified by investigators, with these events occurring in 0.5% of the CT group and 1.9% of the invasive coronary angiography group (HR, 0.26 [95% CI, 0.13-0.55]). Assessments of angina among study participants during the final four weeks of follow-up indicated angina was reported by 8.8% of the CT group and 7.5% of the invasive coronary angiography group (HR, 1.17 [95% CI, 0.92-1.48]).

“Now that it has been standardized and quality tested as part of the DISCHARGE trial, this method could be made more widely available as part of the routine clinical care of people with intermediate CAD risk,” said Henryk Dreger, Deputy Head of Charité’s Department of Cardiology and Angiology.

Articles

For patients with stable chest pain and suspected coronary artery disease (CAD), emerging evidence shows that cardiac computed tomography (CT) has a lower risk of major procedure-related complications than catheterization.

Can Cardiac CT be a Viable Alternative for Diagnosing Coronary Artery Disease?

This article was first published on our sister site Endocrinology Network.

Data gathered from bone density scans (DEXA) shows that older women with higher levels of aortic calcification could also be at greater risk for increased falls and fractures. 

Based on a study of more than 1,000 women in Australia, researchers revealed data that suggests older women with evidence of aortic calcification could be at an increased 

risk of falls and potential for fractures

A look at fall-related hospitalizations over a 14.5-year period, results indicate each unit increase in abdominal aortic calcification (AAC) was associated with a 3-percent increase in relative risk for fall-related hospitalization.

"We know that AAC identifies women at a higher risk of heart attacks and strokes, but our research now shows that it also identifies women at a higher falls risk, independent of other falls risk factors and muscle strength," Joshua Lewis, PhD, a National Heart Foundation Future Leader Fellow at Edith Cowan University, 

Funded by the Rebecca L. Cooper Medical Research Foundation, the current study was conducted Lewis and colleagues from Edith Cowan University with an interest in identifying whether an association existed between AAC and increased risk of long-term fall-related hospitalizations in aging women. To do so, investigators designed their study as an analysis of data from within the Perth Longitudinal Study of Aging in Women (PLSAW).

A 15-year longitudinal study that began in 1998-1999, PLSAW examined the impact of various environmental, anatomical, physiological, metabolic, and genetic factors on health outcomes in aging women and provided investigators with information related to a cohort of 1,053 older women with a mean age of 75.0±2.6 years meeting criterion for inclusion in their study. All women included in the study had AAC assessed from lateral spine images obtained from dual-energy X-ray absorptiometry and were scored using the AAC 24 semiquantitative method. Of note, presence of any AAC was defined as an AAC 24 of 1 or more.

Upon analysis, investigators identified 413 (39.2 percent) women who experienced a fall-related hospitalization during the follow-up period. In adjusted models, results suggested each 1 unit increase in baseline AAC24 was associated with a 3-percent increase in relative risk for a fall-related hospitalization (HJR, 1.03; 95 percent CI, 1.01-1.07).

When compared to women with no AAC, results indicated those with any AAC were at a 40-percent greater risk for fall-related hospitalizations in minimally adjusted models. In fully adjusted models comparing the same groups, women with any AAC were at a 39-percent increased risk for fall-related hospitalizations. Additionally, investigators pointed out these relationships were not attenuated by inclusion of measurements of muscle function.

"If we can capture an additional scan to look for evidence of AAC at the same time, we can potentially identify and prevent future harmful falls,” said Abadi Gebre, a co-investigator and Ph.D. candidate at Edith Cowan University. "We often wait until a person suffers a fall to intervene and at that point the damage is already done."

Abdominal aortic calcification is associated with a higher risk of injurious fall-related hospitalizations in older Australian women

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Assessment of more than 1,000 women in Australia shows abdominal aortic calcification linked to increased risk of fall-related hospitalizations.

DEXA Scans Show Aortic Calcification Predicts Fall Risk in Older Women

This story first appeared on Diagnostic Imaging's sister site 

In patients who are at risk for a heart attack or stroke, coronary artery calcium (CAC) scoring could help providers identify patients who could benefit the most from using aspirin as a primary intervention. 

A new study from a team of investigators from the Preventive Cardiology Program at the University of Texas Southwestern outlines this potential new use for CAC scoring. The team, led by Amit Khera, M.D., professor of internal medicine and director of the Preventive Cardiology Program, used data from the Dallas Heart Study.  

“Aspirin use is not a one-size-fits-all therapy,” Khera said 

. “CAC scanning can be a valuable tool to help us tailor care to help more patients avoid a first heart attack or stroke.”

CT Scans for Arterial Plaque Better Predictor for Heart Attack Than Stroke

With guideline changes altering the use of aspirin in prevention settings, a new emphasis has been placed on predictors and factors associated with increased bleeding when used for primary prevention. In recent years, a multitude of studies have concluded CAC scoring was useful for identifying patients at an increased atherosclerotic cardiovascular disease (ASCVD) risk. With this in mind, Khera and colleagues designed the current study to examine whether CAC scoring could help determine the net estimated effect of aspirin at different risk thresholds.

Using the 6,101-patient Dallas Heart Study as a data source, investigators performed a search of patients free from ASCVD and not taking aspirin at baseline. From this search, investigators identified a cohort of 2,191 patients for inclusion in the current study. This cohort had a mean age of 44 (SD, 9.1) years, 57 percent were women, and 47 percent were Black.

Of note, all patients in the Dallas Heart Study were invited to three sequential visits to collect health information, including various imaging studies and electron beam computed tomography for CAC scoring. Of the 2,191 patients included in the study, 1,063 had a CAC of 0, 967 had a score of 1-99, and 161 had a score of 100 or greater.

The primary outcomes of the study were first bleeding event and first ASCVD event associated with hospitalization or death. Bleeding events were identified through the use of ICD-9 codes and the ASCVD outcome was defined as a composite of nonfatal myocardial infarction, coronary heart disease death, and nonfatal and fatal stroke.

Over a follow-up period lasting a mean of 12.2 (1.9) years, 116 first major bleeding events and 123 ASCVD events were observed. When assessing types of bleeding events, investigators found 81 (70 percent) were gastrointestinal and 18 were intracerebral. Investigators pointed out 24 (21 percent) of the 116 events were fatal bleeds.

Upon analysis, results indicated those with a CAC score of 1-99 were at a greater risk for ASCVD (HR, 4.8; 95 percent CI, 2.8-8.2; 

 <.01) and bleeding events (HR, 1.6; 95 percent C I, 1.1-2.4; 

=.02) when compared to their counterparts with a score of 0. Results indicated those with a CAC score of 100 or greater were also at an increased risk of ASCVD (HR, 5.3; 95 percent CI, 3.6-7.9; 

 <.01) and bleeding events (HR, 2.6; 95 percent CI< 1.5-4.3; 

 <.01) when compared to those with a score of 0. However, investigators pointed out these association between bleeding events and CAC was attenuated in multivariable-adjusted models.

Using meta-analysis estimates for the effects of aspirin, irrespective of CAC, investigators found aspirin use was estimated to result in net harm for individuals at low and intermediate (less than 5 percent) 10-year ASCVD risk. For those considered to be at high-risk (20 percent or greater), aspirin use was associated with a net benefit.

When assessing bleeding risk, results suggested a CAC score of 100 or greater in patients considered to be at low bleeding risk indicated net benefit from aspirin use, but only in those at borderline or higher (5 percent or greater) 10-year ASCVD risk. Among individuals at higher bleeding risk, aspirin use was associated with net harm regardless of CAC and ASCVD risk.

, Miguel Cainzos-Achirica, MD, MPH, PhD, and Philip Greenland, MD, applaud investigators of the current study for adding to a growing body of evidence suggesting CAC scores could help guide aspirin use for primary prevention, but cautions that more conclusive studies are needed before overinterpreting data.

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“Until further studies become available, the overall consistent observations from the DHS and the MESA have important clinical implications…Although it has been proposed that clinical risk scores could aid in the identification of optimal candidates for aspirin therapy, CAC scores seem to be a better tool to inform risk management discussions involving aspirin, leading to a safer allocation in candidates who are appropriate and motivated—particularly in middle-aged populations,” wrote the pair.

Value of Coronary Artery Calcium Scanning in Association With the Net Benefit of Aspirin in Primary Prevention of Atherosclerotic Cardiovascular Disease

An analysis of the Dallas Heart Study from UTSW details how use of CAC scoring can help determine what patients would stand to benefit from aspirin use for primary prevention.

Patrick Campbell

Articles

Can Cardiac CT be a Viable Alternative for Diagnosing Coronary Artery Disease?

DEXA Scans Show Aortic Calcification Predicts Fall Risk in Older Women

CAC Scoring Helps Determine Net Benefit or Harm of Aspirin in Primary Prevention