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Divakaran S.,Harvard University | Cheezum M.K.,Harvard University | Hulten E.A.,U.S. National Institutes of Health | Bittencourt M.S.,University of Sao Paulo | And 3 more authors.
British Journal of Radiology | Year: 2015

Clinicians often use risk factor-based calculators to estimate an individual's risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management. © 2015 The Authors. Published by the British Institute of Radiology. Source


Bittencourt M.S.,Harvard University | Bittencourt M.S.,University of Sao Paulo | Hulten E.A.,Harvard University | Hulten E.A.,U.S. National Institutes of Health | And 2 more authors.
Current Cardiovascular Risk Reports | Year: 2014

Various approaches exist for stratifying cardiovascular risk and predicting future cardiovascular events. While traditional approaches rely on risk scores, which are based on the presence or absence of various risk factors, noninvasive cardiovascular imaging allows for actual identification of coronary artery disease-whether by direct visualization of plaque or imaging-the physiologic manifestations of flow-limiting disease. The presence of such disease is associated with a significant increase in risk of future cardiovascular events and thus, should prompt intensification of preventive therapies. This review will highlight the role of cardiovascular imaging for evaluating disease in individuals without known prior coronary artery disease. The principal findings of each imaging technique will be reviewed and data regarding the risk associated with such findings will be discussed. © 2014 Springer Science+Business Media New York. Source


Hulten E.,Brigham and Womens Hospital | Hulten E.,Uniformed Services University of the Health Sciences | Bittencourt M.S.,Brigham and Womens Hospital | Bittencourt M.S.,University of Sao Paulo | And 17 more authors.
Circulation: Cardiovascular Imaging | Year: 2014

Background-Coronary computed tomographic angiography (CCTA) is an accurate test for the identifcation of coronary artery disease (CAD), yet the impact of CCTA results on subsequent medical therapy and risk factors has not been widely reported. Methods and Results-We identifed consecutive patients aged >18 years without prior CAD who underwent CCTA from 2004 to 2011 and had complete data on medications before and after CCTA. CCTA results were categorized as no CAD, <50% stenosis, and >50% stenosis. Based on the number of involved segments, extent of disease was categorized as nonextensive (<4 segments) or extensive CAD (>4 segments). Electronic medical records and patient interviews were reviewed blinded to CCTA fndings to assess initiation of aspirin and intensifcation of lipid-lowering therapies. Survival analysis was performed to evaluate intensifcation of lipid therapy as a predictor of cardiovascular death or nonfatal myocardial infarction. Among 2839 patients with mean follow-up of 3.6 years, the odds of physician intensifcation of lipid-lowering therapy signifcantly increased for those with nonobstructive CAD (odds ratio, 3.6; 95% confdence interval, 2.9-4.9; P<0.001) and obstructive CAD (odds ratio, 5.6; 95% confdence interval, 4.3-7.3; P<0.001). Low-density lipoprotein cholesterol levels declined signifcantly in association with intensifcation of lipid-lowering therapy after CCTA in all patient subgroups. In a hypothesis-generating analysis, among patients with nonobstructive but extensive CAD, statin use after CCTA was associated with a reduction in cardiovascular death or myocardial infarction (hazards ratio, 0.18; 95% confdence interval, 0.05-0.66; P=0.01). Conclusions-Abnormal CCTA fndings are associated with downstream intensifcation in statin and aspirin therapy. In particular, CCTA may lead to increased use of prognostically benefcial therapies in patients identifed as having extensive, nonobstructive CAD. © 2014 American Heart Association, Inc. Source


Amin N.P.,Johns Hopkins University | Martin S.S.,Johns Hopkins University | Blaha M.J.,Johns Hopkins University | Nasir K.,Johns Hopkins University | And 3 more authors.
Journal of the American College of Cardiology | Year: 2014

The newly released 2013 ACC/AHA Guidelines for Assessing Cardiovascular Risk makes progress compared with previous cardiovascular risk assessment algorithms. For example, the new focus on total atherosclerotic cardiovascular diseases (ASCVD) is now inclusive of stroke in addition to hard coronary events, and there are now separate equations to facilitate estimation of risk in non-Hispanic white and black individuals and separate equations for women. Physicians may now estimate lifetime risk in addition to 10-year risk. Despite this progress, the new risk equations do not appear to lead to significantly better discrimination than older models. Because the exact same risk factors are incorporated, using the new risk estimators may lead to inaccurate assessment of atherosclerotic cardiovascular risk in special groups such as younger individuals with unique ASCVD risk factors. In general, there appears to be an overestimation of risk when applied to modern populations with greater use of preventive therapy, although the magnitude of overestimation remains unclear. Because absolute risk estimates are directly used for treatment decisions in the new cholesterol guidelines, these issues could result in overuse of pharmacologic management. The guidelines could provide clearer direction on which individuals would benefit from additional testing, such as coronary calcium scores, for more personalized preventive therapies. We applaud the advances of these new guidelines, and we aim to critically appraise the applicability of the risk assessment tools so that future iterations of the estimators can be improved to more accurately assess risk in individual patients. © 2014 by the American College of Cardiology Foundation. Published by Elsevier Inc. Source

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