Johns Hopkins Ciccarone Center

Baltimore, MD, United States

Johns Hopkins Ciccarone Center

Baltimore, MD, United States
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Bittencourt M.S.,Brigham and Women's Hospital | Bittencourt M.S.,University of Sao Paulo | Hulten E.,Brigham and Women's Hospital | Ghoshhajra B.,Cardiac MR PET CT Program | And 19 more authors.
Circulation: Cardiovascular Imaging | Year: 2014

Background-The contribution of plaque extent to predict cardiovascular events among patients with nonobstructive and obstructive coronary artery disease (CAD) is not well defined. Our objective was to evaluate the prognostic value of plaque extent detected by coronary computed tomography angiography. Methods and Results-All consecutive patients without prior CAD referred for coronary computed tomography angiography to evaluate for CAD were included. Examination findings were classified as normal, nonobstructive (<50% stenosis), or obstructive (=50%). Based on the number of segments with disease, extent of CAD was classified as nonextensive (=4 segments) or extensive (>4 segments). The cohort included 3242 patients followed for the primary outcome of cardiovascular death or myocardial infarction for a median of 3.6 (2.1-5.0) years. In a multivariable analysis, the presence of extensive nonobstructive CAD (hazard ratio, 3.1; 95% confidence interval, 1.5-6.4), nonextensive obstructive (hazard ratio, 3.0; 95% confidence interval, 1.3-6.9), and extensive obstructive CAD (hazard ratio, 3.9; 95% confidence interval, 2.2-7.2) were associated with an increased rate of events, whereas nonextensive, nonobstructive CAD was not. The addition of plaque extent to a model that included clinical probability as well as the presence and severity of CAD improved risk prediction. Conclusions-Among patients with nonobstructive CAD, those with extensive plaque experienced a higher rate of cardiovascular death or myocardial infarction, comparable with those who have nonextensive disease. Even among patients with obstructive CAD, greater extent of nonobstructive plaque was associated with higher event rate. Our findings suggest that regardless of whether obstructive or nonobstructive disease is present, the extent of plaque detected by coronary computed tomography angiography enhances risk assessment. © 2014 American Heart Association, Inc.

Blaha M.J.,Johns Hopkins Ciccarone Center | Silverman M.G.,Johns Hopkins Ciccarone Center | Budoff M.J.,University of California at Los Angeles
Circulation: Cardiovascular Imaging | Year: 2014

The central principle of primary prevention is that treatment decisions must be carefully matched to accurate estimates of risk. The currently accepted method for determining coronary heart disease (CHD) risk among asymptomatic individuals is through calculation of the risk factor-based Framingham Risk Score (FRS).1 The FRS relies predominantly on age, sex, and to a lesser degree the traditional modifiable CHD risk factors (smoking, blood pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes mellitus) to derive a statistical probability of developing a myocardial infarction or CHD-related death in the ensuing 10 years. Although the FRS has proven to be a useful tool, its overall predictive value in modern cohorts is modest (C-statistic, 0.70-0.75).2 Risk factor profiles widely overlap in those with and without CHD events, with the FRS failing to identify many truly high-risk individuals who are likely to benefit from preventive therapy. For example, 75% of younger patients presenting with ST-elevation myocardial infarction were considered low risk the day before their event.3 The majority of all CHD events continue to occur in patients considered either low or intermediate risk at baseline FRS assessment. © 2014 American Heart Association, Inc.

Nakanishi R.,University of California at Los Angeles | Li D.,University of California at Los Angeles | Blaha M.J.,Johns Hopkins Ciccarone Center | Whelton S.P.,Johns Hopkins Ciccarone Center | And 5 more authors.
International Journal of Cardiology | Year: 2015

Background Coronary artery calcium (CAC) is strongly predictive of all-cause mortality in intermediate-risk groups, but this relationship is not well defined in very low-risk individuals. We investigated the relationship between CAC scoring and the long-term all-cause mortality among patients with ≤ 1 cardiovascular disease (CVD) risk factor. Methods We analyzed a retrospective cohort of 5584 asymptomatic patients with no known CVD (mean 56.6 ;± 11.6 years, 69%men) and ≤ 1 risk factor who were physician referred for a CAC scan. Mortality was ascertained through linkage with the Social Security Death Index. We calculated the prevalence of CAC stratified by age and risk factors. We also examined the association between CAC and mortality using multivariable Cox Proportional hazards models. Results During a mean follow-up of 10.4 ± 3.1 years, 168 individuals (3.0%) died. Overall, 54.5% of patients had a CAC > 0 and 9.8% had CAC ≥ 400. There was a greater risk of mortality with increasing CAC 1-99 (HR 1.9, 95% CI 1.2-3.1), 100-399 (HR 2.1, 95% CI 1.2-3.6) and ≥ 400 (HR 2.8, 95% CI 1.6-4.8) compared to CAC = 0 (p < 0.0001 for trend). Similar results were observed when the population was stratified by zero or one risk factor. Among patients < 45 years old, there was a 0.7% incidence of mortality compared to 8.1% for individuals ≥ 65 years old. Conclusions During long-term follow-up, an increasing CAC was significantly associated with a higher risk of all-cause mortality among patients with a very low CVD risk factor profile. CAC scanning may be a potentially useful tool for risk stratification among low CVD risk individuals who are ≥ 45 years old. © 2014 Published by Elsevier Ireland Ltd.

Barth A.S.,Johns Hopkins Ciccarone Center | Abd T.T.,Johns Hopkins Ciccarone Center | Blumenthal R.S.,Johns Hopkins Ciccarone Center | Blaha M.J.,Johns Hopkins Ciccarone Center
Current Cardiovascular Imaging Reports | Year: 2013

The last decade has seen the emergence of a multitude of novel risk markers for coronary heart disease (CHD), ranging from genetic markers to serum biomarkers and imaging studies. Comparison between different risk markers has been historically difficult because of the paucity of high quality prospective studies evaluating these candidate risk markers side by side in the same population. In the last 2 years, several population based cohorts like MESA, Rotterdam, EISNER, and the Heinz Nixdorf Recall study have provided new data enabling assessment of comparative effectiveness for several of these risk markers. In this review, we evaluate evidence from these 4 large cohort studies regarding the relative improvement in the net reclassification index (NRI) among intermediate-risk patients. We conclude that CAC is the strongest marker for clinical risk prediction and is the most likely to positively influence downstream clinical outcomes. © 2013 Springer Science+Business Media New York.

Minder C.M.,Johns Hopkins Ciccarone Center | Minder C.M.,University of Maryland Baltimore County | Blumenthal R.S.,Johns Hopkins Ciccarone Center | Blaha M.J.,Johns Hopkins Ciccarone Center
Current Opinion in Cardiology | Year: 2013

PURPOSE OF REVIEW: Statins significantly reduce cardiovascular morbidity and mortality in patients with and without coronary heart disease. Recently, much debate has focused on use of statins for primary prevention following a class-wide safety label change by the US Food and Drug Administration amidst concerns of worsened hyperglycemia. Here, we review the evidence for statins in primary prevention and offer guidance for their appropriate use. RECENT FINDINGS: Two meta-analyses published since 2012 unequivocally support statins for primary prevention. Data from the Cholesterol Treatment Trialists' Collaborators demonstrated a 9% [relative risk (RR) 0.91, 95% confidence interval (CI) 0.85-0.97] reduction in all-cause mortality and a 25% (RR 0.75, 95% CI 0.70-0.80) reduction in major vascular events per 1. 0 mmol/l reduction in low-density lipoprotein cholesterol, even among low-risk patients. A 2013 Cochrane review corroborated these findings including a 14% (OR 0.86, 95% CI 0.79-0.94) reduction in all-cause mortality and a 25% (RR 0.75, 95% CI 0.70-0.81) reduction in cardiovascular disease events with statin therapy despite an 18% (RR 1.18, 95% CI 1.01-1.39) increase in incident diabetes. SUMMARY: Statins effectively lower atherogenic lipoproteins and result in clinically significant reductions in cardiovascular morbidity and mortality. When well tolerated, the cardiovascular benefits of statins for primary prevention generally far outweigh the reported harms. Copyright © 2013 Lippincott Williams & Wilkins.

DeFilippis A.P.,Johns Hopkins Ciccarone Center | Blaha M.J.,Johns Hopkins Ciccarone Center | Jacobson T.A.,Johns Hopkins Ciccarone Center
Current Treatment Options in Cardiovascular Medicine | Year: 2010

Major dietary sources of omega-3 fatty acids are fish containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as nuts, seeds, and vegetable oils containing α-linolenic acid (ALA). Omega-3 fatty acids, especially those derived from marine sources, may be a useful tool for the primary and secondary prevention of cardiovascular disease. Omega-3s exert their cardioprotective effects through multiple mechanisms, including reducing arrhythmias and altering production of prostaglandins, which reduces inflammation and improves platelet and endothelial function. To date, no serious adverse effects of omega-3s have been identified, despite extensive study. In adults, any potential harm from mercury exposure from consuming fish rich in omega-3s is outweighed by the proven cardiovascular benefits of eating fish. Concerns over increased bleeding complications have not materialized despite the increased concomitant use of aspirin and clopidogrel. We recommend one serving (200-400 g) of fatty fish two times per week and a diet that includes foods rich in ALA for the primary prevention of cardiovascular disease. We recommend one serving (200-400 g) of fatty fish or a fish oil supplement containing 900 mg of EPA + DHA every day and a diet rich in ALA for patients with known cardiovascular disease or congestive heart failure. © Springer Science+Business Media, LLC 2010.

Desai C.S.,Johns Hopkins Hospital | Desai C.S.,Johns Hopkins Ciccarone Center | Blumenthal R.S.,Johns Hopkins Hospital | Blumenthal R.S.,Johns Hopkins Ciccarone Center | Greenland P.,Northwestern University
Current Atherosclerosis Reports | Year: 2014

A large proportion of cardiovascular events occur in individuals classified by traditional risk factors as "low-risk." Efforts to improve early detection of coronary artery disease among low-risk individuals, or to improve risk assessment, might be justified by this large population burden. The most promising tests for improving risk assessment, or early detection, include the coronary artery calcium (CAC) score, the ankle-brachial index (ABI), and the high-sensitivity C-reactive protein (hsCRP). Data regarding the role of additional testing in low-risk populations to improve early detection or to enhance risk assessment are sparse but suggest that CAC and ABI may be helpful for improving risk classification and detecting the higher-risk people from among those at lower risk. However, in the absence of clinical trials in this patient population, such as has recently been proposed, we do not recommend routine use of any additional testing or screening in low-risk individuals at this time. © Springer Science+Business Media New York 2014.

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