Association of cystatin C with coronary artery calcification in patients undergoing multidetector computed tomography

Cystatin C is associated with atherosclerosis, but the relationship between cystatin C and coronary artery calcification (CAC) is uncertain. The purpose of this study was to evaluate the predictive value of cystatin C on the occurrence and severity of CAC.A total of 1447 hospitalized patients with coronary computed tomography angiography were selected in this study. According to the CAC score (CACS), patients were divided into calcification group (with CAC, n = 749) and control group (without CAC, n = 698). The calcification group was further divided into low calcification group (CACS < 100, n = 407), medium calcification group (CACS 100–400, n = 203), and high calcification group (CACS≥400, n = 139).Patients with CAC had higher cystatin C level than those in control group (P < .05). With the increase of calcification score, the cystatin C level showed an upward trend. The cystatin C level in the high calcification group was significantly higher than those in the low and medium calcification group (P < .05). ROC curve analysis showed that cystatin C had a high predictive value for the occurrence of CAC [area under the curve 0.640, 95% confidence interval (95% CI) 0.591–0.690, cut-off value 0.945 mg/L, sensitivity 0.683, specificity 0.558, P < .05] and severe CAC (area under the curve 0.638, 95% CI 0.550–0.762, cut-off value 0.965 mg/L, sensitivity 0.865, specificity 0.398, P < .05). Multivariate logistic regression analysis showed that cystatin C was an independent predictor of severe CAC (AOR 3.748, 95% CI 1.138–10.044, P < .05).Cystatin C was significantly associated with the occurrence and severity of CAC, suggesting that cystatin C had the potential as a predictor of CAC.     

Prevalence,determinants and prognostic value of high coronary artery calcium score in asymptomatic patients with diabetes: A systematic review and meta-analysis

BackgroundThe pharmacological management of diabetes is mostly based on its cardiovascular risk assessment. For this purpose, coronary artery calcium score (CACS) is proposed with a soft (class IIb) recommendation, as its prognostic implication requires further evidence in different subsets. Thus, we carried-out a systematic review and meta-analysis to address the prevalence of high CACS, its determinants and prognostic value in asymptomatic patients with diabetes, with a special focus on different sex and ethnic groups.MethodsWe carried out a systematic review of the published literature in several databases between 01/2000 and 01/2021. Original studies were included if they presented data on the prevalence, determinants and prognosis of high CACS in patients with diabetes without known cardiovascular disease. Using random effects models, we calculated pooled odds ratios (OR) for CACS determinants and Relative Risk (RR) for CACS prognostic value on all-cause mortality and/or fatal and non-fatal CV events in different categories.ResultsWe included 23 studies (n = 20,999 patients). Female sex and black ethnicity presented the lowest prevalence of CACS>0. Age, male sex, non-black ethnicity and diabetes duration were identified as risk factors for high CACS. Among the 10 studies (n = 110,396 person-years) with prognostic data, the pooled RR for the occurrence of all-cause death and/or cardiovascular events were 4.03 (95%CI: 3.04–5.34), 5.87 (95%CI: 4.32–7.99) and 9.04 (95%CI: 5.81–14.06) respectively for CACS>0 vs. CACS = 0, CACS≥100 vs. CACS<10 and CACS≥400 vs. CACS<10. For similar CACS, these RR were greater in women than in men.ConclusionOur meta-analysis demonstrates that the increase in CACS is strongly associated with an increased risk for all-cause mortality and/or fatal and non-fatal CV events in asymptomatic patients with diabetes.     

Behavior of Small,Asymptomatic, Nonfunctioning Pancreatic Neuroendocrine Tumors (NF-PNETs)

Small nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) usually exhibit minimal or no growth over many years. However, there is a controversy regarding the optimal management of incidentally discovered, small NF-PNETs. This study aimed to gain insights into tumor behavior and potential strategies for clinical management.We retrospectively reviewed a total of 202 patients with a suspected PNET (size 2 cm or smaller) at Samsung Medical Center from January 1, 1995 to April 30, 2012. Among these patients, 72 patients were excluded and 145 patients were enrolled in our study. Patients were included if the size of the tumor was ≤2 cm without familial syndrome, radiographic evidence of local invasion or metastases.Among the 145 patients, 76 patients (52.4%) had pathologically confirmed PNETs. Eleven (14.5%) and 3 (3.9%) of these 76 patients were diagnosed with NET G2 and G3, respectively. PNETs measuring 1.5 cm or more in size had a higher probability of being classified as NET G2 or G3 compared with PNETs measuring <1.5 cm (P = 0.03). Older age (≥55 years) and a meaningful tumor growth (≥20% or ≥5 mm) were significantly associated with NET G2 or G3 (P < 0.05).Older age (≥55 years), larger tumor size (≥1.5 cm), and a meaningful tumor growth (≥20% or ≥5 mm) were associated with NET G2 or G3. Intensive follow-up could be an acceptable approach in small (especially <1.5 cm), asymptomatic, NF-PNETs.     

Risk Score Model for the Assessment of Coronary Artery Disease in Asymptomatic Patients With Type 2 Diabetes

No model has been developed to predict significant coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) in asymptomatic type 2 diabetes. Therefore, we sought to develop a model for the prediction of significant CAD on CCTA in these patients.We analyzed 607 asymptomatic patients with type 2 diabetes who underwent CCTA. The cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, acute coronary syndrome, and coronary revascularization.Significant CAD (diameter stenosis ≥50%) in at least one coronary artery on CCTA was observed in 188 (31.0%). During the follow-up period (median 4.3 [interquartile range, 3.7–4.8] years), 71 patients had 83 cardiac events. Clinical risk factors for significant CAD were age, male gender, duration of diabetes, hypertension, current smoking, family history of premature CAD, previous history of stroke, ratio of total cholesterol to high-density lipoprotein cholesterol, and neuropathy. Using these variables, we formulated a risk score model, and the scores ranged from 0 to 17 (area under the curve = 0.727, 95% confidence interval = 0.714–0.739, P < 0.001). Patients were categorized into low (≤3), intermediate (4–6), or high (≥7) risk group. There were significant differences between the risk groups in the probability of significant CAD (12.6% vs 29.4% vs 57.7%, P for all < 0.001) and 5-year cardiac event-free survival rate (96.6% ± 1.5% vs 88.9% ± 1.8% vs 73.8% ± 4.1%, log-rank P for trend < 0.001).This model predicts significant CAD on CCTA and has the potential to identify asymptomatic type 2 diabetes with high risk.     

Comparative analysis of ischemic changes in electrocardiogram and coronary angiography results: A retrospective study

To improve the correct diagnosis rate of coronary heart disease and to explore the guiding value of electrocardiogram (ECG) ST-T ischemic changes in the clinical diagnosis of coronary heart disease.A retrospective analysis was conducted on a total of 310 cases who underwent a conventional 12-lead ECG, 12-lead dynamic ECG (DECG, Holter) with ST-T ischemic changes, and then coronary angiography (CA) within 1 week in Qingdao Sttarr Heart Hospital from June 2015 to April 2020 in the study. Ischemic ST-T changes were evaluated using conventional diagnostic criteria, and Judkins diagnostic criteria were used in CA. The sensitivity and specificity of ECG were analyzed.The specificity of ST-T changes in conventional ECG for the diagnosis of coronary heart disease is 33.7% and the sensitivity is 66.0%. The specificity of ST-T changes in Holter in the diagnosis of coronary heart disease is 55.6% and the sensitivity is 32.2%. The sensitivity of conventional ECG for the diagnosis of coronary heart disease is better than Holter, but its specificity is inferior to Holter. The negative likelihood ratios of the 2 ECGs for the diagnosis of coronary heart disease were 1.0 and 1.22, both >0.1, and the positive likelihood ratios were 0.99 and 0.73, both <10. The positive results of ST-T in conventional ECG were 128 males (65.7%), 77 females (66.9%), (P < .05), 148 cases (74.7%) in the group ≥60 years old, and 75 cases in the group less than 60 years (67%), (P > .05). The positive results of ST-T change of DECG were 135 males (69.2%), 69 females (60.0%), (P < .05), 152 cases (78.7%) in the group ≥60 years, and 83 cases (70.9%) in the group less than 60 years, (P > .05). Coronary heart disease-related factors: symptoms, hypertension, diabetes, cancer, family history, smoking history as independent variables, and a binary multivariate logistic regression analysis was performed.The sensitivity of DECG in the diagnosis of myocardial ischemia in women and the elderly was slightly higher than that in men and young cases. ST-T ischemic changes in ECG are more significant for the diagnosis of coronary heart disease in male patients. Smoking, hypertension, diabetes, and family history are all high-risk factors for coronary heart disease.     

Relation of cardiovascular risk factors and angina status to obstructive coronary artery disease according to categorical coronary artery calcium score

Coronary artery calcium (CAC) is associated with the presence of coronary artery disease (CAD) and cardiovascular risk factors. However, the relation between cardiovascular risk factors and CAD has not yet been fully elucidated in patients with a zero or low coronary artery calcium score (CACS). The purpose of this study was to evaluate the relation of cardiovascular risk factors and angina status to obstructive CAD according to categorical CACS. A total of 753 patients were enrolled in this study. CAC scoring and coronary computed tomographic angiography (CCTA) were performed with dual-source 64-slice CT scanners. The number of patients with a CACS ≤10 and ≤100 were 358 and 528, respectively. Patients with a higher CACS were older and more frequently male, and had a greater frequency of hypertension, diabetes, and hypercholesterolemia. The prevalence of obstructive CAD increased with the CACS. Among patients with a CACS ≤100, age, male gender, diabetes, hypercholesterolemia, and typical angina pectoris were related to obstructive CAD. The presence of hypercholesterolemia was relatively strongly associated with obstructive CAD (OR 6.67, 95% CI 2.91–15.3, p < 0.001) on multivariate analysis. Among patients with a CACS ≤10, men, hypercholesterolemia, and typical angina pectoris were significantly more frequent in patients with than in those without obstructive CAD (p < 0.01). Our data suggest that neither the absence nor low of coronary calcium burden may reliably exclude obstructive CAD in typical symptomatic male patients with hypercholesterolemia. This result may be useful to interpret the relation of CACS to obstructive CAD.     

Role of Coronary Calcium Scoring in the Assessment of Physiological Ischemia in Patients with Intermediate Stenosis

Although coronary artery calcium (CAC) is an established marker of coronary atherosclerosis, whether it also reflects the physiological significance is unknown. This study aims to evaluate if CAC could indicate physiological ischemia in intermediate stenosis defined by an invasive fractional flow reserve (FFR). CAC score (CACS) derived from either whole coronary arteries or individual arteries was measured by computed tomography among patients with intermediate de novo lesions (percent diameter stenosis from 30% to less than 70%). All stenoses were evaluated by invasive FFR; lesions with an FFR ≤ 0.80 were considered significant. We enrolled 119 patients with 143 lesions. Of these, 42 lesions (29.4%) demonstrated significant ischemia by FFR measurement. FFR values had modest but significant correlations with CACS in individual arteries with intermediate stenosis (r = − 0.290; p < 0.001). A receiver operating characteristic curve analysis showed that CACS of individual arteries with intermediate stenosis had 71.4% sensitivity and 67.3% specificity as a predictor of significant ischemia at a cut off value of 145.9. Multivariable analysis showed that percent diameter stenosis and CACS in individual arteries with intermediate stenosis were independent predictors for significant ischemia. By net reclassification improvement analysis, CACS in individual arteries with intermediate stenosis provided incremental prediction for significant ischemia over minimum lumen diameter, percent diameter stenosis, and lesion length. CACS measured in each artery, but not the total CACS, provides additional information as to whether an angiographically intermediate stenosis within the artery is significant enough to cause myocardial ischemia.     

Serum NSE and S100B protein levels for evaluating the impaired consciousness in patients with acute carbon monoxide poisoning

The aim of this study was to investigate the associations between the levels of neuron-specific enolase (NSE) and S100B protein and coma duration, and evaluate the optimal cut-off values for prediction coma duration ≥ 72 hours in patients with acute carbon monoxide poisoning (ACOP).A total of 60 patients with ACOP were divided into 3 following groups according to their status of consciousness and coma duration at admission: Awake group [Glasgow Coma Scale score (GCS score) ≥ 13 points], Coma < 72 hours group (GCS score < 13 points and coma duration < 72 h), and Coma ≥ 72 hours group (GCS score < 13 points and coma duration ≥ 72 h). The levels of serum NSE and S100B protein were measured after admission.There were significant differences in GCS score, carbon monoxide (CO) exposure time, NSE, and S100B levels between the Coma ≥ 72 h group and the Awake group, and between the Coma < 72 h group and the Awake group. Significant differences in GCS score, NSE, and S100B levels were also found between Coma ≥ 72 h group and Coma < 72 h group. Correlation analysis showed that NSE and S100B were positively correlated (r_s = 0.590, P < .01); NSE and S100B were negatively correlated with GCS score (r_s = -0.583, r_s = -0.590, respectively, both P < .01). The areas under the curve (AUCs) of NSE, S100B, and GCS score to predict the coma duration ≥ 72 hours were 0.754, 0.791, and 0.785, respectively. Pairwise comparisons did not show differences among the 3 groups (all P > .05). The sensitivity and specificity of NSE prediction with a cut-off value of 13 μg/L were 80% and 64%, respectively, and those of S100B prediction with a cut-off value of 0.43 μg/L were 70% and 88%, respectively.The NSE and S100B protein levels were significantly correlated with the degree of impaired consciousness and had the same clinical value in predicting coma duration of ≥ 72 hours in patients with ACOP.     

Association between coronary artery calcification and cognitive function in a Chinese community-based population

BackgroundCoronary atherosclerosis and cognitive impairment are both age-related diseases, with similar risk factors. Coronary artery calcium (CAC), a marker of coronary atherosclerosis, may play a role in early detection of individuals prone to cognitive decline. This study aimed to investigate the relationship between CAC and cognitive function, and the capability of CAC to identify participants with a high risk of dementia in a Chinese community-based population.MethodsA total of 1332 participants, aged 40−80 years and free of dementia from a community located in Beijing were included. All participants completed neurocognitive questionnaires and noncontrast CT examinations. Cognitive performance tests (including verbal memory, semantic fluency, executive function, and global cognitive function tests), the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CIDE) risk score, and the CAC score (CACS) were evaluated by questionnaires and CT. A CAIDE score ≥ 10 was considered to indicate a high risk of dementia in late-life. Participants were divided into three groups according to CACS (0, 1−399, ≥ 400).ResultsAfter adjusting for risk factors, CACS was significantly associated with verbal memory (r = −0.083, P = 0.003) and global cognitive function (r = −0.070, P = 0.012). The prevalence of a high risk of dementia in the subgroups of CACS = 0, 1−399, and ≥ 400 was 4.67%, 13.66%, and 24.79%, respectively (P < 0.001). Individuals with CACS ≥ 400 had a higher risk of CAIDE score ≥ 10 [OR = 2.30 (1.56, 4.56), P = 0.014] than those with CACS = 0. The receiver-operating characteristic curves showed that the capability of CACS to identify participants with a high risk of dementia was moderate (AUC = 0.70, 95% CI: 0.67−0.72,P < 0.001). ConclusionsCAC, a marker of subclinical atherosclerosis, was significantly associated with cognitive performance in verbal memory and global cognitive function. CAC had a moderate capability to identify participants with a high risk of dementia, independent of age, education, and other risk factors.

Coronary atherosclerosis and cognitive impairment are both age-related diseases. The incidences of the two diseases are increasing with the rapid aging of the population. There are 50 million people with dementia in the world, and this number is likely to rise to 152 million by 2015. The cost of dementia is forecasted to be approximately two trillion dollars by 2030.^[1,2] Therefore, early prevention of cognitive impairment is of great significance. Cognitive decline has risk factors similar to those for atherosclerosis such as smoking, hypertension, and diabetes.^[3] Intracranial and carotid artery atherosclerosis has been indicated to be related to a higher risk of cognitive decline or dementia.^[4,5] Coronary artery calcium (CAC), a marker of coronary atherosclerosis, may play a role in the early identification of individuals who are prone to cognitive decline. However, several studies investigating the association between CAC assessed by CT and cognitive function have reported controversial results.^[6–10] In addition, these previous studies mainly focused on Europeans and Americans, and the relationship between CAC and cognitive function in the Chinese population is still uncertain. The Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score was the first dementia risk score developed to predict late-life dementia risk. Individuals with a CAIDE score ≥ 9 or ≥ 10 were considered to have a high risk of dementia.^[11–13] The capability of CAC to identify participants with a high risk of late-life dementia (CAIDE score ≥ 9 or ≥ 10) was discrepant as well.^[14] Moreover, CAC is currently available convenient in clinical practice, and non-contrast chest CT scans and cardiac computed tomography angiography could both be used to assess CAC, especially in smokers undergoing lung cancer screening and patients suspected with coronary artery disease. This study was designed to determine: (1) whether CAC is related to cognitive performance, including verbal memory, semantic fluency, executive function and global cognitive function, and (2) the capability of CAC to identify participants with a high risk of late-life dementia in a Chinese community-based population.     

Reliability and validity of SHMS v1.0 for suboptimal health status assessment of Tianjin residents and factors affecting sub-health: A cross-sectional study

The study aimed to explore the reliability and validity of the Sub-Health Measurement Scale version 1.0 (SHMS v1.0) for the assessment of the suboptimal health status (SHS) of Tianjin residents.This was a cross-sectional study that surveyed 2640 urban residents in Tianjin from June 2016 to January 2018. Demographic and clinical characteristics were collected. Each subject completed the SHMS v1.0 and Short Form-36 (SF-36) scale assessments.The retest coefficient was 0.675. The overall Cronbach''s α coefficient was 0.921. The correlation between SHMS v1.0 and SF-36 was 0.781 (P < .01). The SHS frequency increased with age, from 62.4% in participants ≤25 years of age to 72.8% in those ≥ 56 years of age. The multivariable analysis showed that female sex (P < .001), age >25 years old (P = .009), bachelor degree or above (P < .001), obesity (P < .0), regular smoking (P = .043), frequent drinking (P = .045), sleep time < 6 hours (P = .006), working time >10 hours (P < .001), physical exercise <5 times/mo (P < .001), and adverse events >9 (P < .001) were associated with SHS.The prevalence of SHS is high among urban residents in Tianjin.     

Association Between the Presence of Iron Deficiency Anemia and Hemoglobin A1c in Korean Adults: The 2011–2012 Korea National Health and Nutrition Examination Survey

Few studies have investigated the clinical effect of iron deficiency anemia (IDA) on the use of the Hemoglobin A1c (HbA1c) as a screening parameter for diabetes or prediabetes. We investigated the association between IDA and HbA1c levels in Korean adults.Among the 11,472 adults (≥19 years of age) who participated in the 2011–2012 Korea National Health and Nutrition Examination Survey (a cross-sectional and nationally representative survey conducted by the Korean Center for Disease Control for Health Statistics), 807 patients with diabetes currently taking anti-diabetes medications were excluded from this study. We compared the weighted HbA1c levels and weighted proportion (%) of HbA1c levels of ≥5.7%, ≥6.1%, and ≥6.5% according to the range of fasting plasma glucose (FPG) levels and the presence of IDA.Among 10,665 participants (weighted n = 35,229,108), the prevalence of anemia and IDA was 7.3% and 4.3%, respectively. The HbA1c levels were higher in participants with IDA (5.70% ± 0.02%) than in normal participants (5.59% ± 0.01%; P < 0.001), whereas there was no significant difference in FPG levels. In participants with an FPG level of <100 mg/dL and 100 to 125 mg/dL, the weighted HbA1c level was higher in those with IDA (5.59% ± 0.02% and 6.00% ± 0.05%) than in normal participants (5.44% ± 0.01% and 5.82% ± 0.01%) after adjusting for confounders such as age, sex, FPG level, heavy alcohol drinking, waist circumference, and smoking status as well as after exclusion of an estimated glomerular filtration rate of <60 mL/min/1.73 m² (P < 0.001, <0.01). The weighted proportions (%) of an HbA1c level of ≥5.7% and ≥6.1% were also higher in participants with IDA than in normal participants (P < 0.001, <0.05). However, the weighted HbA1c levels in individuals with an FPG level ≥126 mg/dL and a weighted proportion (%) of an HbA1c level of ≥6.5% showed no significant differences according to the presence of IDA.In conclusion, the presence of IDA shifted the HbA1c level upward only in the normoglycemic and prediabetic ranges, not in the diabetic range. Therefore, IDA should be considered before using HbA1c as a screening test for prediabetes.     

Bivalirudin in patients undergoing percutaneous coronary intervention and independent predictors of postoperative adverse events in these patients: A real world retrospective study

The efficacy and safety of bivalirudin in percutaneous coronary intervention (PCI) has always been a hot topic in perioperative antithrombotic therapy, but there are still some controversies. So studies are needed to provide more evidence, especially the real world study which includes patients excluded from previous RCT studys. Our study aimed to investigate these information and analyze the independent predictors of postoperative adverse events.A retrospective study enrolled 1416 patients underwent PCI in Tianjin Chest Hospital from May 2016 to October 2017. The incidence of stent-thrombosis and net clinical adverse events, including all-cause death, myocardial infarction, stroke, urgent target-vessel revascularization and bleeding, were followed up for 30 days and 1 year. Logistic regression and COX regression were respectively used to analyze independent predictors of bleeding events within 30-days, and independent predictors of Major adverse cardiovascular and cerebrovascular events (MACCE) in patients with stent implantation within 1-year.Seven hundred six patients were treated with bivalirudin while 710 with unfractionated heparin (UFH). The proportions of diabetes, hypertension, anemia, myocardial-infarction history, PCI history, moderate-to-severe renal-impairment, gastrointestinal-bleeding history in the bivalirudin group were significantly higher (P < .05). Women, anemia were independent risk factors for bleeding within 30-days (P < .05). Among 682 patients with stent implantation in bivalirudin group, anemia, Body Mass Index (BMI) >25 kg/m², KILLIP ≥2, ejection fraction (EF) <45%, eGFR <60 ml/minutes were independent risk factors for MACCE, while Statins, proton pump inhibitor (PPI) were independent protective factors for MACCE with-in 1-year (P < .05).Bivalirudin have good anticoagulant effect and lower bleeding risk during PCI, especially in patients with higher bleeding risk. In patients treated with bivalirudin, female, anemia were independent predictors of bleeding within 30-days, BMI >25 kg/m², anemia, KILLIP ≥2, EF <45%, eGFR <60 ml/minutes were independent risk factors and Statins, PPI were independent protective factors of MACCE within 1-year.     

Appraisal of transthoracic echocardiography for opportunistic screening of abdominal aortic aneurysm

Abdominal aortic aneurysm is a life threatening disease. Most of the patients diagnosed incidentally because of the asymptomatic nature of this disease. This study aimed to determine the frequency of abdominal aortic aneurysm and evaluate the value of opportunistic screening during transthoracic echocardiography.A total of 5138 patients referred for echocardiographic evaluation for any reason were screened for abdominal aortic aneurysm between November 2014 to July 2019. The aneurysm was defined as an abdominal aorta with a diameter greater than 30 mm, or segmental dilatation of more than 50% of its size in non-dilated parts.The overall frequency of abdominal aortic aneurysm was 2.2% (n = 109) in the study population. Male sex (P < .001), older age (P < .001), presence of diastolic dysfunction (P = .036), hypertension (P < .001), coronary artery disease (P < .001), and hyperlipidemia (P < .001) were associated with abdominal aortic aneurysm. Patients with aneurysm had significantly increased diameters of the aortic trunk (P < .001) and ascending aorta (P < .001), significantly thicker interventricular septum (P < .001) and posterior wall (P < .001), significantly increased end-diastolic diameter (P < .001) and enlarged left atrium (P < .001), and significantly decreased ejection fraction (P < .001). The mostly met criteria for screening abdominal aortic aneurysm in international guidelines was the age of the patients.Based on the results of this study, screening patients over 60 years of age who undergo a transthoracic echocardiography for any reason would be beneficial to detect an asymptomatic abdominal aortic aneurysm in Turkish population.     

Risk Factors for Carotid Artery Stenosis in Chinese Patients Undergoing Coronary Artery Bypass Graft Interventions

Current guidelines established in the USA and Europe for coronary artery bypass graft (CABG) suggest that patients ≥65 and ≥70 years of age, or with certain atherosclerotic-risk factors, should be screened preoperatively for extracranial carotid artery stenosis (CAS) to assess their risk of perioperative stoke. We sought factors that should be taken into consideration when treating Chinese CABG patients using CABG guidelines based on an analysis of CAS in a large cohort of Chinese CABG patients.We analyzed data for 1558 Chinese CABG patients who were screened preoperatively for CAS using duplex ultrasonography at a single institution. We defined significant and severe CAS as ≥50% and ≥70% stenosis, respectively, in one or more common or internal carotid arteries. We investigated the prevalence of CAS, the incidence of perioperative stroke, and the risk factors for CAS in the CABG cohort.The prevalence of CAS in the CABG cohort was 21.2%. Multivariate stepwise logistic regression analysis showed that an age ≥50 years and a history of smoking (odds ratios = 8.36 and 1.83, respectively) were independent risk factors for CAS (P < 0.05 for both). The incidence of perioperative stroke among CABG patients with significant or severe CAS was significantly higher (2.4% and 2.9%, respectively) than in CABG patients with <50% stenosis (0.5%; P = 0.004 and 0.029, respectively).Chinese CABG patients with a history of smoking or ≥50 years of age should undergo preoperative screening for CAS to assess their risk of perioperative stroke.     

Validation of Scoring Systems That Predict Outcomes in Patients With Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting Surgery

Several risk stratification scores, based on angiographic or clinical parameters, have been developed to evaluate outcomes in patients with left main coronary artery disease (LMCAD) who undergo coronary artery bypass grafting (CABG). This study aims to validate the predictive ability of different risk scoring systems with regard to long-term outcomes after CABG.This single-center study retrospectively re-evaluated the Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score; EuroSCORE; age, creatinine, and ejection fraction (ACEF) score; modified ACEF score; clinical SYNTAX; logistic clinical SYNTAX score (logistic CSS); and Parsonnet scores for 305 patients with LMCAD who underwent CABG. The endpoints were 5-year rate of all-cause death and major adverse cardio-cerebral events (MACCEs), including cardiovascular (CV) death, myocardial infarction (MI), and stroke and target vessel revascularization (TVR).Compared with the SYNTAX score, other scores were significantly higher in discriminative ability for all-cause death (SYNTAX vs others: P < 0.01). The EuroSCORE ≥6 showed significant outcome difference on all-cause death, CV death, MI, and MACCE (P < .01). Multivariate analysis indicated the SYNTAX score was a non-significant predictor for different outcomes. Adjusted multivariate analysis revealed that the EuroSCORE was the strongest predictor of all-cause death (hazard ratio[HR]: 1.17; P < 0.001), CV death (HR: 1.16; P < 0.001), and MACCE (HR: 1.09; P = 0.01). The ACEF score and logistic CSS were predictive factors for TVR (HR: 0.25, P = 0.03; HR: 0.85, P = 0.01).The EuroSCORE scoring system most accurately predicts all-cause death, CV death, and MACCE over 5 years, whereas low ACEF score and logistic CSS are independently associated with TVR over the 5-year period following CABG in patients with LMCAD undergoing CABG.     

Coronary Artery Calcification,ADMA, and Insulin Resistance in CKD Patients

Background and objectives: It is known that coronary artery calcification (CAC) develops in chronic kidney disease (CKD) before initiation of renal replacement therapy, and factors associated with CKD mineral and bone disorders (CKD-MBDs) are involved. However, little information is available about any association between plasma levels of asymmetric dimethylarginine (ADMA), insulin resistance, and CAC.Design, setting, participants, & measurements: A total of 111 CKD patients (79 men, 32 women; glomerular filtration rate [GFR] median, 33.7 ml/min per 1.73 m²), free of cardiovascular disease, were consecutively recruited along with 30 age-matched healthy subjects. Coronary artery calcification scores (CACS) were measured by multidetector-row CT according to Agatston score.Results: In CKD patients, CACS was distributed widely from 0 to 2901, while in age-matched, healthy control subjects (n = 30), CACS showed a range from 0 to 307. GFR had a significant negative correlation with CACS. Plasma ADMA levels were negatively correlated with GFR and positively correlated with CACS. When CACS was divided into quartiles (<50, n = 56; 50 to 300, n = 24; 300 to 600, n = 14; >600, n = 17), the patients with CACS >600 had significantly higher values of HOMA-IR, plasma ADMA levels, and fibrinogen along with serum levels of phosphorus, compared with those in patients having CACS <50. Multivariate regression analysis determined HOMA-IR as an independent contributing factor to CACS.Conclusions: CAC becomes more prevalent and severe with a decline in GFR, and plasma ADMA levels and insulin resistance, independent of factors associated with CKD-MBD, are correlated with CAC.Coronary artery calcification (CAC) is regarded as an index of the severity of atherosclerotic vascular disease and may predict future adverse cardiovascular events in patients on dialysis (1–3). In patients with chronic kidney disease (CKD) before initiation of renal replacement therapy, CAC is already present in the early phase of CKD (4–6) and among diabetic nephropathy (7). Associated factors with CAC besides age, calcium, phosphorus, iPTH, and inflammation have not been fully elucidated.Insulin resistance is known to play an important role for atherosclerosis (8) and to develop at an early stage of nondiabetic CKD in U.S. general populations (9). We report a similar result using a hyperinsulinemic euglycemic glucose clamp method and also showed that acidemia and dyslipidemia are independently associated with insulin resistance in CKD (10). In progressive renal disease, the relationship between hyperinsulinemia and hypertension is well documented (11). Arad et al. have reported that asymptomatic individuals with insulin resistance have elevated coronary calcification in general populations (12). However, it remains unknown whether insulin resistance is also correlated with CAC in CKD patients. Insulin resistance leading to atherosclerosis may be explained by increased plasma levels of asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor (13). Concentrations of ADMA are related to endothelial dysfunction (14,15) because increased ADMA may impair blood flow, accelerate atherogenesis, and interfere with angiogenesis by inhibiting the production of nitric oxide (16). Of note, ADMA concentrations are higher in dialysis patients with clinically manifest atherosclerosis than in those without atherosclerotic disease (17), which suggests that accumulation of ADMA might be an important cardiovascular risk factor in end-stage renal disease. Moreover, the clinical importance of ADMA in coronary artery disease is highlighted in a recent trial by Meinitzer et al. (18) in which ADMA predicted cardiovascular events in 3200 patients. In addition, ADMA predicts coronary events in middle-aged white men (19).With this background in mind, we aimed to study the prevalence and associated factors of CAC in CKD patients before initiation of renal replacement therapy. Particularly, we wanted to know whether insulin resistance and/or plasma levels of ADMA would be correlated with CAC.     

A Preoperative Assessment of Significant Coronary Stenosis Based on a Semiquantitative Analysis of Coronary Artery Calcification on Noncontrast Computed Tomography in Aortic Stenosis Patients Undergoing Aortic Valve Replacement

Invasive coronary angiography (ICA) is the recommended assessment for coronary artery disease in patients undergoing elective aortic valve replacement (AVR). Noncontrast computed tomography (CT) is useful for evaluating lung lesions and calcifications at the cannulation site of the ascending aorta. The purpose of this study was to evaluate the role of noncontrast CT in the visual assessment of coronary artery calcification (CAC) in patients undergoing AVR.We retrospectively identified patients with significant aortic stenosis (AS) who were referred for AVR between January 2006 and December 2013. Among these, we included 386 patients (53.6% males, 69.2 ± 8.4 years) who underwent both noncontrast CT and ICA. Significant coronary artery stenosis (CAS) in the ICA was defined as luminal stenosis ≥70%. The 4 main coronary arteries were visually assessed on noncontrast CT and were scored based on the Weston score as follows: 0, no visually detected calcium; 1, a single high-density pixel detected; 3, calcium was dense enough to create a blooming artifact; and 2, calcium in between 1 and 3. Four groups were reclassified by the sum of the Weston scores from each vessel, as follows: noncalcification (0); mild calcification (1–4); moderate calcification (5–8); and severe calcification (9–12). Receiver-operating characteristic (ROC) analysis was generated to identify the cutoff Weston score values for predicting significant CAS. Diagnostic estimates were calculated based on these cutoffs.In the ICA analysis, 62 of the 386 patients (16.1%) had significant CAS. All patients were divided into 4 groups. The noncalcification group had 97 subjects (Weston score 0), the mild degree group had 100 (2.6 ± 1.0), the moderate calcification group had 114 (6.6 ± 1.1), and the severe calcification group had 75 (10.7 ± 1.1). The prevalence of significant CAS in the noncalcification, mild, moderate, and severe groups was 1% (1/97), 5% (5/100), 24% (27/114), and 39% (29/75), respectively. The group with CAS had significantly more CAC than the group without CAS (8.37 ± 2.93 vs 4.01 ± 3.75, P < 0.001). The cutoff value (by Weston score) for predicting significant CAS is ≥5 (sensitivity 90.3%, specificity 59.0%, positive predictive value 29.6%, and negative predictive value 97%).The degree of CAC detected on noncontrast CT can help to predict significant CAS in AS patients who are referred for AVR. For the clinicians, the visual assessment of CAC on noncontrast CT was easy and useful for estimating CAS. Therefore, ICA should be recommended to selective patients based on patients’ CAC and Weston scores during the preoperative evaluation for elective AVR.     

Time to sputum culture conversion and its predictors among patients with multidrug-resistant tuberculosis in Hangzhou,China: A retrospective cohort study

The objective is to investigate the time to initial sputum culture conversion (SCC) and its predictors among multidrug-resistant tuberculosis (MDR-TB) patients in Hangzhou, China.A retrospective cohort study was conducted among patients who initiated MDR-TB treatment from 2011 to 2015 in Hangzhou, China. Successful achievement of initial SCC was defined as 2 consecutive negative cultures taken at least 30 days apart after initiation of treatment of MDR-TB. Successful treatment outcomes included being cured and completing treatment, while poor treatment outcomes included treatment failure, loss to follow-up, and death. Time to initial SCC was analyzed using the Kaplan–Meier method, and Cox proportional hazards regression was used to identify predictors of SCC.Among 384 patients enrolled with MDR-TB, 359 (93.5%) successfully achieved initial SCC after a median of 85 days (interquartile range, 40–112 days). A higher rate of SCC was observed in participants with successful treatment outcomes than those with poor treatment outcomes (P<.01). Multivariate analysis showed that age 25 to 64 years (compared with age<25; adjusted odds ratio [AOR], 0.7; 95% confidence interval [CI], 0.5–0.9; P < .01), age ≥65 years (compared with age < 25; AOR, 0.5; 95% CI, 0.3–0.8; P < .01), and household registration in Hangzhou (compared with non-Hangzhou registration; AOR, 1.3; 95% CI, 1.0–1.5; P < .05) were found to be associated with SCC.Although high SCC and treatment success rates were observed among MDR-TB patients in Hangzhou, the prolonged duration to initial SCC underscores the importance of emphasizing measures for infection control. A new policy of shifting outpatient treatment to inpatient treatment in China may reduce the risk of transmission from patients in the time window prior to SCC.     

Association between plasma endothelial microparticles and contrast-induced nephropathy in patients underwent coronary angiography

We aim to investigate the association between plasma endothelial microparticles (EMPs) and contrast-induced nephropathy of patients underwent coronary angiography.The patients were divided into normal renal function group and renal dysfunction group based on the estimated glomerular filtration rate (eGFR). Among the 180 cases, 117 received determination of EMP and serum creatinine after percutaneous coronary intervention (PCI) and/or coronary angiography. The patients were divided into contrast-induced-nephropathy (CIN) group and non-CIN group. EMPs collection and determination were performed, together with biochemical analysis and digital subtraction angiography (DSA) analysis.Spearman correlation showed that the expression of EMP was negatively correlated with eGFR (r = –0.201, P < .01). The serum hypersensitive C-reactive protein (hs-CRP), cystatin C (Cys-C), uric acid (UA) were significantly higher in CIN group than that in the non CIN group. Spearman correlation showed that the expression of EMP was positively correlated with serum interleukin-6 (IL-6, r = 0.393, P < .01). The expression of EMP was positively correlated with serum hs-CRP (r = 0.360, P < .01). Logistic regression analysis showed that the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), eGFR, UA, and Cys-C were correlated with the incidence of contrast induced nephropathy.In patients with contrast-induced-nephropathy, the plasma EMPs were significantly increased after coronary angiography. The expression of plasma EMPs may play a role in the occurrence of contrast-induced-nephropathy.     

Cardiovascular Risk Factors Increase the Risks of Diabetic Peripheral Neuropathy in Patients With Type 2 Diabetes Mellitus: The Taiwan Diabetes Study

This study aimed to examine whether poor glycemic control, measured by glycated hemoglobin A1C (HbA1c) and other cardiovascular risk factors, can predict diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (DM).Patients aged ≥30 years with type 2 DM, enrolled in the National Diabetes Care Management Program, and free of DPN (n = 37,375) in the period 2002 to 2004 were included and followed up until 2011. The related factors were analyzed using Cox proportional hazards regression models.For an average follow-up of 7.00 years, 8379 cases of DPN were identified, with a crude incidence rate of 32.04/1000 person-years. After multivariate adjustment, patients with HbA1c levels 7 to 8%, 8 to 9%, 9 to 10%, and ≥10% exhibited higher risk of DPN (adjusted HR: 1.11 [1.04–1.20], 1.30 [1.21–1.40], 1.32 [1.22–1.43], and 1.62 [1.51–1.74], respectively) compared with patients with HbA1c level 6 to 7%. There was a significant linear trend in DPN incidence with increasing HbA1c (P < 0.001) and significant HRs of DPN for patients with HbA1c level ≥7%, blood pressure ≥130/85 mm Hg, triglycerides (TG) ≥150 mg/dL, high density of lipoprotein-cholesterol (HDL-C) <40 mg/dL in males and <50 mg/dL in females, low density of lipoprotein-cholesterol (LDL-C) ≥100 mg/dL, and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m².Patients with type 2 DM and HbA1c ≥7.0% exhibit increased risk of DPN, demonstrating a linear relationship. The incidence of DPN is also associated with poor glucose control and cardiovascular risk factors like hypertension, hyper-triglyceridemia, low HDL-C, high LDL-C, and decreased eGFR.