Publications by authors named "Ron Blankstein"

428 Publications

Coronary artery disease in East and South Asians: differences observed on cardiac CT.

Heart 2021 May 13. Epub 2021 May 13.

MonashHEART, Monash Health and Monash University, Clayton, Victoria, Australia

Epidemiological studies have observed East Asians (EAs) are significantly less likely to develop or die from coronary artery disease (CAD) compared with Caucasians. Conversely South Asians (SAs) develop CAD at higher rate and earlier age. Recently, a range of features derived from cardiac CT have been identified which may further characterise ethnic differences in CAD. Emerging data suggest EAs exhibit less coronary calcification and high-risk, non-calcified plaque compared with Caucasians on CT, with no difference in luminal stenosis. In contrast, SAs exhibit similar to higher coronary calcification and luminal stenosis, smaller luminal dimensions and more high-risk, non-calcified plaque than Caucasians. Beyond demonstrating ethnic differences in CAD, cardiac CT may enhance and individualise cardiovascular risk stratification in EAs and SAs. While data thus far in EAs have demonstrated calcium score and CT-derived luminal stenosis may incrementally predict cardiovascular risk beyond traditional risk scores, there remains a paucity of data assessing its use in SAs. Future studies may clarify the prognostic value of cardiac CT in SAs and investigate how this modality may guide preventative therapy and coronary intervention of CAD in EAs and SAs.
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http://dx.doi.org/10.1136/heartjnl-2020-318929DOI Listing
May 2021

Becoming an Expert Practitioner: The Lifelong Journey of Education in Cardiovascular Imaging.

JACC Cardiovasc Imaging 2021 Apr 7. Epub 2021 Apr 7.

Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology Brigham and Women's Hospital, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.jcmg.2021.03.006DOI Listing
April 2021

Role of Cardiac CT in Pre-Procedure Planning for Transcatheter Mitral Valve Replacement.

JACC Cardiovasc Imaging 2021 Apr 7. Epub 2021 Apr 7.

Cardiovascular Imaging Program (Departments of Medicine and Radiology), Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA. Electronic address:

Objectives: This study sought to evaluate cardiac computed tomography (CCT) findings and their clinical impact among patients being considered for transcatheter mitral valve replacement (TMVR).

Background: CCT is used to evaluate whether patients are candidates for TMVR, but limited data exist on the yield of such tests.

Methods: Patients referred for pre-procedural CCT for TMVR planning in the context of failing mitral bioprosthetic valves, annuloplasty rings, and severe native valve disease with annular calcification were included in this study. CCT findings were analyzed to evaluate for suitability for TMVR. In the subset of patients who underwent TMVR, echocardiographic and procedural characteristics were recorded.

Results: Among 80 patients who underwent pre-procedural CCT, the mean age was 71.8 ± 11.4 years, 60% were women, and the mean Society of Thoracic Surgeon score was 9.4 ± 6.7. Most cases were referred for valve-in-native annular calcification planning (n = 43), followed by valve-in-valve (n = 29), and valve-in-ring procedures (n = 8). A total of 51 (64%) patients did not undergo TMVR, 37 of whom had high-risk features identified on CCT. The most common reason for exclusion was related to large annular size, followed by heightened risk of left ventricular outflow tract (LVOT) obstruction. Among 29 patients (36%) who underwent TMVR, the 30-day mortality rate was 17%. Five patients experienced LVOT obstruction, 4 of whom were predicted by CCT. Following TMVR, 5 patients had at least moderate peri-valvular regurgitation.

Conclusions: A minority of patients referred for TMVR planning ultimately undergo the procedure. CCT identifies unsuitable anatomy and leads to exclusion in a significant number of cases.
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http://dx.doi.org/10.1016/j.jcmg.2020.12.018DOI Listing
April 2021

The evolving role of coronary CT angiography in Acute Coronary Syndromes.

J Cardiovasc Comput Tomogr 2021 Feb 23. Epub 2021 Feb 23.

Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA. Electronic address:

In the United States, non-obstructive coronary disease has been on the rise, and each year, nearly one million adults suffer myocardial infarction, 70% of which are non-ST-segment elevation myocardial infarction (NSTEMI). In addition, approximately 15% of patients suffering NSTEMI will have subsequent readmission for a recurrent acute coronary syndrome (ACS). While invasive angiography remains the standard of care in the diagnostic and therapeutic approach to these patients, these methods have limitations that include procedural complications, uncertain specificity in diagnosis of the culprit lesion in patients with multi-vessel coronary artery disease (CAD), and challenges in following coronary disease over time. The role of coronary computed tomography angiography (CCTA) for evaluating patients with both stable and acute chest pain has seen a paramount upshift in the last decade. This paper reviews the established role of CCTA for the rapid exclusion of obstructive plaque in troponin negative acute chest pain, while exploring opportunities to address challenges in the current approach to evaluating NSTEMI.
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http://dx.doi.org/10.1016/j.jcct.2021.02.002DOI Listing
February 2021

Association of inflammatory disease and long-term outcomes among young adults with myocardial infarction: the Mass General Brigham YOUNG-MI Registry.

Eur J Prev Cardiol 2021 Mar 30. Epub 2021 Mar 30.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.

Aims: Autoimmune systemic inflammatory diseases (SIDs) are associated with an increased risk of cardiovascular (CV) disease, particularly myocardial infarction (MI). However, there are limited data on the prevalence and effects of SID among adults who experience an MI at a young age. We sought to determine the prevalence and prognostic implications of SID among adults who experienced an MI at a young age.

Methods And Results: The YOUNG-MI registry is a retrospective cohort study from two large academic centres, which includes patients who experienced a first MI at 50 years of age or younger. SID was ascertained through physician review of the electronic medical record (EMR). Incidence of death was ascertained through the EMR and national databases. The cohort consisted of 2097 individuals, with 53 (2.5%) possessing a diagnosis of SID. Patients with SID were more likely to be female (36% vs. 19%, P = 0.004) and have hypertension (62% vs. 46%, P = 0.025). Over a median follow-up of 11.2 years, patients with SID experienced an higher risk of all-cause mortality compared with either the full cohort of non-SID patients [hazard ratio (HR) = 1.95, 95% confidence interval (CI) (1.07-3.57), P = 0.030], or a matched cohort based on age, gender, and CV risk factors [HR = 2.68, 95% CI (1.18-6.07), P = 0.018].

Conclusions: Among patients who experienced a first MI at a young age, 2.5% had evidence of SID, and these individuals had higher rates of long-term all-cause mortality. Our findings suggest that the presence of SID is associated with worse long-term survival after premature MI.
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http://dx.doi.org/10.1093/eurjpc/zwaa154DOI Listing
March 2021

Coronary Iodine Concentration by Using Spectral CT and Success of Flow Restoration in Chronic Total Occlusion.

Radiol Cardiothorac Imaging 2020 Aug 20;2(4):e200296. Epub 2020 Aug 20.

Heart Institute at the Edith Wolfson Medical Center, Holon, Israel (R.R.); Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (R.R.); and Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (R.B.).

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http://dx.doi.org/10.1148/ryct.2020200296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977973PMC
August 2020

The Intersection of Cardiovascular Imaging and Prevention.

Radiol Cardiothorac Imaging 2021 Feb 25;3(1):e210045. Epub 2021 Feb 25.

Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (R.B.); and Cardiothoracic Imaging Division, Department of Radiology, University of Texas Southwestern, Dallas, Tex (S.A.).

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http://dx.doi.org/10.1148/ryct.2021210045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977710PMC
February 2021

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

Radiol Cardiothorac Imaging 2021 Feb 15;3(1):e200480. Epub 2020 Oct 15.

Division of Cardiology & Department of Radiology, The George Washington University School of Medicine, 2150 Pennsylvania Ave NW, Suite 4-417, Washington, DC 20037 (A.D.C.); Heart Institute, Parkview Health, Fort Wayne, Ind (D.M.T.); Department of Medicine, Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Mich (J.L., D.D.W.); Division of Cardiothoracic Imaging, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (S.A.); Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, FL, United States and Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL (R.C.C.); Department of Radiology, St. Paul's Hospital, Vancouver, Canada (J.A.L.); Department of Radiology, Naval Medical Center, Portsmouth, Va (C.M.); Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (P.N.); Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States (M.L.S.); University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom (M.C.W.); Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV (I.Z.); and Division of Cardiology, University of Virginia Health System, Charlottesville, Va (T.C.V.); Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA, United States (R.B.).

Cardiovascular computed tomography (CCT) is a well-validated noninvasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT. This article is being published synchronously in , , and © 2020 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
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http://dx.doi.org/10.1148/ryct.2020200480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978013PMC
February 2021

Role of Coronary CT Angiography in Spontaneous Coronary Artery Dissection.

Radiol Cardiothorac Imaging 2020 Dec 19;2(6):e200364. Epub 2020 Nov 19.

Department of Radiology, Cardiovascular Division (S.G., N.M.S., B.B.G., S.S.H.), and Department of Medicine, Cardiology Division (M.J.W.), Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114; Department of Radiology (M.L.S.) and Department of Medicine, Cardiovascular Division (R.B.), Brigham and Women's Hospital, Boston, Mass.

Spontaneous coronary artery dissection (SCAD) is more common than previously thought and is present in up to 4% of patients presenting with acute coronary syndrome. SCAD predominantly occurs in relatively young women and is an important cause of myocardial infarction in young patients without traditional risk factors of atherosclerotic coronary artery disease. There have been substantial improvements in spatial and temporal resolution and reduction in ionizing radiation dose with new generation scanners. The risk of dissection propagation with an invasive coronary angiogram, improved CT scanner parameters, and predominantly conservative management of SCAD make coronary CT angiography a useful noninvasive imaging modality for the assessment of SCAD. © RSNA, 2020.
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http://dx.doi.org/10.1148/ryct.2020200364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978024PMC
December 2020

Impaired Coronary Vasodilator Reserve and Adverse Prognosis in Patients With Systemic Inflammatory Disorders.

JACC Cardiovasc Imaging 2021 Mar 10. Epub 2021 Mar 10.

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objectives: The purpose of this study was to evaluate the prognostic value of quantitative myocardial blood flow (MBF) and myocardial flow reserve (MFR), reflecting the integrated effects of diffuse atherosclerosis and microvascular dysfunction in patients with systemic inflammatory disorders.

Background: Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriasis (PsO) are common inflammatory conditions with excess cardiovascular (CV) risk compared to the general population. Systemic inflammation perturbs endothelial function and has been linked to coronary vasomotor dysfunction. However, the prognostic significance of this vascular dysfunction is not known.

Methods: This was a retrospective study of patients with RA, SLE, and PsO undergoing clinically indicated rest and stress myocardial perfusion positron emission tomography (PET). Patients with an abnormal myocardial perfusion study or left ventricular dysfunction were excluded. MFR was calculated as the ratio of myocardial blood flow (MBF, ml/min/g) at peak stress compared to that at rest.

Results: Among the 198 patients (median age: 65 years; 80% female), 20.7% had SLE, 31.8% had PsO, and 47.5% had RA. There were no differences in mean MFR between these conditions. Over a median follow-up of 7.8 years, there were 51 deaths and 63 major adverse cardiovascular events (MACE). Patients in the lowest tertile (MFR <1.65) had higher all-cause mortality than the highest tertile, which remained significant after adjusting for age, sex, and the pre-test clinical risk score (hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.05 to 5.4; p = 0.038). Similarly, compared to the highest MFR tertile, those in the lowest tertile had a lower MACE-free survival after adjusting for age, sex, and the pre-test clinical risk score (HR: 3.6; 95% CI: 1.7 to 7.6; p = 0.001).

Conclusions: In patients with systemic inflammatory disorders, impaired coronary vasodilator reserve was associated with worse cardiovascular outcomes and all-cause mortality.
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http://dx.doi.org/10.1016/j.jcmg.2020.12.031DOI Listing
March 2021

Very High Coronary Artery Calcium (≥1000) and Association With Cardiovascular Disease Events, Non-Cardiovascular Disease Outcomes, and Mortality: Results From MESA.

Circulation 2021 Apr 2;143(16):1571-1583. Epub 2021 Mar 2.

Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (A.W.P., Z.A.D., R.S.B., O.D., O.H.O., S.M.I.U., M.B.M., M.J.Blaha).

Background: There are limited data on the unique cardiovascular disease (CVD), non-CVD, and mortality risks of primary prevention individuals with very high coronary artery calcium (CAC; ≥1000), especially compared with rates observed in secondary prevention populations.

Methods: Our study population consisted of 6814 ethnically diverse individuals 45 to 84 years of age who were free of known CVD from MESA (Multi-Ethnic Study of Atherosclerosis), a prospective, observational, community-based cohort. Mean follow-up time was 13.6±4.4 years. Hazard ratios of CAC ≥1000 were compared with both CAC 0 and CAC 400 to 999 for CVD, non-CVD, and mortality outcomes with the use of Cox proportional hazards regression adjusted for age, sex, and traditional risk factors. Using a sex-adjusted logarithmic model, we calculated event rates in MESA as a function of CAC and compared them with those observed in the placebo group of stable secondary prevention patients in the FOURIER clinical trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk).

Results: Compared with CAC 400 to 999, those with CAC ≥1000 (n=257) had a greater mean number of coronary vessels with CAC (3.4±0.5), greater total area of CAC (586.5±275.2 mm), similar CAC density, and more extensive extracoronary calcification. After full adjustment, CAC ≥1000 demonstrated a 4.71- (3.63-6.11), 7.57- (5.50-10.42), 4.86-(3.32-7.11), and 1.94-fold (1.57-2.41) increased risk for all CVD events, all coronary heart disease events, hard coronary heart disease events, and all-cause mortality, respectively, compared with CAC 0 and a 1.65- (1.25-2.16), 1.66- (1.22-2.25), 1.51- (1.03-2.23), and 1.34-fold (1.05-1.71) increased risk compared with CAC 400 to 999. With increasing CAC, hazard ratios increased for all event types, with no apparent upper CAC threshold. CAC ≥1000 was associated with a 1.95- (1.57-2.41) and 1.43-fold (1.12-1.83) increased risk for a first non-CVD event compared with CAC 0 and CAC 400 to 999, respectively. CAC 1000 corresponded to an annualized 3-point major adverse cardiovascular event rate of 3.4 per 100 person-years, similar to that of the total FOURIER population (3.3) and higher than those of the lower-risk FOURIER subgroups.

Conclusions: Individuals with very high CAC (≥1000) are a unique population at substantially higher risk for CVD events, non-CVD outcomes, and mortality than those with lower CAC, with 3-point major adverse cardiovascular event rates similar to those of a stable treated secondary prevention population. Future guidelines should consider a less distinct stratification algorithm between primary and secondary prevention patients in guiding aggressive preventive pharmacotherapy.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.050545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058297PMC
April 2021

Arrhythmias in Cardiac Sarcoidosis Bench to Bedside: A Case-Based Review.

Circ Arrhythm Electrophysiol 2021 Feb 16;14(2):e009203. Epub 2021 Feb 16.

University of Washington School of Medicine, Seattle (L.L.V., K.K.P., R.K.C.).

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.
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http://dx.doi.org/10.1161/CIRCEP.120.009203DOI Listing
February 2021

Letter by DeFilippis et al Regarding Article, "Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young".

Circ Heart Fail 2021 Feb 25;14(2):e008033. Epub 2021 Jan 25.

Division of Cardiovascular Medicine, Department of Medicine (E.M.D., M.M.G., R.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.008033DOI Listing
February 2021

The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction.

J Clin Lipidol 2021 Jan-Feb;15(1):33-60. Epub 2020 Dec 11.

Department of Medicine, Emory University.

An Expert Panel of the National Lipid Association reviewed the evidence related to the use of coronary artery calcium (CAC) scoring in clinical practice for adults seen for primary prevention of atherosclerotic cardiovascular disease. Recommendations for optimal use of this test in adults of various races/ethnicities, ages and multiple domains of primary prevention, including those with a 10-year ASCVD risk <20%, those with diabetes or the metabolic syndrome, and those with severe hypercholesterolemia were provided. Recommendations were also made on optimal timing for repeat calcium scoring after an initial test, use of CAC scoring in those taking statins, and its role in informing the clinician patient discussion on the benefit of aspirin and anti-hypertensive drug therapy. Finally, a vision is provided for the future of coronary calcium scoring.
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http://dx.doi.org/10.1016/j.jacl.2020.12.005DOI Listing
December 2020

Society of Cardiovascular Computed Tomography / North American Society of Cardiovascular Imaging - Expert Consensus Document on Coronary CT Imaging of Atherosclerotic Plaque.

J Cardiovasc Comput Tomogr 2021 Mar-Apr;15(2):93-109. Epub 2020 Nov 9.

Mount Sinai School of Medicine, New York, NY, USA.

Coronary computed tomographic angiography (CCTA) provides a wealth of clinically meaningful information beyond anatomic stenosis alone, including the presence or absence of nonobstructive atherosclerosis and high-risk plaque features as precursors for incident coronary events. There is, however, no uniform agreement on how to identify and quantify these features or their use in evidence-based clinical decision-making. This statement from the Society of Cardiovascular Computed Tomography and North American Society of Cardiovascular Imaging addresses this gap and provides a comprehensive review of the available evidence on imaging of coronary atherosclerosis. In this statement, we provide standardized definitions for high-risk plaque (HRP) features and distill the evidence on the effectiveness of risk stratification into usable practice points. This statement outlines how this information should be communicated to referring physicians and patients by identifying critical elements to include in a structured CCTA report - the presence and severity of atherosclerotic plaque (descriptive statements, CAD-RADS™ categories), the segment involvement score, HRP features (e.g., low attenuation plaque, positive remodeling), and the coronary artery calcium score (when performed). Rigorous documentation of atherosclerosis on CCTA provides a vital opportunity to make recommendations for preventive care and to initiate and guide an effective care strategy for at-risk patients.
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http://dx.doi.org/10.1016/j.jcct.2020.11.002DOI Listing
November 2020

Life's Simple 7 and Nonalcoholic Fatty Liver Disease: The Multiethnic Study of Atherosclerosis.

Am J Med 2021 04 5;134(4):519-525. Epub 2020 Dec 5.

Preventive Cardiology, Houston Methodist DeBakey Cardiology Associates, Houston Tex.

Background: The American Heart Association (AHA) has defined Life's Simple 7 (LS7) as a measure of overall cardiovascular health . Nonalcoholic fatty liver disease (NAFLD) has been involved as a risk factor for cardiovascular disease. We evaluated the association between LS7 and NAFLD.

Methods: We evaluated participants form the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. Cardiovascular health score was calculated from the Life's Simple 7 metrics. A score of 0-8 was considered inadequate, 9-10 average, and 11-14 optimal. NAFLD was defined using noncontrast cardiac computed tomography (CT) and a liver/spleen attenuation ratio (L/S) < 1. Multivariable regression were performed to evaluate the association.

Results: Our cross-sectional analysis of 3901 participants showed 19% (n = 747) had optimal cardiovascular health, 33% (n = 1270) had average, and 48% (n = 1884) had inadequate. White participants were most likely to have an optimal score (51%, n = 378), whereas African American participants had the lowest proportion with optimal scores (16%, n = 120; P < 0.001). The overall prevalence of NAFLD was 18% with a distribution of 7%, 14%, and 25% in the optimal, average, and inadequate score categories, respectively (P < 0.001). Adjusted for risk factors, average and optimal health categories had lower odds of NAFLD compared to those with inadequate scores: odds ratio for average, 0.44 (95% confidence interval 0.36-0.54); optimal, odds ratio 0.19 (95% confidence interval 0.14-0.26). This association was similar across gender, race and age groups.

Conclusion: A more favorable cardiovascular health score was associated with a lower prevalence of NAFLD. This study may suggest a potential of Life's Simple 7 in the prevention of liver disease.
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http://dx.doi.org/10.1016/j.amjmed.2020.09.023DOI Listing
April 2021

Declining interest in clinical imaging during the COVID-19 pandemic: An analysis of Google Trends data.

Clin Imaging 2021 May 25;73:20-22. Epub 2020 Nov 25.

Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Radiology and Neuroradiology, Charité, Berlin, Germany; Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address:

Objective: Current evidence suggests a decrease in elective diagnostic imaging procedures during the COVID-19 pandemic with potentially severe long-term consequences. The aim of this study was to quantify recent trends in public interest and related online search behavior for a range of imaging modalities, and "nowcast" future scenarios with respect to imaging use.

Methods: We used Google Trends, a publicly available database to access search query data in systematic and quantitative fashion, to search for key terms related to clinical imaging. We queried the search volume for multiple imaging modalities, identified the most common terms, extracted data for the United States over the time range from August 1, 2016 to August 1, 2020. Results were given in relative terms, using the Google metric 'search volume index'.

Results: We report a decrease in public interest across all imaging modalities since March 2020 with a subsequent slow increase starting in May 2020. Mean relative search volume (RSV) has changed by -19.4%, -38.3%, and -51.0% for the search terms "Computed tomography", "Magnetic resonance imaging", and "Mammography", respectively, and comparing the two months prior to and following March 1, 2020. RSV has since steadily recuperated reaching all-year highs.

Conclusion: Decrease in public interest coupled with delays and deferrals of diagnostic imaging will likely result in a high demand for healthcare in the coming months. To respond to this challenge, measures such as risk-stratification algorithms must be developed to allocate resources and avoid the risk of overstraining the healthcare system.
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http://dx.doi.org/10.1016/j.clinimag.2020.11.037DOI Listing
May 2021

Use of cardiac CT amidst the COVID-19 pandemic and beyond: North American perspective.

J Cardiovasc Comput Tomogr 2021 Jan-Feb;15(1):16-26. Epub 2020 Nov 13.

Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Harvard Medical School, Boston, MA, USA. Electronic address:

The COVID-19 pandemic has affected patient care deliver throughout the world, resulting in a greater emphasis on efficiently and safety. In this article, we discuss the experiences of several North American centers in utilizing cardiac CT during the pandemic. We also provide a case-based overview which highlights the advantages of cardiac CT in evaluating the following scenarios: (1) patients with possible myocardial injury versus myocardial infarction; (2) patients with acute chest pain; (3) patients with stable chest pain; (4) patients with possible intracardiac thrombus; (5) patients with valvular heart disease. For each scenario, we also provide an overview of various societies recommendations which have highlighted the use of cardiac CT during different phases of the COVID-19 pandemic. We hope that the advantages of cardiac CT that have been realized during the pandemic can help promote wider adoption of this technique and improved coverage and payment by payors.
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http://dx.doi.org/10.1016/j.jcct.2020.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661966PMC
March 2021

Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle.

Am J Med 2021 03 20;134(3):310-316. Epub 2020 Nov 20.

Department of Medicine, Division of Cardiology, National Jewish Health, Denver, Colo.

Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.
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http://dx.doi.org/10.1016/j.amjmed.2020.09.033DOI Listing
March 2021

Coronary Artery Calcium to Improve the Efficiency of Randomized Controlled Trials in Primary Cardiovascular Prevention.

JACC Cardiovasc Imaging 2021 May 18;14(5):1005-1016. Epub 2020 Nov 18.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA; Center for Outcomes Research, Houston Methodist, Houston, Texas, USA; Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objectives: This study sought to assess the value, in terms of sample size and cost, of using the coronary artery calcium (CAC) score to enrich the study population of primary prevention randomized controlled trials (RCTs) with participants at high absolute risk of atherosclerotic cardiovascular disease (ASCVD) events.

Background: The feasibility of RCTs assessing the efficacy of novel add-on therapies for primary prevention among high-risk individuals treated with statins may be limited by sample size and cost.

Methods: We evaluated 3,075 statin-naive participants from the MESA (Multi-Ethnic Study of Atherosclerosis) with estimated 10-year ASCVD risk of ≥7.5%. CAC of >100, CAC of >400, high sensitivity C-reactive protein levels of >2 and >3 mg/l, ankle-brachial index of <0.9, and triglyceride levels of >175 mg/dl were each evaluated as enrichment criteria on top of estimated ASCVD risk of ≥7.5%, ≥10%, ≥15% and ≥20%. For each criterion, using the observed 5-year incidence of CVD, we projected the incidence of CVD assuming a 28% relative risk reduction with high-intensity statin therapy and after addition of novel therapy with additive relative risk reductions of 15% and 25%. Sample size and cost of a hypothetical primary prevention 5-year RCT of a novel therapy on top of statins versus statins alone were then computed by using the projected incidences. Yearly costs per included participant of $6,000 to $9,000 and of $500/$600 per screened nonparticipant were assumed.

Results: CAC of >400, present in 15% to 23% participants, consistently identified the subgroups with highest 5-year incident events and outperformed the other features yielding the smallest projected sample size, ranging 33% to 58% lower than using risk estimations alone for participant selection. CAC of >400 also yielded the lowest projected RCT costs, at least $40 million lower than using risk estimations alone. CAC of >100 showed the second-best performance in most scenarios.

Conclusions: High CAC scores used as study entry criteria can improve the efficiency and feasibility of primary prevention RCTs evaluating the incremental efficacy of novel add-on therapies.
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http://dx.doi.org/10.1016/j.jcmg.2020.10.016DOI Listing
May 2021

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

JACC Cardiovasc Imaging 2021 Jan 6;14(1):272-287. Epub 2020 Nov 6.

Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts.

Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.
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http://dx.doi.org/10.1016/j.jcmg.2020.09.004DOI Listing
January 2021

Warranty Period of a Calcium Score of Zero: Comprehensive Analysis From MESA.

JACC Cardiovasc Imaging 2021 May 28;14(5):990-1002. Epub 2020 Oct 28.

Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objectives: This study sought to quantify and model conversion of a normal coronary artery calcium (CAC) scan to an abnormal CAC scan.

Background: Although the absence of CAC is associated with excellent prognosis, progression to CAC >0 confers increased risk. The time interval for repeated scanning remains poorly defined.

Methods: This study included 3,116 participants from the MESA (Multi-Ethnic Study of Atherosclerosis) with baseline CAC = 0 and follow-up scans over 10 years after baseline. Prevalence of incident CAC, defined by thresholds of CAC >0, CAC >10, or CAC >100, was calculated and time to progression was derived from a Weibull parametric survival model. Warranty periods were modeled as a function of sex, race/ethnicity, cardiovascular risk, and desired yield of repeated CAC testing. Further analysis was performed of the proportion of coronary events occurring in participants with baseline CAC = 0 that preceded and followed repeated CAC testing at different time intervals.

Results: Mean participants' age was 58 ± 9 years, with 63% women, and mean 10-year cardiovascular risk of 14%. Prevalence of CAC >0, CAC >10, and CAC >100 was 53%, 36%, and 8%, respectively, at 10 years. Using a 25% testing yield (number needed to scan [NNS] = 4), the estimated warranty period of CAC >0 varied from 3 to 7 years depending on sex and race/ethnicity. Approximately 15% of participants progressed to CAC >10 in 5 to 8 years, whereas 10-year progression to CAC >100 was rare. Presence of diabetes was associated with significantly shorter warranty period, whereas family history and smoking had small effects. A total of 19% of all 10-year coronary events occurred in CAC = 0 prior to performance of a subsequent scan at 3 to 5 years, whereas detection of new CAC >0 preceded 55% of future events and identified individuals at 3-fold higher risk of coronary events.

Conclusions: In a large population of individuals with baseline CAC = 0, study data provide a robust estimation of the CAC = 0 warranty period, considering progression to CAC >0, CAC >10, and CAC >100 and its impact on missed versus detectable 10-year coronary heart disease events. Beyond age, sex, race/ethnicity, diabetes also has a significant impact on the warranty period. The study suggests that evidence-based guidance would be to consider rescanning in 3 to 7 years depending on individual demographics and risk profile.
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http://dx.doi.org/10.1016/j.jcmg.2020.06.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076346PMC
May 2021

What is Multimodality Cardiovascular Imaging and How Can It Be Delivered?

Heart 2020 Oct 27. Epub 2020 Oct 27.

Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States

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http://dx.doi.org/10.1136/heartjnl-2019-316214DOI Listing
October 2020

Women who experience a myocardial infarction at a young age have worse outcomes compared with men: the Mass General Brigham YOUNG-MI registry.

Eur Heart J 2020 11;41(42):4127-4137

Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.

Aims: There are sex differences in presentation, treatment, and outcomes of myocardial infarction (MI) but less is known about these differences in a younger patient population. The objective of this study was to investigate sex differences among individuals who experience their first MI at a young age.

Methods And Results: Consecutive patients presenting to two large academic medical centres with a Type 1 MI at ≤50 years of age between 2000 and 2016 were included. Cause of death was adjudicated using electronic health records and death certificates. In total, 2097 individuals (404 female, 19%) had an MI (mean age 44 ± 5.1 years, 73% white). Risk factor profiles were similar between men and women, although women were more likely to have diabetes (23.7% vs. 18.9%, P = 0.028). Women were less likely to undergo invasive coronary angiography (93.5% vs. 96.7%, P = 0.003) and coronary revascularization (82.1% vs. 92.6%, P < 0.001). Women were significantly more likely to have MI with non-obstructive coronary disease on angiography (10.2% vs. 4.2%, P < 0.001). They were less likely to be discharged with aspirin (92.2% vs. 95.0%, P = 0.027), beta-blockers (86.6% vs. 90.3%, P = 0.033), angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (53.4% vs. 63.7%, P < 0.001), and statins (82.4% vs. 88.4%, P < 0.001). There was no significant difference in in-hospital mortality; however, women who survived to hospital discharge experienced a higher all-cause mortality rate (adjusted HR = 1.63, P = 0.01; median follow-up 11.2 years) with no significant difference in cardiovascular mortality (adjusted HR = 1.14, P = 0.61).

Conclusions: Women who experienced their first MI under the age of 50 were less likely to undergo coronary revascularization or be treated with guideline-directed medical therapies. Women who survived hospitalization experienced similar cardiovascular mortality with significantly higher all-cause mortality than men. A better understanding of the mechanisms underlying these differences is warranted.
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http://dx.doi.org/10.1093/eurheartj/ehaa662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700756PMC
November 2020