Coronary artery calcium (CAC) scoring is an established marker of subclinical atherosclerosis that improves cardiovascular risk stratification beyond traditional risk factors. Since the 2007 ACCF (American College of Cardiology Foundation)/AHA (American Heart Association) Clinical Expert Consensus Statement, the role of CAC in prevention guidelines has progressively evolved. The strength of CAC recommendations has increased from a Class IIb recommendation for selected intermediate-risk adults in 2007 to a Class IIa recommendation for risk refinement in the 2018 ACC/AHA cholesterol guideline and to Class I recommendations for selected CAC-defined populations in the 2026 ACC (American College of Cardiology)/AHA multisociety dyslipidemia guideline. The 2018 guideline incorporated CAC primarily to guide statin allocation when treatment decisions were uncertain. The 2026 guideline further expands CAC-based recommendations by incorporating age- and sex-adjusted percentiles, CAC-guided treatment intensity, and low-density lipoprotein-cholesterol goals, including management of very high CAC phenotypes. In this brief report, the authors review the evolution of CAC across the 2007, 2018, and 2026 ACC/AHA guideline documents and discuss the expanding role of CAC in personalized cardiovascular prevention.
Background 124I-evuzamitide is a pan-amyloid positron emission tomography (PET) radiotracer. Objectives We conducted an open-label study to assess the performance and safety of 124I-evuzamitide PET/magnetic resonance imaging (MRI) in patients with known or suspected cardiac amyloidosis (CA). Methods Consecutive patients with suspected or known CA, were invited to participate in the trial and underwent imaging with 124I-evuzamitide (mean administered activity 1.05±0.02 mCi), using PET/MRI preferentially, and PET/computed tomography (CT) as an alternative. A positive scan was defined visually as tracer uptake in the left ventricular (LV) myocardium greater than blood pool activity by 3 expert readers. Equivocal scans were prespecified to be classified as negative (except for inter-reader agreement). Results A total of 126 patients (mean age 71.6 ± 10.6 years, 76.2% male) completed the 124I-evuzamitide PET/MRI (n=123) or PET/CT (n=3) scan, where 87 (69%) received a diagnosis of CA. All patients with CA had a visually positive scan and all patients without CA had a visually negative scan by all 3 readers (100% sensitivity and specificity). There was disagreement on 5 patients who were graded as equivocal or negative scans (Fleiss' Kappa 0.94, none received CA diagnosis). Quantitatively, mean LV/blood pool standardized uptake value ratio (SUVRmean) was 1.89 ±0.29 and 0.91 ±0.15, in patients with and without CA, respectively (p<0.001). 124I-evuzamitide was well-tolerated without significant tracer-related adverse events. Conclusion 124I-evuzamitide PET provides excellent diagnostic accuracy in patients known or suspected to have cardiac amyloidosis, and might provide a single upstream assessment for the presence or absence of cardiac amyloidosis.
BACKGROUND:In patients with peripheral artery disease and chronic limb-threatening ischemia (CLTI), there is a lack of effective treatment options when arterial revascularization is not feasible. In preclinical models, ultrasound (US) cavitation of microbubble contrast agents can augment limb perfusion through multiple shear-mediated vasoactive pathways. OBJECTIVES:This study aims to evaluate whether US cavitation increases limb tissue perfusion and accelerates healing of ischemic ulcers in patients with CLTI. METHODS:Patients (n = 24) with CLTI and chronic nonhealing ulcers were randomized to standard care or cavitation therapy, which was performed every 3 days × 6. Definity was infused, and US (1.3 MHz, mechanical index: 1.3) was performed for 15 minutes at the wound site and simultaneously over the ipsilateral femoral artery to leverage conducted vasodilation. The primary endpoints at day 18 were change in ulcer area and ulcer microvascular perfusion. RESULTS:Complete or partial ulcer healing occurred in almost all cavitation-treated patients, with a significant reduction in ulcer size only in the cavitation group and not the control group (median: -36.6% [Q1-Q3: -15.4% to -65.0%] vs +3.4% [Q1-Q3: -14.7% to +20.0%]; P = 0.039). In cavitation-treated patients, there was a 2.5-fold increase in ulcer margin perfusion, a 1.6-fold increase in functional microvascular density on super-resolution US microangiography, and a 1.8-fold increase in femoral artery flow (P < 0.05 for all parameters). These flow parameters did not increase in control patients. CONCLUSIONS:In patients with CLTI and nonhealing ulcers, periodic therapy with cavitation of microbubbles using US parameters approved for diagnostic imaging promotes healing of ischemic ulcers, likely through improvement in tissue perfusion and microvascular vascularity.
BACKGROUND:Optical coherence tomography (OCT) can differentiate plaque morphology (fibrous, lipidic, and calcified) within atherosclerotic lesions. The prognostic impact of predominant OCT plaque type after percutaneous coronary intervention (PCI) is unclear. OBJECTIVES:The aim of this study was to investigate clinical outcomes after PCI based on the preprocedural predominant plaque morphology from the OCT cohort of the ILUMIEN IV trial. METHODS:Subjects assigned to OCT guidance (n = 1,233) underwent core laboratory analysis to determine predominant lesion plaque morphology: lipidic (maximum arc ≥180° or thin-cap fibroatheroma), calcific (maximum arc ≥180°), or fibrotic. The primary endpoint was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization (ID-TVR). RESULTS:PCI of a single de novo lesion was performed in 926 patients. By OCT, the plaque was predominantly lipidic, calcific, and fibrotic in 309 (33%), 252 (27%), and 365 (39%) cases, respectively. After multivariable adjustment, patients undergoing PCI of a predominantly calcific lesion had increased rates of TVF (10.7% vs 4.0%; adjusted HR: 2.20 [95% CI: 1.12-4.33]; P = 0.02) driven by greater ID-TVR (8.2% vs 3.1%; adjusted HR: 2.31 [95% CI: 1.08-4.96]; P = 0.03) compared with PCI of a fibrotic lesion. Event rates in patients undergoing PCI of a predominantly lipidic lesion were intermediate (TVF 5.6% and ID-TVR 4.0%). CONCLUSIONS:Based on preprocedural OCT, PCI of calcific and fibrotic plaques was associated with the highest and lowest 2-year rates of TVF and ID-TVR, respectively, with lipidic plaques being of intermediate risk. This is the first report from a large-scale clinical trial that demonstrates the prognostic utility of baseline OCT plaque morphology on post-PCI outcomes. (ILUMIEN IV: OPTIMAL Percutaneous Coronary Intervention [PCI]; NCT03507777).
