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Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography., Competing Interests: Funding Support and Author Disclosures Dr Blaha has received grants from the National Institutes of Health, U.S. Food and Drug Administration, AHA, Amgen, Novo Nordisk, and Bayer; and is on the advisory boards for Amgen, Sanofi, Regeneron, Novartis, Novo Nordisk, Bayer, 89Bio, Kaleido, Roche, Inozyme, emocha, VoxelCloud, and Kowa. Dr Dzaye has received support from National Institutes of Health grant T32 HL007227. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The burden of obesity worldwide is high and projected to rise. Obesity increases the risk of several cardiovascular diseases and cardiometabolic risk factors; hence, utilizing effective long-term therapies for obesity is of utmost importance. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as effective therapies that achieve substantial weight loss and improve cardiometabolic risk. The purpose of this review is to discuss the role of GLP-1RAs in obesity management., Recent Findings: Two subcutaneous GLP-1RAs, liraglutide and semaglutide, have been evaluated in several clinical trials for weight loss. Liraglutide achieves a mean weight loss of 4-7 kg, and more than 50% of treated individuals achieve 5% or more weight loss. Semaglutide has a greater impact on weight loss, with a mean weight loss of 9-16 kg, and more than 50% of treated individuals achieve 10-15% or more weight loss. These results led to regulatory approval of these agents for weight loss in individuals with obesity, regardless of diabetes status. In addition to weight loss, the benefits of GLP-1RAs extend to other risk factors, such as glycemic control and blood pressure. Gastrointestinal symptoms are the most frequently encountered adverse events with incidences between 5 and 30%. Finally, the cost remains one of the most critical challenges that limit GLP-1RAs use. GLP-1RAs have robust weight loss benefits and are expected to have a critical role in the management of obesity in the coming years. Upcoming studies will evaluate the durability of weight loss achieved with GLP-1RAs and the impact on cardiovascular outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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., Competing Interests: Funding Support and Author Disclosures This research was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168 and N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences (NCATS). This publication was developed under the Science to Achieve Results (STAR) research assistance agreements, No. RD831697 (MESA Air) and RD-83830001 (MESA Air Next Stage), awarded by the U.S Environmental Protection Agency. It has not been formally reviewed by the EPA. The views expressed in this document are solely those of the authors and the EPA does not endorse any products or commercial services mentioned in this publication. All authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: There is limited knowledge about the association of lipoprotein particles and markers of coronary atherosclerosis such as coronary artery calcification (CAC) in relatively young high-risk persons. This study examines the association of lipoprotein subfractions and CAC in high cardiometabolic risk individuals., Methods: The study presents analysis from baseline data of a randomized trial targeted at high-risk workers. Employees of Baptist Health South Florida with metabolic syndrome or diabetes were recruited. At baseline, all 182 participants had lipoprotein subfraction analysis using the ion mobility technique and participants above 35 years (N=170) had CAC test done. Principal components (PC) were computed for the combination of lipoprotein subclasses. Multiple bootstrapped regression analyses (BSA) were conducted to assess the relationship between lipoprotein subfractions and CAC., Results: The study population (N=170) was largely female (84%) with a mean age of 58 years. Three PCs accounted for 88% variation in the sample. PC2, with main contributions from VLDL particles in the positive direction and large LDL particles in the negative direction was associated with a 22% increase in CAC odds (P value ＜0.05 in 100% of BSA). PC3, with main contributions from HDL lipoprotein particles in the positive direction and small/medium LDL and large IDL particles in the negative direction, was associated with a 9% reduction in CAC odds (P＜0.05 in 88% of BSA). PC1, which had approximately even contributions from HDL, LDL, IDL and VLDL lipoprotein subfractions in the positive direction, was not associated with CAC., Conclusion: In a relatively young but high-risk population, a lipoprotein profile predominated by triglyceride-rich lipoproteins was associated with increased risk of CAC, while one predominated by HDL lipoproteins offered modest protection. Lipoprotein sub-fraction analysis may help to further discriminate patients who require more intensive cardiovascular work-up and treatment.

Aims: The European Society of Cardiology (ESC) guideline on cardiovascular risk assessment considers coronary artery calcium a class B indication for risk assessment. We evaluated the degree to which coronary artery calcium can change the recommendation for individuals based on a change in estimated risk., Methods and Results: We stratified 5602 MESA participants according to the ESC recommendation as: no lipid-lowering treatment recommended ( N = 2228), consider lipid-lowering treatment if uncontrolled ( N = 1686), or lipid-lowering treatment recommended ( N = 1688). We evaluated the ability of coronary artery calcium to reclassify cardiovascular risk. Among the selected sample, 54% had coronary artery calcium of zero, 25% had coronary artery calcium of 1-100 and 21% had coronary artery calcium greater than 100. In the lipid-lowering treatment recommended group 31% had coronary artery calcium of zero, while in the lipid-lowering treatment if uncontrolled group about 50% had coronary artery calcium of zero. The cardiovascular mortality rate was 1.7%/10 years in the lipid-lowering treatment if uncontrolled, and 7.0%/10 years in the lipid-lowering treatment recommended group. The absence of coronary artery calcium was associated with 1.4%/10 years in the lipid-lowering treatment if uncontrolled group and 3.0%/10 years in the lipid-lowering treatment recommended group. Compared with coronary artery calcium of zero, any coronary artery calcium was associated with significantly higher cardiovascular mortality in the lipid-lowering treatment recommended group (9.0%/10 years), whereas only coronary artery calcium greater than 100 was significantly associated with a higher cardiovascular mortality in the lipid-lowering treatment if uncontrolled group (3.2%/10 years)., Conclusion: The absence of coronary artery calcium is associated with a low incidence of cardiovascular mortality or coronary heart disease events even in individuals in whom lipid-lowering therapy is recommended. A significant proportion of individuals deemed to be candidates for lipid-lowering therapy might be reclassified to a lower risk group with the use of coronary artery calcium.

Background and Aims: Depression is a mood disorder characterized by persistent feelings of loss of interest along with a cluster of clinical symptoms. It is a significant public health concern affecting 350 million people worldwide. Depression has an association with increased risk of cardiovascular disease. The World Health Organization estimates both depression and coronary artery disease to be the two major causes of disability-adjusted life years by year 2020. Early identification of subclinical cardiovascular disease in people suffering from depression may significantly impact risk stratification of these patients., Methods: An electronic search of MEDLINE database was carried out using PubMed and OvidSP. Subclinical atherosclerosis was identified by coronary artery calcium (CAC). A total of 24 studies were identified to be included in the review., Results: In this review of twenty-four studies, we found that twelve studies identified a positive association between depression and subclinical atherosclerosis. Ten studies found no significant association between depressive symptoms and coronary calcification. Whereas, two studies showed negative association., Conclusions: There is mixed evidence assessing the relationship between depression and CAC. Depressive symptoms may represent a potentially modifiable risk factor for early prevention of cardiovascular disease especially in younger patients with moderate to severe depression., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To examine the association of favorable cardiovascular health (CVH) status with 1-year health care expenditures and resource utilization in a large health care employee population., Participants and Methods: Employees of Baptist Health South Florida participated in a health risk assessment from January 1 through September 30, 2014. Information on dietary patterns, physical activity, blood pressure, blood glucose level, total cholesterol level, and smoking were collected. Participants were categorized into CVH profiles using the American Heart Association's ideal CVH construct as optimal (6-7 metrics), moderate (3-5 metrics), and low (0-2 metrics). Two-part econometric models were used to analyze health care expenditures., Results: Of 9097 participants (mean ± SD age, 42.7±12.1 years), 1054 (11.6%) had optimal, 6945 (76.3%) had moderate, and 1098 (12.1%) had low CVH profiles. The mean annual health care expenditures among those with a low CVH profile was $10,104 (95% CI, $8633-$11,576) compared with $5824 (95% CI, $5485-$6164) and $4282 (95% CI, $3639-$4926) in employees with moderate and optimal CVH profiles, respectively. In adjusted analyses, persons with optimal and moderate CVH had a $2021 (95% CI, -$3241 to -$801) and $940 (95% CI, -$1560 to $80) lower mean expenditure, respectively, than those with low CVH. This trend remained even after adjusting for demographic characteristics and comorbid conditions as well as across all demographic subgroups. Similarly, health care resource utilization was significantly lower in those with optimal CVH profiles compared with those with moderate or low CVH profiles., Conclusion: Favorable CVH profile is associated with significantly lower total medical expenditures and health care utilization in a large, young, ethnically diverse, and fully insured employee population., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: The current study aimed to determine the relationship between self-reported sleep duration and morbid obesity in an employee population., Methods: Baptist Health South Florida conducts an annual Health Risk Assessment (HRA) for its employees. Data for this cross-sectional study was collected via this HRA in 2014, and included information on self-reported sleep duration, height and weight for body mass index (BMI), and other biometric measures. Average sleep duration was categorized as short sleep (<6 hr), optimal sleep (6-7.9 hr), and long sleep duration (≥8 hr), while obesity status was categorized as nonobese (BMI <30 kg/m 2 ), obese (30-34.9 kg/m 2 ), and morbid obese (≥35 kg/m 2 )., Results: A total of 9505 participants (mean age 42.8 ± 12.1 years, 75% females, and 55% Hispanic) were included in this study. Prevalence of morbid obesity was about 24% among employees who were sleeping for less than 6 hr compared to 13% and 14% among those sleeping for 6-7.9 hours, and 8 or more hours respectively. In regression analyses, persons who slept less than 6 hr had almost twice the odds of morbid obesity compared to those who slept 6-7.9 hr (odds ratio = 1.8; 1.5-2.2)., Conclusion: Our finding that short sleep duration (<6 hr) is significantly associated with a higher risk of morbid obesity should facilitate the development of workplace-based programs that focus on improving sleep among at-risk employees, especially those who work in shift duties to reduce the risk of morbid obesity and other comorbid conditions. Future studies are needed to further explore the relationship of sleep duration and morbid obesity in employee populations.

This is a single-arm, pre and post effectiveness study that evaluated the impact of a comprehensive workplace lifestyle program on severe obesity among high cardiovascular disease risk individuals in a large, diverse employee population. Employees of Baptist Health South Florida were considered eligible to participate if they had 2 or more of the following cardiometabolic risk factors: total cholesterol ≥200 mg/dL, systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, hemoglobin A1c ≥6.5%, body mass index ≥30kg/m(2). Participants received a personalized diet plan and physical activity intervention, and were followed for 1 year. Data on anthropometric measurements, blood pressure, blood glucose, and other biochemical measures were collected. Participants' body mass index was calculated and their eligibility for bariatric surgery (BS) also assessed. A total of 297 persons participated in the program; 160 participants completed all procedures through 12 months of follow-up. At baseline, 34% (n = 100) of all participants were eligible for BS. In an intention-to-treat analysis, 27% (n = 27) of BS eligible participants at baseline became ineligible after 12 months. Considering program completers only, 46% of BS eligible participants at baseline became ineligible. Irrespective of BS eligibility at 12 months, mean values of cardiometabolic risk factors among program completers improved after the follow-up period. Workplace wellness programs provide an important option for weight loss that can obviate the need for BS, reduce cardiovascular disease risk, and potentially reduce costs. However, in designing future worksite lifestyle interventions, measures should be taken to improve participation and retention rates in such programs.

Background: Cardiac computed tomography (CT) image quality (IQ) is very important for accurate diagnosis. We propose to evaluate IQ expressed as Likert scale, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) from coronary CT angiography images acquired with a new volumetric single-beat CT scanner on consecutive patients and assess the IQ dependence on heart rate (HR) and body mass index (BMI)., Methods: We retrospectively analyzed the data of the first 439 consecutive patients (mean age, 55.13 [SD, 12.1] years; 51.47% male), who underwent noninvasive coronary CT angiography in a new single-beat volumetric CT scanner (Revolution CT) to evaluate chest pain at West Kendall Baptist Hospital. Based on patient BMI (mean, 29.43 [SD, 5.81] kg/m), the kVp (kilovolt potential) value and tube current were adjusted within a range of 80 to 140 kVp and 122 to 720 mA, respectively. Each scan was performed in a single-beat acquisition within 1 cardiac cycle, regardless of the HR. Motion correction software (SnapShot Freeze) was used for correcting motion artifacts in patients with higher HRs. Autogating was used to automatically acquire systolic and diastolic phases for higher HRs with electrocardiographic milliampere dose modulation. Image quality was assessed qualitatively by Likert scale and quantitatively by SNR and CNR for the 4 major vessels right coronary, left main, left anterior descending, and left circumflex arteries on axial and multiplanar reformatted images. Values for Likert scale were as follows: 1, nondiagnostic; 2, poor; 3, good; 4, very good; and 5, excellent. Signal-to-noise ratio and CNR were calculated from the average 2 CT attenuation values within regions of interest placed in the proximal left main and proximal right coronary artery. For contrast comparison, a region of interest was selected from left ventricular wall at midcavity level using a dedicated workstation. We divided patients in 2 groups related to the HR: less than or equal to 70 beats/min (bpm) and greater than 70 bpm and also analyzed them in 2 BMI groupings: BMI less than or equal to 30 kg/m and BMI greater than 30 kg/m., Results: Mean SNR was 8.7 (SD, 3.1) (n = 349) for group with HR 70 bpm or less and 7.7 (SD, 2.4) (n = 78) for group with HR greater than 70 bpm (P = 0.008). Mean CNR was 6.9 (SD, 2.7) (n = 349) for group with HR 70 bpm or less and 5.9 (SD, 2.2) (n = 78) for group with HR 70 bpm or greater (P = 0.002). Mean SNR was 8.8 (SD, 3.2) (n = 249) for group with BMI 30 kg/m or less and 8.1 (SD, 2.6) (n = 176) for group with BMI greater than 30 kg/m (P = 0.008). Mean CNR was 7.0 (SD, 2.8) (n = 249) for group with BMI 30 kg/m or less and 6.4 (SD, 2.4) (n = 176) for group with BMI greater than 30 kg/m (P = 0.002). The results for mean Likert scale values were statistically different, reflecting difference in IQ between people with HR 70 bpm or less and greater than 70 bpm, BMI 30 kg/m or less, and BMI greater than 30 kg/m.

Several population-based studies have examined the prevalence and trends of the American Heart Association's ideal cardiovascular health (CVH) metrics as well as its association with cardiovascular disease (CVD)-related morbidity and mortality and with non-CVD outcomes. However, no efforts have been made to aggregate these studies. Accordingly, we conducted a systematic review to synthesize available data on the distribution and outcomes associated with ideal CVH metrics in both US and non-US populations. We conducted a systematic search of relevant studies in the MEDLINE and CINAHL databases, as well as the Cochrane Register of Controlled Trials (CENTRAL). Search terms used included "life's simple 7", "AHA 2020" and "ideal cardiovascular health". We included articles published in English Language from January 1, 2010, to July 31, 2015. Of the 14 US cohorts, the prevalence of 6 to 7 ideal CVH metrics ranged from as low as 0.5% in a population of African Americans to 12% in workers in a South Florida health care organization. Outside the United States, the lowest prevalence was found in an Iranian study (0.3%) and the highest was found in a large Chinese corporation (15%). All 6 mortality studies reported a graded inverse association between the increasing number of ideal CVH metrics and the all-cause and CVD-related mortality risk. A similar relationship between ideal CVH metrics and incident cardiovascular events was found in 12 of 13 studies. Finally, an increasing number of ideal CVH metrics was associated with a lower prevalence and incidence of non-CVD outcomes such as cancer, depression, and cognitive impairment. The distribution of ideal CVH metrics in US and non-US populations is similar, with low proportions of persons achieving 6 or more ideal CVH metrics. Considering the strong association of CVH metrics with both CVD and non-CVD outcomes, a coordinated global effort for improving CVH should be considered a priority., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: This study details 6- and 12-month cardio-metabolic outcomes of an intense 12-week workplace lifestyle intervention program, the My Unlimited Potential (MyUP), conducted in a large healthcare organization., Methods: This study was conducted among 230 employees of Baptist Health South Florida with high cardiovascular disease (CVD) risk. Employees were considered at high risk and eligible for the study if they had two or more of the following cardio-metabolic risk factors: total cholesterol ≥ 200 mg/dl, systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg, hemoglobin A1C (HbA1c) ≥ 6.5%, body mass index (BMI) ≥ 30 kg/m(2) ., Results: At the end of 12 weeks, there was significant reduction in the mean BMI, SBP and DBP, serum lipids, and HbA1c among persons with diabetes. At 1 year, there was significant decline in the mean BMI, SBP and DBP, HbA1c, and high-sensitivity C-reactive protein, and in the prevalence of poor BP control, BMI ≥ 35 kg/m(2) , and abnormal HbA1c among all persons and those with diabetes., Conclusions: This intensive 12-week lifestyle change program was successful at improving cardio-metabolic risk factors at 1 year. This study provides a template for other workplace programs aimed at improving CVD risk in high-risk employees., (© 2015 The Obesity Society.)

Objectives: To determine the relationship between clinically relevant blood pressure (BP) groups and nonalcoholic fatty liver disease (NAFLD) presence and severity especially in the milieu of other metabolic risk factors., Patients and Methods: From a Brazilian cohort of 5362 healthy middle-aged men and women who presented for yearly physical examination and testing, the cross-sectional relationship between BP categories and NAFLD was assessed. BP groups were categorized as normal, prehypertension (PHT), and hypertension (HTN) according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure classification. NAFLD was ultrasound diagnosed, excluding persons with alcohol consumption more than 20 g/day. NAFLD severity was estimated using the Fibrosis-4 (FIB-4) risk score., Results: The prevalence of NAFLD was 36.2%. Participants with NAFLD were older (mean 46 vs. 42 years, P < 0.001) and had elevated BMI (mean 29.0 vs. 24.7 kg/m, P < 0.001). The prevalence of NAFLD among persons with normal BP, PHT, and HTN was 16.5, 37.5, and 59.3%, respectively. In multivariate analyses, PHT and HTN were associated with elevated odds of NAFLD (PHT-adjusted odds ratio 1.3, 95% confidence interval 1.1, 1.6; HTN-adjusted odds ratio 1.8, 95% confidence interval 1.4-2.3) compared with normal BP. Among nonobese hypertensive patients, BP control (BP < 140/90 mmHg) was independently associated with 40% lower odds of prevalent NAFLD. Compared with hypertensive patients, both normotensive individuals and prehypertensive patients were more likely to have a low fibrosis risk (FIB-4 ≥ 1.3)., Conclusion: Prevalent NAFLD may be seen early in the development of hypertension, even in the absence of other metabolic risk factors. Controlling BP among nonobese hypertensive patients may be beneficial in preventing or limiting NAFLD.

Patients with obstructive sleep apnea (OSA) have a high burden of cardiovascular disease (CVD) but a causal relationship between OSA and atherosclerotic CVD remains unclear. We systematically reviewed the literature analyzing the relationship. A review of the Medline database for studies noninvasively evaluating subclinical CVD in OSA was conducted. A total of fifty-two studies were included in this review. Across the studies the prevalence of atherosclerosis, as assessed by coronary artery calcification, carotid intima-media thickness, brachial artery flow-mediated dilation and pulse wave velocity was higher in patients with OSA and correlated with increasing severity and duration of OSA. This study shows OSA is an independent predictor of subclinical CVD as CVD is more likely to occur in patients with long standing and severe OSA. Further research is however necessary to identify specific OSA populations that would benefit from aggressive screening., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Emerging data suggests that the combination of smoking and metabolic syndrome (MetS) markedly increases cardiovascular disease risk well beyond that of either condition. In this study we assess if this interaction can be explained by an additive increase in the risk of systemic inflammation by MetS and cigarette smoking., Methods: We evaluated 5,503 healthy non-diabetic Brazilian subjects (mean age of 43 ± 10 years, 79% males). Participants were divided into sub-groups of smokers and non-smokers with or without MetS. High-sensitivity C reactive protein (hs-CRP) was measured to assess degree of underlying inflammation., Results: Overall (19%) had hs-CRP > 3 mg/L. In adjusted regression analyses, compared to non-smokers, there was a 0.19 mg/L (95% CI: 0.05, 0.32) increase in hs-CRP among smokers in the entire population and 0.63 mg/L (95% CI: 0.26, 1.01) increase among smokers with MetS while there was no significant increase among smokers without MetS (β = 0.09 95% CI: -0.05, 0.24). In a fully adjusted logistic regression model, smokers compared to non-smokers were 55% more likely to have elevated hs-CRP in the entire population (OR 1.55, 95% CI: 1.25, 1.92) and more than twice as likely to have elevated hs-CRP if they had MetS ( OR 2.05, 95% CI: 1.40, 3.01) while the risk was non-significant among those without MetS (OR = 1.29, 95% CI: 0.98, 1.69)., Conclusion: The study demonstrates an additive effect of cigarette smoking on the risk of systemic inflammation in MetS thus highlighting the need for determining smoking status among those with MetS and aggressively targeting smoking cessation in this population.

Objectives: The aim of this study was to evaluate the impact of coronary artery calcium (CAC) burden and regional distribution on the need for and type of future coronary revascularization-percutaneous versus surgical (coronary artery bypass graft [CABG])-among asymptomatic subjects., Background: The need for coronary revascularization and the chosen mode of revascularization are thought to be functions of disease burden and anatomic distribution. The association between the baseline burden and regional distribution of CAC and the risk and type of future coronary revascularization remains unknown., Methods: A total of 6,540 participants in the MESA (Multi-Ethnic Study of Atherosclerosis) (subjects aged 45 to 84 years, free of known baseline cardiovascular disease) with vessel-specific CAC measurements were followed for a median of 8.5 years (interquartile range: 7.7 to 8.6 years). Annualized rates and multivariate-adjusted hazard ratios for revascularization and revascularization type were analyzed according to CAC score category, number of vessels with CAC (0 to 4, including the left main coronary artery), and involvement of individual coronary arteries., Results: A total of 265 revascularizations (4.2%) occurred during follow-up, and 206 (78% of the total) were preceded by adjudicated symptoms. Revascularization was uncommon when CAC score was 0.0 (0.6%), with a graded increase over both rising CAC burden and increasingly diffuse CAC distribution. The revascularization rates per 1,000 person-years for CAC scores of 1 to 100, 101 to 400, and >400 were 4.9, 11.7, and 25.4, respectively; for 1, 2, 3, and 4 vessels with CAC, the rates were 3.0, 8.0, 16.1, and 24.8, respectively. In multivariate models adjusting for CAC score, the number of vessels with CAC remained predictive of revascularization and mode of revascularization. Independent predictors of CABG versus percutaneous coronary intervention included 3- or 4-vessel CAC, higher CAC burden, and involvement of the left main coronary artery. Risk for CABG was extremely low with <3-vessel baseline CAC. Results were similar when considering only symptom-driven revascularizations., Conclusions: In this multiethnic cohort of asymptomatic subjects, baseline CAC was highly predictive of future coronary revascularization procedures, with measures of CAC burden and distribution each independently predicting need for percutaneous coronary intervention versus CABG over an 8.5-year follow-up., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Non-alcoholic fatty liver disease (NAFLD) is an emerging disease and a leading cause of chronic liver disease. The prevalence in the general population is approximately 15-30% and it increases to 70-90% in obese or diabetic populations. NAFLD has been linked to increased cardiovascular disease (CVD) risk. It is therefore critical to evaluate the relationship between markers of subclinical CVD and NAFLD., Method: An extensive search of databases; including the National Library of Medicine and other relevant databases for research articles meeting inclusion criteria: observational or cohort, studies in adult populations and clearly defined NAFLD and markers of subclinical CVD., Results: Twenty-seven studies were included in the review; 16 (59%) presented the association of NAFLD and carotid intima-media thickness (CIMT), 7 (26%) the association with coronary calcification and 7 (26%) the effect on endothelial dysfunction and 6 (22%) influence on arterial stiffness. CIMT studies showed significant increases among NAFLD patients compared to controls. These were independent of traditional risk factors and metabolic syndrome. The association was similar in coronary calcification studies. The presence of NAFLD is associated with the severity of the calcification. Endothelial dysfunction and arterial stiffness showed significant independent associations with NAFLD. Two studies argued the associations were not significant; however, these studies were limited to diabetic populations., Conclusion: There is evidence to support the association of NAFLD with subclinical atherosclerosis independent of traditional risk factors and metabolic syndrome. However, there is need for future longitudinal studies to review this association to ascertain causality and include other ethnic populations., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Visceral adipose tissue (VAT) is a source of inflammatory cytokines that in obese subjects may contribute to low-level systemic inflammation and development of metabolic syndrome. Expansion of VAT involves adipocyte hyperplasia and hypertrophy and requires breakdown of the extracellular matrix and increased vascular outgrowth. To investigate changes of gene expression associated with VAT expansion and the role of combined genetics and diet, we implemented gene microarray analyses of VAT in NONcNZO10 (NZ10) and control SWR/J mice subjected to control chow (CD) or a diet of high protein and fish oil (HPO). NZ10 mice on CD showed increased body weight, hyperglycemia, and hyperinsulinemia at 25 weeks whereas those on HPO diet retained normal insulin levels and were normoglycemic. Two-way ANOVA revealed a significant interaction between diet and strain on blood glucose, serum insulin, and percent fat but not for body weight. Microarray heat maps revealed a remarkable combined effect of genetics and diet on genes that regulate extracellular matrix as well as angiogenic genes. Real time-PCR (RT-PCR) confirmed markedly increased expression of matrix metalloproteinases (MMPs) 2, 3, 11, and 12, vascular endothelial growth factor-A and C (VEGF-A and C), Von Willebrand Factor, and peroxisome proliferator-activated receptor-γ (PPAR-γ) selectively in the NZ10/CD group. MMP7 was significantly decreased. Protein levels of MMP2, 3, and 9 were significantly increased in the VA of NZ10 mice fed CD while those of MMP7 were downregulated. Microarrays also revealed diet-dependent two to fourfold increased expression of all four tissue inhibitor of metalloproteinases (TIMP) isoforms in NZ10 mice. Two-way ANOVA confirmed strongly interactive roles of diet and genetics on fat deposition and progression of type 2 diabetes in this polygenic mouse model.

Background: Elevated levels of C-reactive protein (CRP) are associated with poor cardiovascular outcomes, even after accounting for traditional cardiovascular risk factors. We sought to analyze the relationship between levels of CRP and coronary plaque subtypes as assessed by coronary computed tomography angiography., Methods and Results: We evaluated 1004 asymptomatic South Korean subjects (mean age, 49±9.3 years) who underwent coronary computed tomography angiography as part of a health screening evaluation. We examined the association between increasing CRP levels and plaque subtypes using multivariable linear and logistic regression analysis. Coronary plaque was observed in 211 of 1004 individuals (21%). Subjects with high CRP (≥2 mg/L) had an increased prevalence of any plaque type (30.7% versus 16.7% P<0.001) and mixed calcified arterial plaque (MCAP) (19.3% versus 6.3% P<0.001) as compared with subjects with low-normal CRP. Multivariable logistic regression analysis demonstrated that elevated CRP predicted the presence of any MCAP (high versus low-normal CRP group; odds ratio, 2.81; 95% confidence interval, 1.62 to 4.89). When examining the multivariable logistic regression analysis between the presence of ≥2 plaques and CRP, subjects with high CRP were more likely to have MCAP than those with low-normal CRP levels (odds ratio, 3.78; 95% confidence interval, 1.49 to 9.55)., Conclusions: Elevated levels of CRP are associated with an increased prevalence of MCAP as assessed by coronary computed tomography angiography. Longitudinal studies will determine if the excess risk observed in persons with elevated CRP may be mediated, at least in part, by an increased burden of MCAP.

Introduction: Successfully addressing childhood onset obesity requires multilevel (individual, community, and governmental), multi-agency collaboration., Methods: The Healthier Options for Public Schoolchildren (HOPS)/OrganWise Guys (OWG) quasi-experimental controlled pilot study (four intervention schools, one control school, total N=3,769; 50.2% Hispanic) was an elementary school-based obesity prevention intervention designed to keep children at a normal, healthy weight, and improve health status and academic achievement. The HOPS/OWG included the following replicable, holistic components: (1) modified dietary offerings, (2) nutrition/lifestyle educational curricula; (3) physical activity component; and (4) wellness projects. Demographic, anthropometric (body mass index [BMI]), blood pressure, and academic data were collected during the two-year study period (2004-6)., Results: Statistically significant improvements in BMI, blood pressure, and academic scores, among low-income Hispanic and White children in particular, were seen in the intervention versus controls., Conclusion: Holistic school-based obesity prevention interventions can improve health outcomes and academic performance, in particular among high-risk populations.

Statins produce large, clinically important beneficial effects on total low-density lipoprotein (LDL) cholesterol and triglycerides while raising high-density lipoprotein (HDL) cholesterol--each of which increases the risks for cardiovascular disease (CVD). In randomized trials of secondary and primary prevention, and their meta-analyses, statins confer statistically significant, clinically important reductions in myocardial infarction, stroke, and CVD death. In 2001, the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III included LDL as the primary target, recommending optional goals of < 100 mg/dL for high-risk patients, < 130 mg/dL for moderate-risk patients, and < 160 mg/dL for low-risk patients. We conducted a search of randomized trials of statins whose results were published since May 15, 2001. We extracted overall trial results and data on adverse events, when available. We reviewed 7 published trials of statins, some of which contributed to the recent addendum to the NCEP ATP III guidelines that recommend reducing LDL goals to < 70 for very high-risk and < 100 for moderately high-risk patients via statins. Data from these trials demonstrate that greater LDL reductions produce larger CVD benefits in various categories of high- and moderate-risk patients, including a large number of primary prevention patients with metabolic syndrome who should be treated as aggressively as patients who have survived a myocardial infarction or stroke. Together, these recent statin trials and the NCEP ATP III revised guidelines, if implemented by primary healthcare providers, would result in many more patients receiving statins of proven benefit and reassuring adverse event profile.

The key to healthy eating is choosing "good fats"--foods high in omega-3 fatty acids and unsaturated fats, and "good carbohydrates"--foods high in fiber and having a low glycemic index. The healthiest diet is the Mediterranean type, consisting of lean meats, fish, nuts, vegetables, whole fruits, and whole grains.

In the United States, cardiovascular disease (CVD) is the leading killer accounting for about 1 million fatalities annually, with hypertension being a major risk factor for stroke, coronary heart disease (CHD), cardiovascular (CV) death, heart failure, and end-stage renal disease--all of which have higher prevalence in African Americans, who also experience greater severity at clinical presentation. In numerous randomized trials and meta-analyses, drug therapy for hypertension has been shown to reduce blood pressure by 4-6 millimeters of mercury (mm Hg) with resultant decreases in stroke of 35%-40%, CHD of 20%-25%, and CV death of about 25%. Cardiovascular drug therapies of proven benefit, including diuretics, angiotensin converting enzyme (ACE inhibitors), and beta-blockers, are safe and effective, alone and in combination. Since African Americans with hypertension tend to have a more severe presentation, they will be even more likely to require multiple drug therapies, which also will include diuretics and calcium channel blockers. Effective strategies to encourage widespread use of these therapies of proven benefit would provide progress toward decreasing the adverse mortality experiences, especially CVD, among African Americans.

We examined a 56-year-old man who presented with dyspnea and lower extremity edema. A 2-D echocardiogram showed a large mass within the right ventricle which spared the right atrium and the inferior vena cava. Pathologic evaluation identified a renal cell carcinoma with sarcomatoid features. The tumor had metastasized to and invaded the right ventricular myocardium without right atrial or caval involvement. This pattern of metastases is rare and suggests that this tumor's aggressive nature contributed to the degree of myocardial invasion as well as the patient's rapid demise.

In the past year, Doppler echocardiography has continued to transform the "echo laboratory" into a "cardiac imaging and hemodynamics laboratory." Evaluation of blood flow through the cardiac chambers and great vessels is moving from semiquantitative to quantitative. The potential for measuring mitral regurgitant flow more precisely has been demonstrated by evaluating the zone of flow acceleration that occurs on the left ventricular side of the mitral valve. Direct imaging of pulmonary venous return to the left atrium using transesophageal Doppler echocardiography has also allowed more precise quantification of mitral regurgitation. Left ventricular systolic function may be better quantified in patients with mitral regurgitation by calculating the ratio of the change in pressure to the change in time from the continuous wave spectrum of regurgitant flow. The practical application of transmitral flow.in evaluating diastolic function has been applied to cardiac amyloidosis.