Prevalence of unrecognised myocardial infarction in a low-intermediate risk asymptomatic cohort and its relation to systemic atherosclerosis

The study was funded by the Souter Charitable Foundation and the Chest, Heart and Stroke Scotland Charity. J.R.W.M. is supported by the Wellcome Trust through the Scottish Translational Medicine and Therapeutics Initiative (grant no. WT 085664) in the form of a clinical research fellowship.Aims :  Unrecognized myocardial infarctions (UMIs) have been described in 19-30% of the general population using late gadolinium enhancement (LGE) on cardiac magnetic resonance. However, these studies have focused on an unselected cohort including those with known cardiovascular disease (CVD). The aim of the current study was to ascertain the prevalence of UMIs in a non-high-risk population using magnetic resonance imaging (MRI). Methods and Results :  A total of 5000 volunteers aged >40 years with no history of CVD and a 10-year risk of CVD of <20%, as assessed by the ATP-III risk score, were recruited to the Tayside Screening for Cardiac Events study. Those with a B-type natriuretic peptide (BNP) level greater than their gender-specific median were invited for a whole-body MR angiogram and cardiac MR including LGE assessment. LGE was classed as absent, UMI, or non-specific. A total of 1529 volunteers completed the imaging study; of these, 53 (3.6%) were excluded because of either missing data or inadequate LGE image quality. Ten of the remaining 1476 (0.67%) displayed LGE. Of these, three (0.2%) were consistent with UMI, whereas seven were non-specific occurring in the mid-myocardium (n = 4), epicardium (n = 1), or right ventricular insertion points (n = 2). Those with UMI had a significantly higher BNP [median 116 (range 31-133) vs. 22.6 (5-175) pg/mL, P = 0.015], lower ejection fraction [54.6 (36-62) vs. 68.9 (38-89)%, P = 0.007], and larger end-systolic volume [36.3 (27-61) vs. 21.7 (5-65) mL/m(2), P = 0.014]. Those with non-specific LGE had lower diastolic blood pressure [68 (54-70) vs. 72 (46-98) mmHg, P = 0.013] but no differences in their cardiac function. Conclusion :  Despite previous reports describing high prevalence of UMI in older populations, in a predominantly middle-aged cohort, those who are of intermediate or low cardiovascular risk have a very low risk of having an unrecognized myocardial infarct.Publisher PDFPeer reviewe

Left Ventricular Noncompaction:Anatomical Phenotype or Distinct Cardiomyopathy?

The present study was funded by the Souter Charitable Foundation and the Chest, Heart and Stroke Scotland Charity. Dr. Weir-McCall is supported by the Wellcome Trust through the Scottish Translational Medicine and Therapeutics Initiative (Grant no. WT 085664) in the form of a Clinical Research Fellowship.Background:  There is considerable overlap between left ventricular noncompaction (LVNC) and other cardiomyopathies. LVNC has been reported in up to 40% of the general population, raising questions about whether it is a distinct pathological entity, a remodeling epiphenomenon, or merely an anatomical phenotype. Objectives:   The authors determined the prevalence and predictors of LVNC in a healthy population using 4 cardiac magnetic resonance imaging diagnostic criteria. Methods:   Volunteers >40 years of age (N = 1,651) with no history of cardiovascular disease (CVD), a 10-year risk of CVD < 20%, and a B-type natriuretic peptide level greater than their gender-specific median underwent magnetic resonance imaging scan as part of the TASCFORCE (Tayside Screening for Cardiac Events) study. LVNC ratios were measured on the horizontal and vertical long axis cine sequences. All individuals with a noncompaction ratio of ≥2 underwent short axis systolic and diastolic LVNC ratio measurements, and quantification of noncompacted and compacted myocardial mass ratios. Those who met all 4 criteria were considered to have LVNC. Results:  Of 1,480 participants analyzed, 219 (14.8%) met ≥1 diagnostic criterion for LVNC, 117 (7.9%) met 2 criteria, 63 (4.3%) met 3 criteria, and 19 (1.3%) met all 4 diagnostic criteria. There was no difference in demographic or allometric measures between those with and without LVNC. Long axis noncompaction ratios were the least specific, with current diagnostic criteria positive in 219 (14.8%), whereas the noncompacted to compacted myocardial mass ratio was the most specific, only being met in 61 (4.4%). Conclusions:   A significant proportion of an asymptomatic population free from CVD satisfy all currently used cardiac magnetic resonance imaging diagnostic criteria for LVNC, suggesting that those criteria have poor specificity for LVNC, or that LVNC is an anatomical phenotype rather than a distinct cardiomyopathy.Publisher PDFPeer reviewe

Follow-up of atheroma burden with sequential whole body contrast enhanced MR angiography:a feasibility study

Assess the feasibility of whole body magnetic resonance angiography (WB-MRA) for monitoring global atheroma burden in a population with peripheral arterial disease (PAD). 50 consecutive patients with symptomatic PAD referred for clinically indicated MRA were recruited. Whole body MRA (WB-MRA) was performed at baseline, 6 months and 3 years. The vasculature was split into 31 anatomical arterial segments. Each segment was scored according to degree of luminal narrowing: 0 = normal, 1 = <50 %, 2 = 50–70 %, 3 = 71–99 %, 4 = vessel occlusion. The score from all assessable segments was summed, and then normalised to the number of assessable vessels. This normalised score was divided by four (the maximum vessel score) and multiplied by 100 to give a final standardised atheroma score (SAS) with a score of 0–100. Progression was assessed with repeat measure ANOVA. 36 patients were scanned at 0 and 6 months, with 26 patients scanned at the 3 years follow up. Only those who completed all three visits were included in the final analysis. Baseline atherosclerotic burden was high with a mean SAS of 15.7 ± 10.3. No significant progression was present at 6 months (mean SAS 16.4 ± 10.5, p = 0.67), however there was significant disease progression at 3 years (mean SAS 17.7 ± 11.5, p = 0.01). Those with atheroma progression at follow-up were less likely to be on statin therapy (79 vs 100 %, p = 0.04), and had significantly higher baseline SAS (17.6 ± 11.2 vs 10.7 ± 5.1, p = 0.043). Follow up of atheroma burden is possible with WB-MRA, which can successfully quantify and monitor atherosclerosis progression at 3 years follow-up

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p&lt;0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p&lt;0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p&lt;0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP &gt;5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Can artificial intelligence pass the Fellowship of the Royal College of Radiologists examination? Multi-reader diagnostic accuracy study.

Peer reviewed: TrueFunder: National Institute for Health and Care Research; FundRef: http://dx.doi.org/10.13039/501100000272OBJECTIVE: To determine whether an artificial intelligence candidate could pass the rapid (radiographic) reporting component of the Fellowship of the Royal College of Radiologists (FRCR) examination. DESIGN: Prospective multi-reader diagnostic accuracy study. SETTING: United Kingdom. PARTICIPANTS: One artificial intelligence candidate (Smarturgences, Milvue) and 26 radiologists who had passed the FRCR examination in the preceding 12 months. MAIN OUTCOME MEASURES: Accuracy and pass rate of the artificial intelligence compared with radiologists across 10 mock FRCR rapid reporting examinations (each examination containing 30 radiographs, requiring 90% accuracy rate to pass). RESULTS: When non-interpretable images were excluded from the analysis, the artificial intelligence candidate achieved an average overall accuracy of 79.5% (95% confidence interval 74.1% to 84.3%) and passed two of 10 mock FRCR examinations. The average radiologist achieved an average accuracy of 84.8% (76.1-91.9%) and passed four of 10 mock examinations. The sensitivity for the artificial intelligence was 83.6% (95% confidence interval 76.2% to 89.4%) and the specificity was 75.2% (66.7% to 82.5%), compared with summary estimates across all radiologists of 84.1% (81.0% to 87.0%) and 87.3% (85.0% to 89.3%). Across 148/300 radiographs that were correctly interpreted by >90% of radiologists, the artificial intelligence candidate was incorrect in 14/148 (9%). In 20/300 radiographs that most (>50%) radiologists interpreted incorrectly, the artificial intelligence candidate was correct in 10/20 (50%). Most imaging pitfalls related to interpretation of musculoskeletal rather than chest radiographs. CONCLUSIONS: When special dispensation for the artificial intelligence candidate was provided (that is, exclusion of non-interpretable images), the artificial intelligence candidate was able to pass two of 10 mock examinations. Potential exists for the artificial intelligence candidate to improve its radiographic interpretation skills by focusing on musculoskeletal cases and learning to interpret radiographs of the axial skeleton and abdomen that are currently considered "non-interpretable.

No association between systemic arteriosclerosis and atherosclerosis on cardiac MRI and whole body MR angiography:the TASCFORCE study

Introduction: Arteriosclerosis (arterial stiffening) and atherosclerosis (plaque formation) are pathophysiological processes afflicting the vasculature, both of which are associated with future cardiovascular events. However the degree to which they overlap or simply co-exist is poorly understood. The aim of the current study is to determine if these two processes are significantly associated with one another.Methods: 1651 volunteers with no clinical manifestation of cardiovascular disease and &lt;20% 10-year cardiovascular risk underwent a cardiac MRI and whole body MR angiogram as part of the TASCFORCE study. Systemic arterial stiffness was measured using total arterial compliance (TAC) – calculated as the indexed stroke volume divided by the pulse pressure. Systemic atheroma burden (AB) was calculated by scoring 30 arterial segments within the body based on the degree of stenosis, summating these scores and normalising it to the number of assessable segments.Results: 1515 (574 male, 53.8±8.2 years-old) completed the study. On multiple linear regression age (B=–0.001 (95%CI –?0.002–−0.000), p=0.004), heart rate (B=–0.003 (95%CI –?0.003–−0.002), p&lt;0.001) and blood pressure (B=–0.008 (95%CI –0.009–−0.008), p&lt;0.001) were independently associated with TAC, while age (B=0.061 (95%CI 0.04–0.08), p&lt;0.001), and smoking pack-year history (B=0.003 (95%CI 0.005), p=0.022) were independently associated with AB. TAC and AB?demonstrated a significant correlation with each other (Spearman rho=–0.12, p&lt;0.001), however on multivariable analysis accounting for age, blood pressure, sex, BMI, smoking status and cholesterol no significant association persisted (B=–?0.001 (95%CI –0.004–0.002), p=0.62).Conclusion: Systemic arteriosclerosis and atherosclerosis are separate entities with each determined by different risk factors. Future efforts in cardiovascular risk prevention should seek to address both of these pathophysiological entities

No association between systemic arteriosclerosis and atherosclerosis on cardiac MRI and whole body MR angiography:the TASCFORCE study

Introduction: Arteriosclerosis (arterial stiffening) and atherosclerosis (plaque formation) are pathophysiological processes afflicting the vasculature, both of which are associated with future cardiovascular events. However the degree to which they overlap or simply co-exist is poorly understood. The aim of the current study is to determine if these two processes are significantly associated with one another.Methods: 1651 volunteers with no clinical manifestation of cardiovascular disease and &lt;20% 10-year cardiovascular risk underwent a cardiac MRI and whole body MR angiogram as part of the TASCFORCE study. Systemic arterial stiffness was measured using total arterial compliance (TAC) – calculated as the indexed stroke volume divided by the pulse pressure. Systemic atheroma burden (AB) was calculated by scoring 30 arterial segments within the body based on the degree of stenosis, summating these scores and normalising it to the number of assessable segments.Results: 1515 (574 male, 53.8±8.2 years-old) completed the study. On multiple linear regression age (B=–0.001 (95%CI –?0.002–−0.000), p=0.004), heart rate (B=–0.003 (95%CI –?0.003–−0.002), p&lt;0.001) and blood pressure (B=–0.008 (95%CI –0.009–−0.008), p&lt;0.001) were independently associated with TAC, while age (B=0.061 (95%CI 0.04–0.08), p&lt;0.001), and smoking pack-year history (B=0.003 (95%CI 0.005), p=0.022) were independently associated with AB. TAC and AB?demonstrated a significant correlation with each other (Spearman rho=–0.12, p&lt;0.001), however on multivariable analysis accounting for age, blood pressure, sex, BMI, smoking status and cholesterol no significant association persisted (B=–?0.001 (95%CI –0.004–0.002), p=0.62).Conclusion: Systemic arteriosclerosis and atherosclerosis are separate entities with each determined by different risk factors. Future efforts in cardiovascular risk prevention should seek to address both of these pathophysiological entities