Imaging to End Points: Cardiovascular Disease Risk Assessment in HIV.
Imaging to End Points: Cardiovascular Disease Risk Assessment in HIV.
复制标题
终点成像：艾滋病毒心血管疾病风险评估。
DOI：
10.1161/circimaging.117.007120
复制
发表时间：
2017
期刊：
影响因子：
--
通讯作者：
Hadigan,Colleen
中科院分区：
文献类型：
--
作者：
Gharib,AhmedM;Hadigan,Colleen
2 Gharib和Hadigan心血管疾病风险评估在HIV间期，1.05-7.63; P= 0.03）。在HIV受试者中，在颈动脉非钙化斑块和高危斑块与随后的CVD事件风险之间观察到类似的相关性。这些数据与对一般人群的研究结果一致。例如，Cao等人10在心血管健康研究（一项针对无已知CVD的成人（≥ 65岁）的研究）中发现，颈动脉超声显示存在中高危颈动脉斑块，在调整传统CVD风险因素后，CVD事件的风险增加约2倍。在年轻的梅萨队列（多种族动脉粥样硬化研究）中，颈动脉斑块评分也是校正传统危险因素后CVD事件的重要预测因子（风险比，1.27; 95%置信区间，1.16-1.40; P< 0.001）。11在HIV感染者队列中观察到的无症状颈动脉斑块与随后的CVD事件之间的联系支持颈动脉斑块测量作为CVD风险分层和CVD风险降低的生物标志物的潜在用途。绝大多数评价颈动脉粥样硬化和颈动脉内膜中层厚度的HIV研究都使用了超声技术，而不是目前报告中使用的CT成像。虽然两者都是无创成像方法，但辐射暴露和造影剂给药的额外负担限制了CT作为大人群通用筛查工具的广泛应用。视野中甲状腺的存在进一步加重了辐射风险，这可能解释了无症状人群中与动脉粥样硬化相关的颈动脉CT研究数量明显较少的原因，特别是那些可能需要随访的人群。因此，很难证明使用该技术作为识别或监测心血管事件高风险的无症状HIV受试者的手段是合理的。不可否认，Janjua等人7没有前瞻性地将颈动脉CT作为一般筛查工具。研究者回顾性评估了具有临床指征颈部CT数据的人群中的颈动脉CT，但该方法存在其他限制。使用< 3 mm的点状钙化和1 mm直径的低衰减病灶（< 40 HU）作为高危斑块的体征将需要更高分辨率的采集（更多的辐射）和完美的造影剂给药。后一个组成部分甚至更关键，因为除了动脉粥样硬化斑块中注意到的密度的广泛变化之外，一些高风险斑块可能根据炎症状态而迅速增强或洗脱。12-14高场磁共振成像克服了与CT相关的许多挑战，提高了信噪比以及空间和时间分辨率。15-17磁共振成像技术的多功能性也允许斑块表征。12，14超声的相对技术简单性、移动性和较低的成本使这种模式对于幽闭恐惧症患者和可能不具备磁共振成像能力的地点具有优势。12，14考虑到这些因素和可用的替代方案，将本研究的结果转化为临床实践可能具有挑战性。
2 Gharib and Hadigan Cardiovascular Disease Risk Assessment in HIV interval, 1.05–7.63; P= 0.03). Similar associations were observed between noncalcified carotid plaque and high-risk plaque and the risk of subsequent CVD events in HIV subjects. These data are consistent with research in the general population. For example, Cao et al10 showed that the presence of intermediate-and high-risk carotid plaque on carotid ultrasound conferred approximately a 2-fold increased risk of CVD event after adjustment for traditional CVD risk factors in the Cardiovascular Health Study, a study of adults (≥ 65 years) without known CVD. In the younger MESA cohort (Multi-Ethnic Study of Atherosclerosis), carotid plaque score was also a significant predictor of CVD events after adjustment for traditional risk factors (hazard ratio, 1.27; 95% confidence interval, 1.16–1.40; P< 0.001). 11 The observed link between asymptomatic carotid plaque and subsequent CVD events in a cohort of people living with HIV supports the potential use of carotid plaque measurements as a biomarker of CVD risk stratification and CVD risk reduction. The overwhelming majority of HIV research evaluating carotid atherosclerosis and carotid intima-media thickness has used ultrasound technology and not CT imaging, as used in the current report. Although both are noninvasive imaging approaches, the additional burden of radiation exposure and contrast administration limits the broader appeal for the use of CT as a general screening tool in large populations. Radiation risk is further accentuated by the presence of the thyroid gland in the field of view and may explain the conspicuously low number of carotid CT studies related to atherosclerosis in asymptomatic populations, particularly those that may require follow-up. Therefore, it would be difficult to justify using this technology as a means of identifying or monitor asymptomatic HIV subjects at high risk for cardiovascular events. Admittedly, Janjua et al7 did not prospectively apply carotid CT as a general screening tool. The investigators evaluated carotid CT retrospectively among a population with clinically indicated neck CT data, but additional limitations to this approach exist. The use of< 3 mm spotty calcifications and 1 mm diameter foci of low attenuation (< 40 HU) as signs of high-risk plaque would require higher resolution acquisitions (more radiation) and perfectly timed contrast administration. The latter component is even more critical as some high-risk plaques may enhance or washout rapidly depending on the inflammatory status in addition to the wide range of variability in densities noted in atherosclerotic plaque. 12–14 Many of the challenges associated with CT are overcome by high-field magnetic resonance imaging which has improved signal to noise and spatial and temporal resolution. 15–17 The technical versatility of magnetic resonance imaging also allows for plaque characterization. 12, 14 The relative technical simplicity, mobility, and lower cost of ultrasound places this modality at an advantage for claustrophobic patients and locations that might not have the magnetic resonance imaging capabilities. 12, 14 Given these factors and available alternatives, translation of the findings of this study into clinical practice may be challenging.