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  • br Introduction br Breast cancer patients commonly undergo computed tomography


    1. Introduction
    Breast cancer patients commonly undergo computed tomography (CT) chest imaging [1]. At CT chest coincidental coronary artery calcifi-cation (CAC) may be detected [2]. CAC denotes calcified coronary atherosclerosis and predicts cardiovascular mortality [3]. Cardiovascular disease is an important determinant of long term survival in breast cancer [4]. Coincidental CAC detection at chest CT in breast cancer patients could therefore influence physician and patient attitudes toward cardiovascular risks and cardiovascular primary prevention strategies.
    For breast cancer patients, coronary artery disease, heart failure and atrial fibrillation can be important clinical events. In the absence of a clinical risk score to predict all three conditions, clinicians often employ
    Corresponding author at: University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Canada. E-mail address: [email protected] (G.R. Small).
    cardiovascular primary prevention scoring systems to help determine a cardiovascular risk. This approach also acknowledges the role of ische-mic heart disease in the pathology of heart failure and atrial fibrillation.
    As a primary risk stratifier, the Framingham risk score (FRS) is widely used to define cardiovascular disease susceptibility [5]. FRS however may not be reliable in predicting heart failure events or the incidence of atrial fibrillation. Furthermore in some demographic popu-lations FRS may not be accurate at predicting coronary artery disease such as the elderly in whom it over estimates risk; or in patients with cancer in whom it may under estimate risk [5,6]. This reflects the derivation of FRS using a population based approach to predict cardio-vascular disease.
    Coincidental detection of CAC at chest CT may offer a more personal-ized assessment of cardiovascular risks in the cancer population. Such personalized data could assist primary prevention strategies. An indi-vidualized approach to cardiovascular risk assessment is of particular interest to cancer patients who are often subject to polypharmacy and
    focused care [7]. In addition: CAC, in A 61603 to FRS, may also be predic-tive of other important cardiac conditions which contribute to morbid-ity in cancer patients such as atrial fibrillation and heart failure [8–10]. CAC could therefore provide a potential risk stratification concerning both cardiovascular and cardiac risk assessment in cancer patients.
    Assessment of cardiac risk and cardiovascular susceptibility are often undertaken at cardiac-oncology clinics [11]. We therefore sought to establish the prevalence of CAC on CT chest exams from patients with breast cancer attending a cardiac oncology clinic. We hypothesized that CAC would predict cardiovascular and cardiac events in this popu-lation and that CAC would be incremental to FRS in risk prediction.
    2. Methods
    Permission for the study was granted by the Ottawa Hospitals research ethics board.
    408 consecutive breast cancer patients of all stages referred to the cardio-oncology clinic at the Ottawa General Hospital from 2009 to 2017 were included in the study. 269 patients had undergone prior non-ECG gated Chest CT either as part of cancer staging, disease surveillance or to investigate concomitant morbidity (pneumonia or pulmonary embolism). 256 fulfilled the inclusion criteria (a history of breast cancer, prior non-ECG gated CT chest and no documented coronary artery disease, or atrial fibrillation). Patients were excluded from the analysis due to the absence of chest CT or a clinical history of prior atrial fibrillation or coronary artery disease (myocardial infarction or coronary revascularization).
    2.2. CT chest derived coronary calcium score
    CT scans were performed using multi-detector CTs [12]. Images were non-ECG gated chest CT scans with or without contrast enhancement [1,13,14]. Soft tissue kernel slice-thickness images ranged from 1.0 to 5.0 mm and were acquired using Aquillon 16-, 64-, 320-detector (Toshiba Canada Medical Systems Limited, Markham, Ontario); Lightspeed Plus 16- and Lightspeed 64-detector (General Electric Healthcare, Mississauga, Ontario) and Definition Flash dual source 64 × 2-detector (Siemens Medical Solutions Canada, Oakville, Ontario). CT studies were reviewed to determine the presence of CAC without additional processing using patient archiving and communication system (PACS) software (McKesson Radiology 12.3, McKesson Canada, Mississauga, Ontario).
    2.3. Coronary artery calcification (CAC)
    CAC was identified using a visual ordinal scoring system [2,15]. Calcium in the left main, left anterior descending artery, left circumflex and right coronary arteries was categorized as absent (0) or present. The degree of calcification (1, 2, or 3) was classified according to the vessel length that was calcified. 1 point was given for involvement of 1/3. 2 if 2/3 and 3 if N2/3 were calcified. The final score was the sum of the individual artery scores from 0 to 12 (see Fig. 3 in Supplementary data). Patients were divided into 4 groups based on their final scores: 0, 1–3, 4–5 and 6–12. These scores correspond to Agatston scores of 0, 1–100, 101–400 and N400 [15].