- Email: [email protected]
Medial Arterial Calcification: Active Reversible Disease in Human Breast Arteries
984
Letters to the Editor
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 8, 2015 AUGUST 2015:983–9
catheter (St. Jude Medical, Westford, Massachusetts).
distinct from atherosclerosis (1). Because MAC is
OCT demonstrated high-intensity superficial regions
actively
of the intimal tissue with intensity attenuation (not
similarities
stent strut) after DEB dilation (Figures 1D to 1I).
formation, reversibility of MAC can be expected (1).
regulated to
the
by
processes
dynamic
bearing
process
of
great bone
The high-intensity superficial regions are thought
Although regression has been observed in animal
to represent an iopromide/paclitaxel mixture because
models, surprisingly limited observations of MAC
SeQuent Please uses the contrast medium iopromide
regression in humans are available. Currently none
to separate and evenly distribute paclitaxel molecules
of the cardiovascular medications has convincingly
over the surface of the balloon.
been shown to modify arterial calcification.
After the PCI procedure, we assessed whether the
Breast arterial calcification (BAC) is a type of MAC
contrast media could be visualized by OCT in an in vitro
regularly observed in mammography. In breast cancer
setting using the same system. We performed OCT on
screening programs, these arteries are visualized re-
a surgical grove that was wet with contrast medium
peatedly in a highly systematic fashion in the general
iomeprol, with a glove with dried contrast medium on
population. BAC can therefore serve as a convenient
the surface, and a glove without contrast medium.
model for MAC. BAC was found to be independently
We confirmed similar high-intensity superficial
associated with a moderately increased cardiovascular
regions due to dry contrast medium smeared on the
disease risk in the general population (2). A few cases of
surgical glove visualized by OCT. However, we could
BAC regression have been reported (3). The extent to
not visualize high-intensity superficial regions with
which BAC regression occurs remains unknown.
wet contrast medium or without contrast media.
We hypothesized that BAC regression would be
Further studies are required to determine whether
present in a population of women participating in
these areas do indeed represent iopromide and/or
breast cancer screening. From August 1, 1998, to
paclitaxel because we do not know with certainty the
January 31, 1999, we screened 32,589 women by
composition of the high-intensity regions.
mammography within the
Utrecht area in
the
Netherlands. After approval was obtained from the Tsubasa Sakamoto, MD Tomonori Itoh, MD* Yudai Shimoda, MD Tetsuya Fusazaki, MD Yoshihiro Morino, MD
institutional review board of the University Medical
*Division of Cardiology
with previous mammograms, if available. Regression
Department of Internal Medicine, Memorial Heart Center
was defined as a decrease of arterial calcification
Iwate Medical University
in at least 1 segment of an artery compared with
Center Utrecht, the mammograms of these women were systematically investigated for BAC by 1 of 2 board-certified radiologists. If BAC was present, the index mammogram was retrospectively compared
19-1, Uchimaru
previous mammograms, as illustrated in Figure 1. To
Morioka-City
determine whether regression had occurred, both
Iwate 020-8505
radiologists assessed the mammograms and resolved
Japan
disagreements in consensus meetings.
E-mail: [email protected] http://dx.doi.org/10.1016/j.jcmg.2014.09.013
REFERENCES 1. Xu B, Gao R, Wang J, et al. A prospective, multicenter, randomized trial of paclitaxel-coated balloon versus paclitaxel-eluting stent for the treatment of drug-eluting stent in-stent restenosis: results from the PEPCAD China ISR trial. J Am Coll Cardiol Intv 2014;7:204–11. 2. Lee SY, Hong MK, Shin DH, et al. Mechanisms of postintervention and ninemonth luminal enlargement after treatment of drug-eluting in-stent restenosis with a drug-eluting balloon. Am J Cardiol 2014;113:1468–73.
At least 1 previous mammogram was available for 25,296 women; of these, 2,948 (11.8%) had BAC in at least 1 breast on the index mammogram. Among these 2,948 women with BAC, the BAC had regressed in 98 women (3.3%; 95% confidence interval: 2.7 to 4.0). All women with regression of BAC were sent a questionnaire regarding their medical history and cardiovascular risk factors. The 43 women (44%) who completed the questionnaire were on average 72.5 years of age with a body mass index of 25.5 kg/m 2. Cardiovascular risk factors were common: 34.9% cur-
Medial Arterial Calcification:
rent or previous smokers, 37.2% with hypertension,
Active Reversible Disease in Human
36.6% with hypercholesterolemia, 14.6% with dia-
Breast Arteries
betes, and 11.9% with renal disease. Although no direct comparison is possible, the characteristics of these
Medial arterial calcification (MAC) is currently gaining
women appear comparable to those of women with
interest as a possible cause of cardiovascular disease
BAC described in published reports (2). Regression of
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 8, 2015
Letters to the Editor
AUGUST 2015:983–9
F I G U R E 1 Regression of Breast Artery Calcification
Two mammograms taken 4 years apart, showing regression of breast artery calcification.
BAC has been reported to occur after renal transplant, but this cannot fully explain our findings (3). The dual assessment of mammograms with BAC regression has diminished measurement error due to interrater variability; however, some measurement error may remain, due to between-mammogram variability. Most of the regression found, however,
REFERENCES 1. Lanzer P, Boehm M, Sorribas V, et al. Medial vascular calcification revisited: review and perspectives. Eur Heart J 2014;35:1515–25. 2. Iribarren C, Go AS, Tolstykh I, Sidney S, Johnston SC, Spring DB. Breast vascular calcification and risk of coronary heart disease, stroke, and heart failure. J Womens Health 2004;13:381–9. 3. McDougal BA, Lukert BP. Resolution of breast pain and calcification with renal transplantation. Arch Intern Med 1977;137:375–7.
represented clear interruptions in chains of calcium that were previously not interrupted, which was easy to ascertain. In conclusion, our study convincingly showed that
Tako-Tsubo Cardiomyopathy: A Heart Stressed Out of Energy?
MAC is a reversible process in the population. Further research into the causes of regression and possible effective therapy is warranted.
Tako-tsubo cardiomyopathy (TTC) is an acute form of left ventricular (LV) systolic dysfunction often
Eva J.E. Hendriks, MD* Pim A. de Jong, MD, PhD Joline W.J. Beulens, PhD Willem P.Th.M. Mali, MD, PhD Yvonne T. van der Schouw, PhD David Beijerinck, MD
following intense stress, but its pathophysiology
*University Medical Center Utrecht
Whatever the etiology of the acute insult, it is
Julius Center for Health Sciences and Primary Care
important to establish the nature of this state of
Postbus 85500
intense myocardial contractile dysfunction with
Huispostnummer Stratenum 6.131
preserved viability, as this may point to a potential
Utrecht
therapeutic target in those cases with a less favorable
3508 GA
clinical course. It is known that impaired cardiac
the Netherlands
energetic status is directly linked to clinical and
E-mail: [email protected]
subclinical LV dysfunction. We hypothesized that
http://dx.doi.org/10.1016/j.jcmg.2014.09.014
impaired cardiac energetics may occur in acute
remains elusive. Because of its reversible natural course without much apparent myocyte damage, as inferred by the lack of late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR), it has been a priori assumed that its evolution is benign (1).
985
Letters to the Editor
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 8, 2015 AUGUST 2015:983–9
catheter (St. Jude Medical, Westford, Massachusetts).
distinct from atherosclerosis (1). Because MAC is
OCT demonstrated high-intensity superficial regions
actively
of the intimal tissue with intensity attenuation (not
similarities
stent strut) after DEB dilation (Figures 1D to 1I).
formation, reversibility of MAC can be expected (1).
regulated to
the
by
processes
dynamic
bearing
process
of
great bone
The high-intensity superficial regions are thought
Although regression has been observed in animal
to represent an iopromide/paclitaxel mixture because
models, surprisingly limited observations of MAC
SeQuent Please uses the contrast medium iopromide
regression in humans are available. Currently none
to separate and evenly distribute paclitaxel molecules
of the cardiovascular medications has convincingly
over the surface of the balloon.
been shown to modify arterial calcification.
After the PCI procedure, we assessed whether the
Breast arterial calcification (BAC) is a type of MAC
contrast media could be visualized by OCT in an in vitro
regularly observed in mammography. In breast cancer
setting using the same system. We performed OCT on
screening programs, these arteries are visualized re-
a surgical grove that was wet with contrast medium
peatedly in a highly systematic fashion in the general
iomeprol, with a glove with dried contrast medium on
population. BAC can therefore serve as a convenient
the surface, and a glove without contrast medium.
model for MAC. BAC was found to be independently
We confirmed similar high-intensity superficial
associated with a moderately increased cardiovascular
regions due to dry contrast medium smeared on the
disease risk in the general population (2). A few cases of
surgical glove visualized by OCT. However, we could
BAC regression have been reported (3). The extent to
not visualize high-intensity superficial regions with
which BAC regression occurs remains unknown.
wet contrast medium or without contrast media.
We hypothesized that BAC regression would be
Further studies are required to determine whether
present in a population of women participating in
these areas do indeed represent iopromide and/or
breast cancer screening. From August 1, 1998, to
paclitaxel because we do not know with certainty the
January 31, 1999, we screened 32,589 women by
composition of the high-intensity regions.
mammography within the
Utrecht area in
the
Netherlands. After approval was obtained from the Tsubasa Sakamoto, MD Tomonori Itoh, MD* Yudai Shimoda, MD Tetsuya Fusazaki, MD Yoshihiro Morino, MD
institutional review board of the University Medical
*Division of Cardiology
with previous mammograms, if available. Regression
Department of Internal Medicine, Memorial Heart Center
was defined as a decrease of arterial calcification
Iwate Medical University
in at least 1 segment of an artery compared with
Center Utrecht, the mammograms of these women were systematically investigated for BAC by 1 of 2 board-certified radiologists. If BAC was present, the index mammogram was retrospectively compared
19-1, Uchimaru
previous mammograms, as illustrated in Figure 1. To
Morioka-City
determine whether regression had occurred, both
Iwate 020-8505
radiologists assessed the mammograms and resolved
Japan
disagreements in consensus meetings.
E-mail: [email protected] http://dx.doi.org/10.1016/j.jcmg.2014.09.013
REFERENCES 1. Xu B, Gao R, Wang J, et al. A prospective, multicenter, randomized trial of paclitaxel-coated balloon versus paclitaxel-eluting stent for the treatment of drug-eluting stent in-stent restenosis: results from the PEPCAD China ISR trial. J Am Coll Cardiol Intv 2014;7:204–11. 2. Lee SY, Hong MK, Shin DH, et al. Mechanisms of postintervention and ninemonth luminal enlargement after treatment of drug-eluting in-stent restenosis with a drug-eluting balloon. Am J Cardiol 2014;113:1468–73.
At least 1 previous mammogram was available for 25,296 women; of these, 2,948 (11.8%) had BAC in at least 1 breast on the index mammogram. Among these 2,948 women with BAC, the BAC had regressed in 98 women (3.3%; 95% confidence interval: 2.7 to 4.0). All women with regression of BAC were sent a questionnaire regarding their medical history and cardiovascular risk factors. The 43 women (44%) who completed the questionnaire were on average 72.5 years of age with a body mass index of 25.5 kg/m 2. Cardiovascular risk factors were common: 34.9% cur-
Medial Arterial Calcification:
rent or previous smokers, 37.2% with hypertension,
Active Reversible Disease in Human
36.6% with hypercholesterolemia, 14.6% with dia-
Breast Arteries
betes, and 11.9% with renal disease. Although no direct comparison is possible, the characteristics of these
Medial arterial calcification (MAC) is currently gaining
women appear comparable to those of women with
interest as a possible cause of cardiovascular disease
BAC described in published reports (2). Regression of
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 8, 2015
Letters to the Editor
AUGUST 2015:983–9
F I G U R E 1 Regression of Breast Artery Calcification
Two mammograms taken 4 years apart, showing regression of breast artery calcification.
BAC has been reported to occur after renal transplant, but this cannot fully explain our findings (3). The dual assessment of mammograms with BAC regression has diminished measurement error due to interrater variability; however, some measurement error may remain, due to between-mammogram variability. Most of the regression found, however,
REFERENCES 1. Lanzer P, Boehm M, Sorribas V, et al. Medial vascular calcification revisited: review and perspectives. Eur Heart J 2014;35:1515–25. 2. Iribarren C, Go AS, Tolstykh I, Sidney S, Johnston SC, Spring DB. Breast vascular calcification and risk of coronary heart disease, stroke, and heart failure. J Womens Health 2004;13:381–9. 3. McDougal BA, Lukert BP. Resolution of breast pain and calcification with renal transplantation. Arch Intern Med 1977;137:375–7.
represented clear interruptions in chains of calcium that were previously not interrupted, which was easy to ascertain. In conclusion, our study convincingly showed that
Tako-Tsubo Cardiomyopathy: A Heart Stressed Out of Energy?
MAC is a reversible process in the population. Further research into the causes of regression and possible effective therapy is warranted.
Tako-tsubo cardiomyopathy (TTC) is an acute form of left ventricular (LV) systolic dysfunction often
Eva J.E. Hendriks, MD* Pim A. de Jong, MD, PhD Joline W.J. Beulens, PhD Willem P.Th.M. Mali, MD, PhD Yvonne T. van der Schouw, PhD David Beijerinck, MD
following intense stress, but its pathophysiology
*University Medical Center Utrecht
Whatever the etiology of the acute insult, it is
Julius Center for Health Sciences and Primary Care
important to establish the nature of this state of
Postbus 85500
intense myocardial contractile dysfunction with
Huispostnummer Stratenum 6.131
preserved viability, as this may point to a potential
Utrecht
therapeutic target in those cases with a less favorable
3508 GA
clinical course. It is known that impaired cardiac
the Netherlands
energetic status is directly linked to clinical and
E-mail: [email protected]
subclinical LV dysfunction. We hypothesized that
http://dx.doi.org/10.1016/j.jcmg.2014.09.014
impaired cardiac energetics may occur in acute
remains elusive. Because of its reversible natural course without much apparent myocyte damage, as inferred by the lack of late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR), it has been a priori assumed that its evolution is benign (1).
985