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Coronary Artery Disease: HELP
Articles by Naser Ahmadi
Based on 24 articles published since 2010
(Why 24 articles?)
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Between 2010 and 2020, Naser Ahmadi wrote the following 24 articles about Coronary Artery Disease.
 
+ Citations + Abstracts
1 Editorial Aortic valve calcification and subclinical coronary atherosclerosis. 2010

Ahmadi, Naser / Clouse, Melvin. · ·J Cardiovasc Comput Tomogr · Pubmed #20159628.

ABSTRACT: -- No abstract --

2 Clinical Trial Coronary distensibility index measured by computed tomography is associated with the severity of coronary artery disease. 2010

Ahmadi, Naser / Shavelle, David / Nabavi, Vahid / Hajsadeghi, Fereshteh / Moshrefi, Shahin / Flores, Ferdinand / Azmoon, Shahdad / Mao, Song S / Ebrahimi, Ramin / Budoff, Matthew. ·Los Angeles Biomedical Research Institute at Harbor University of California Los Angeles (UCLA) Medical Center, Torrance, CA 90502, USA. nahmadi@labiomed.org ·J Cardiovasc Comput Tomogr · Pubmed #20430343.

ABSTRACT: BACKGROUND: Atherosclerotic changes within the coronary artery wall can affect vessel distensibility. OBJECTIVE: This study evaluated the relationship between the coronary distensibility index (CDI) and the severity of coronary artery disease (CAD) measured by computed tomographic angiography (CTA). METHODS: One hundred thirteen subjects, age 63 +/- 10 years, 32% women, who underwent coronary artery calcium (CAC) scanning and CTA, were studied. Early diastolic and mid diastolic (MD) cross-section area (CSA) of the left anterior descending (LAD) artery were measured 5 mm distal to the left main bifurcation. CDI was defined as Deltalumen CSA/[lumen CSA in MD x estimated central pulse pressure (eCPP)] x 10(3) {eCPP = 0.77 x peripheral pulse pressure}. LAD diameter measured by CTA and quantitative coronary angiography (QCA) was compared in 19 subjects without CAD. CAD was defined as normal (no stenosis and CAC 0), mild (stenosis or= 70%) on CTA. RESULTS: Excellent correlation was observed between CTA and QCA measured by CDI (r(2) = 0.96, P = 0.0001). CDI decreased from normal coronaries (6.75 +/- 1.43) to arteries with mild (5.78 +/- 1.45), moderate (3.96 +/- 1.06), and severe (3.31 +/- 1.06) disease (P = 0.004). The risk factor adjusted odds ratio of lowest versus 2 upper tertiles of CDI was 1.28 for mild, 8.47 for moderate, and 10.59 for severe CAD compared with the normal cohort. The area under the ROC curve to predict obstructive CAD (stenosis >or= 50%) increased significantly from 0.71 to 0.84 by addition of CDI to CAC (P < 0.05). CONCLUSION: CTA-measured CDI is inversely related to the severity of CAD independent of age, sex, cardiovascular risk factors, and CAC.

3 Article The Long-Term Clinical Outcome of Posttraumatic Stress Disorder With Impaired Coronary Distensibility. 2018

Ahmadi, Naser / Hajsadeghi, Fereshteh / Nabavi, Volker / Olango, Garth / Molla, Mohammed / Budoff, Matthew / Vaidya, Nutan / Quintana, Javier / Pynoos, Robert / Hauser, Peter / Yehuda, Rachel. ·From the David Geffen School of Medicine (Ahmadi, Hajsadeghi, Nabavi, Olango, Molla, Budoff, Quintana, Pynoos, Hauser), University of California Los Angeles · Captain James A Lovell Federal Health Care Center (Vaidya), Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL · and James J Peters Veteran Healthcare System (Yehuda), Icahn School of Medicine at Mount Sinai, New York, NY. ·Psychosom Med · Pubmed #29538055.

ABSTRACT: OBJECTIVE: Coronary Distensibility Index (CDI) impairments reflect endothelial-dependent process associated with vulnerable-plaque composition. This study investigated the relation of impaired CDI with posttraumatic stress disorder (PTSD) and their predictive value for major adverse cardiovascular events (MACE). METHODS: This study involved 246 patients (age = 63 [10] years, 12% women) with (n = 50) and without (n = 196) PTSD, who underwent computed tomography angiography to determine coronary artery disease and CDI. Extent of coronary artery disease was defined as normal, nonobstructive (<50% luminal stenosis), and obstructive (>50%). Incidence of MACE, defined as myocardial infarction or cardiovascular death, was documented during a mean follow-up of 50 months. Survival regression was employed to assess the longitudinal association of impaired CDI and PTSD with MACE. RESULTS: A significant inverse correlation between CDI and Clinical Global Impression Severity scale of PTSD symptoms was noted (r = .81, p = .001). CDI was significantly lower in patients with PTSD (3.3 [0.2]) compared with those without PTSD (4.5 [0.3]), a finding that was more robust in women (p < .05). Covariate-adjusted analyses revealed that the relative risk of MACE was higher in patients with PTSD (hazard ratio [HR] = 1.56, 95% CI = 1.34-3.14) and those with impaired CDI (HR = 1.95, 95% CI = 1.27-3.01, per standard deviation lower CDI value). There was also a significant interaction between PTSD and impaired CDI (HR = 3.24, 95% CI = 2.02-5.53). CONCLUSIONS: Impaired CDI is strongly associated with the severity of PTSD symptoms. Both impaired CDI and PTSD were independently associated with an increased risk of MACE during follow-up, and evidence indicated an interaction between these two factors. These findings highlight the important role of CDI in identifying individuals with PTSD at risk for MACE.

4 Article Randomized trial evaluating the effect of aged garlic extract with supplements versus placebo on adipose tissue surrogates for coronary atherosclerosis progression. 2018

Zeb, Irfan / Ahmadi, Naser / Flores, Ferdinand / Budoff, Matthew J. ·Department of Cardiology, Mount Sinai St Luke's Hospital (Bronx-Lebanon), New York, New York. · Department of Cardiology, David Geffen School of Medicine. · Department of Cardiology, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, California, USA. ·Coron Artery Dis · Pubmed #29140808.

ABSTRACT: AIMS: Increased epicardial adipose tissue (EAT), pericardial adipose tissue (PAT), periaortic adipose tissue (PaAT), and subcutaneous adipose tissue (SAT) are mediators of metabolic risk, and are associated with the severity of coronary artery calcium (CAC). Aged garlic extract (AGE) has been shown to reduce the progression of coronary atherosclerosis. This study evaluates the effect of AGE with supplements (AGE+S) on EAT, PAT, SAT, and PaAT. METHODS: Sixty asymptomatic participants participated in a randomized trial evaluating the effect of AGE+S versus placebo on coronary atherosclerosis progression, and underwent CAC at baseline and after 12 months of treatment. EAT, PAT, PaAT, and SAT volumes were measured on CAC scans. PAT was calculated as: intrathoracic adipose tissue-EAT. SAT was defined as the volume of fat depot anterior to the sternum and posterior to the vertebra. PaAT was defined as fat depot around the descending aorta. RESULTS: At 1 year, the increase in EAT, PAT, PaAT, and SAT was significantly lower in the AGE+S as compared with the placebo group (P<0.05). The odds ratios of increase in EAT, PAT, PaAT, and SAT were 0.63 [95% confidence interval (CI): 0.43-0.90], 0.72 (95% CI: 0.45-0.93), 0.81 (95% CI: 0.65-0.98), and 0.87 (CI: 0.52-0.98), respectively, compared with the placebo group, which even remained significant (all P<0.05) after adjustment for cardiovascular risk factors and statin therapy and BMI. CONCLUSION: This study shows that AGE+S is associated with favorable effects on reducing the progression rate of adipose tissue volumes.

5 Article Impaired coronary artery distensibility is an endothelium-dependent process and is associated with vulnerable plaque composition. 2016

Ahmadi, Naser / Ruiz-Garcia, Juan / Hajsadeghi, Fereshteh / Azen, Stanley / Mack, Wendy / Hodis, Howard / Lerman, Amir. ·David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. · Mayo Clinic, Mayo Graduate School of Medicine, Rochester, MN, USA. · Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. ·Clin Physiol Funct Imaging · Pubmed #25524149.

ABSTRACT: Coronary endothelial-dependent microvascular dysfunction, an early reversible stage of coronary artery disease (CAD), is associated with poor clinical outcome. The current study investigated whether coronary artery distensibility index (CDI) is associated with: (i) coronary endothelial-dependent microvascular dysfunction and (ii) vulnerable plaque composition among subjects with non-obstructive CAD. Seventy-four subjects with non-obstructive CAD (luminal stenosis <30%) were studied. In 20 subjects with and without coronary endothelial-dependent microvascular dysfunction, coronary flow reserve (CFR) of target segment during intracoronary (IC) infusion of acetylcholine (Ach) and bolus injection of adenosine as well as CDI at rest of corresponding target segment were measured. In 54 subjects, plaque compositions and CDI at rest of 154 non-obstructive coronary segments as well as proximal segment without disease were measured by intravascular ultrasound (IVUS). CDI was defined as: [(Early-diastolic cross-sectional-area (CSA) - End-diastolic CSA of target segment)/(end-diastolic CSA of target segment × coronary-pulse-pressure) × 10(3) ]. There is a direct association between endothelial dysfunction and impaired CDI of a coronary segment both in the given coronary segment and corresponding microvessels in which a strong agreement between CDI and CFR Ach (r(2)  = 0·85, P = 0·0001) was observed. Multivariable regression-analysis showed that CDI was an independent predictor of the vulnerable plaque characteristics. The risk of impaired CDI was 125% higher in segments with necrotic core and 60% higher in segments with fibrofatty components as compared to normal segments (P = 0·001). In conclusions, the current study reveals that impaired CDI is an endothelial-dependent process of both given coronary segment and corresponding microvessels and is associated with vulnerable plaque composition.

6 Article Traumatic brain injury, coronary atherosclerosis and cardiovascular mortality. 2015

Ahmadi, Naser / Hajsadeghi, Fereshteh / Yehuda, Rachel / Anderson, Nils / Garfield, David / Ludmer, Charles / Vaidya, Nutan. ·a University of California Los Angeles, School of Medicine , Los Angeles , CA , USA . · b Chicago Medical School, Rosalind Franklin University of Medicine and Science , North Chicago , IL , USA , and. · c James J. Peters Veterans Affairs Medical Center, Mount Sinai School of Medicine , New York , NY , USA. ·Brain Inj · Pubmed #26399477.

ABSTRACT: BACKGROUND: Traumatic-brain-injury (TBI) is a devastating-condition resulting in cerebral edema and ischemia. This study investigates the association of mild-TBI (mTBI) to sub-clinical atherosclerosis and cardiovascular (CV) mortality. METHODS: Five hundred and forty-three veterans without known coronary artery disease or diagnosed mental disorder, who underwent coronary artery calcium (CAC) scanning for clinical indications, were followed for a median of 4-years. Veterans' medical diagnoses and neuropsychiatric health status (mTBI vs non-mTBI) were evaluated using VA electronic medical records. CAC was defined as 0, 1-100, 101-400 and 400+. RESULTS: CAC was higher in mTBI, compared to without-mTBI (p < 0.05). TBI was more prevalent with the-severity of CAC (p < 0.05). Regression-analyses revealed that mTBI is an independent-predictor of CAC (p < 0.01). The CV mortality rate was 25% in mTBI and 10.5% in without-mTBI (p = 0.0001). Multivariable survival regression analyses revealed a significant-association between mTBI and CAC, with increased-risk of CV mortality (p < 0.05). The hazard-ratio of CV mortality was 5.25 in mTBI & CAC > 0, compared to without-mTBI & CAC = 0 (p < 0.05). The risk of CV-mortality was 2.25 for mTBI & CAC = 1-100, 4.93 for mTBI & CAC = 101-400 and 7.06 for mTBI & CAC ≥ 400, compared to matched CAC-categories without-mTBI (p < 0.05). The area under ROC curve to predict CV mortality was 0.64 for mTBI, 0.69 for mTBI & PTSD, 0.85 for mTBI & CAC > 0 and 0.92 for the combination. The prognostication of mTBI to predict CV mortality is superior to the Framingham risk score. Also the combination of mTBI & PTSD provided incremental prognostic values to predict CV mortality (p < 0.05). CONCLUSIONS: mTBI is associated with the severity of sub-clinical coronary atherosclerosis and independently predicts CV mortality.

7 Article Coronary CT angiography versus standard of care strategies to evaluate patients with potential coronary artery disease; effect on long term clinical outcomes. 2014

Budoff, Matthew J / Liu, Sandy / Chow, David / Flores, Ferdinand / Hsieh, Brian / Gebow, Dan / DeFrance, Tony / Ahmadi, Naser. ·Los Angeles Biomedical Research Institute, Torrance, CA, USA. Electronic address: mbudoff@labiomed.org. · Los Angeles Biomedical Research Institute, Torrance, CA, USA. · Stanford Medical Group, Palo Alto, CA, USA. ·Atherosclerosis · Pubmed #25463080.

ABSTRACT: BACKGROUND: Previous studies have shown that computed tomography coronary angiography (CTA) in patients with suspected coronary artery disease (CAD) predicts short term adverse events. However, there is no current data on whether identifying atherosclerosis on CTA impacts outcomes. We performed a case-control study to assess whether information from CTA can improve outcomes. METHODS: 4244 symptomatic patients (mean age 58 ± 9, 62.5% male) without known CAD who underwent CTA (n = 2538) to rule out CAD were matched to 1706 patients who underwent standard of care in an academic cardiology clinic. Patients were propensity-matched by gender, age, ethnicity, CAD risk factors and follow-up duration. The primary outcome measure was all-cause mortality. Multivariable Cox proportional hazards models incorporated age, gender and traditional risk factors for coronary disease as well as pre-test probability of CAD. RESULTS: There were no significant differences in age, gender, conventional risk factors between groups (p > 0.05). During a mean follow up of 80 ± 11 months, the overall death rate was 6.3% (270 deaths). Death rate was significantly lower in CTA group (n = 106, 4.2%) as compared to the control group (n = 184, 10.8%, p = 0.001). Event free survival was 95.8% and 89.2% in CTA and standard of care groups, respectively. Risk-adjusted hazard ratio of death were 2.5 (95%CI: 1.6-6.7, p = 0.003) in standard of care cohort as compared to CTA group. Multivariate analysis demonstrated that undergoing coronary CTA resulted in a risk reduction of 32%, p = 0.0001. CONCLUSIONS: Improved knowledge of atherosclerosis or increased anti-atherosclerotic therapies among those undergoing CTA may have contributed to improved survival. Our results provide evidence of potential benefit from scanning for atherosclerosis with CTA in symptomatic patients. Large randomized trials are warranted.

8 Article Increased epicardial adipose tissue is associated with coronary artery disease and major adverse cardiovascular events. 2014

Hajsadeghi, Fereshteh / Nabavi, Vahid / Bhandari, Ajay / Choi, Andrew / Vincent, Hunter / Flores, Ferdinand / Budoff, Matthew / Ahmadi, Naser. ·David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. Electronic address: drfsadeghi@gmail.com. · David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. ·Atherosclerosis · Pubmed #25463078.

ABSTRACT: BACKGROUND: Increased-epicardial-adipose tissue (EAT) is associated with the presence and severity of subclinical-atherosclerosis. This study investigates the long-term clinical-outcome of subjects with and without increased-EAT. METHODS: Two hundred and forty-five subjects, aged 61 ± 9 years and 34% women underwent clinically-indicated computed-tomography-angiography (CTA), and body-surface-area adjusted EAT was measured and were followed prospectively. CTA-diagnosed coronary-artery-disease (CAD) was defined as obstructive (luminal-stenosis ≥ 50%), non-obstructive (luminal-stenosis: 1-49%) and zero-obstruction. Major-adverse-cardiac-event (MACE) was defined as myocardial-infarction or cardiovascular-death. RESULTS: EAT increased significantly from subjects with zero-obstruction-coronaries (93 ± 37 cm(3)/m(2)) to non-obstructive-CAD (132 ± 25 cm(3)/m(2)) to obstructive-CAD (145 ± 35 cm(3)/m(2)) (P = 0.01). During the 48-month follow-up, the event-rate was 8.6% (21). The event free survival-rate decreased significantly from 99% in the lowest-quartile to 86.6% in the highest-quartile of EAT. After adjustment for risk-factors, the hazard ratio of MACE was 1.4, 3.1 and 5.7 in lower mid-, upper mid- and highest-quartiles of EAT as compared to lowest-quartile of EAT (P < 0.05). CONCLUSION: Increased EAT is directly associated with CAD and predicts MACE independent of the age, gender and conventional-risk-factors.

9 Article Relation of vascular stiffness with epicardial and pericardial adipose tissues, and coronary atherosclerosis. 2013

Choi, Tae-Young / Ahmadi, Naser / Sourayanezhad, Souraya / Zeb, Irfan / Budoff, Matthew J. ·Division of Cardiology, Kwandong University College of Medicine, Myongji Hospital, Goyang-Si, South Korea. ·Atherosclerosis · Pubmed #23537929.

ABSTRACT: OBJECTIVES: Increased measured vascular stiffness is an early marker of atherosclerosis and is associated with cardiovascular risk factors. Coronary artery calcium (CAC) and adipose tissues are accurate markers of overall burden of coronary atherosclerosis and metabolic status, respectively. We evaluated the relation of vascular stiffness with epicardial (EAT) and pericardial (PAT) adipose tissues, as well as the presence and severity of CAC. METHODS: One hundred and eleven consecutive subjects, mean age 59 ± 11 years, 78% male, underwent 64-multidetector row cardiac computed tomography (MDCT) and their carotid-radial pulse wave velocity (PWV) was measured using SphygmoCor tonometry. EAT and total thoracic adipose tissue (TAT) volumes were measured using MDCT. PAT was calculated as TAT-EAT. The highest tertile of EAT (≥111 ml) and PAT (≥103 ml) were defined as significant adipose tissue depots. RESULTS: PWV was moderately associated with EAT (r = 0.46, p < 0.001), and PAT (r = 0.41, p < 0.001). PWV increased proportionally with the severity of CAC from 0 to 400+. The relative risk of highest vs. lowest tertile of PWV was 3.03 (95% CI 1.22-7.51, p = 0.01) for significant EAT, 2.34 (95% CI 1.10-4.90, p = 0.02) for significant PAT and 2.46 (95% CI 1.13-3.14, p = 0.01) for significant CAC (CAC 100+) after adjustment for conventional cardiovascular risk factors. This relative risk was increased after combination of CAC 100+ with each significant adipose tissue. CONCLUSIONS: Increased vascular stiffness is associated with increase in EAT, PAT and coronary atherosclerosis. EAT was associated with higher relative risk of PWV, compared with CAC, suggesting a role of adipose tissue in vascular stiffness.

10 Article Aged garlic extract with supplement is associated with increase in brown adipose, decrease in white adipose tissue and predict lack of progression in coronary atherosclerosis. 2013

Ahmadi, Naser / Nabavi, Vahid / Hajsadeghi, Fereshteh / Zeb, Irfan / Flores, Ferdinand / Ebrahimi, Ramin / Budoff, Matthew. ·Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA; Greater Los Angeles Veterans Administration Medical Center, UCLA-School of Medicine, Los Angeles, CA, USA. Electronic address: ahmadi@ucla.edu. ·Int J Cardiol · Pubmed #23453866.

ABSTRACT: BACKGROUND: Aged garlic extract with supplement (AGE-S) significantly reduces coronary artery calcium (CAC). We evaluated the effects of AGE-S on change in white (wEAT) and brown (bEAT) epicardial adipose tissue, homocysteine and CAC. METHODS: Sixty subjects, randomized to a daily capsule of placebo vs. AGE-S inclusive of aged garlic-extract (250 mg) plus vitamin-B12 (100 μg), folic-acid (300 μg), vitamin-B6 (12.5mg) and L-arginine (100mg) underwent CAC, wEAT and bEAT measurements at baseline and 12 months. The postcuff deflation temperature-rebound index of vascular function was assessed using a reactive-hyperemia procedure. Vascular dysfunction was defined according to the tertiles of temperature-rebound at 1 year of follow-up. CAC progression was defined as an annual-increase in CAC>15%. RESULTS: From baseline to 12 months, there was a strong correlation between increase in wEAT and CAC (r(2)=0.54, p=0.0001). At 1 year, the risks of CAC progression and increased wEAT and homocysteine were significantly lower in AGE-S to placebo (p<0.05). Similarly, bEAT and temperature-rebound were significantly higher in AGE-S as compared to placebo (p<0.05). Strong association between increase in temperature-rebound and bEAT/wEAT ratio (r(2)=0.80, p=0.001) was noted, which was more robust in AGE-S. Maximum beneficial effect of AGE-S was noted with increase in bEAT/wEAT ratio, temperature-rebound, and lack of progression of homocysteine and CAC. CONCLUSIONS: AGE-S is associated with increase in bEAT/wEAT ratio, reduction of homocysteine and lack of progression of CAC. Increases in bEAT/wEAT ratio correlated strongly with increases in vascular function measured by temperature-rebound and predicted a lack of CAC progression and plaque stabilization in response to AGE-S.

11 Article Impact of coronary artery calcium progression and statin therapy on clinical outcome in subjects with and without diabetes mellitus. 2013

Kiramijyan, Sarkis / Ahmadi, Naser / Isma'eel, Hussain / Flores, Ferdinand / Shaw, Leslee J / Raggi, Paolo / Budoff, Matthew J. ·Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA. skiramijyan@gmail.com ·Am J Cardiol · Pubmed #23206921.

ABSTRACT: Coronary artery calcium (CAC) is a marker of atherosclerosis, and CAC progression is independently associated with all-cause mortality in the general population but not convincingly in subjects with diabetes mellitus (DM). The aim of this study was to ascertain the differences in the rates of CAC progression, the effect of statin therapy, and all-cause mortality in subjects with and without DM. The study group consisted of 296 asymptomatic subjects with type 2 DM and 300 controls (mean age 59 ± 6 years, 29% women) who underwent baseline and follow-up CAC scans within a 2-year interval. Absolute annual CAC score change, percentage annual CAC progression(ΔCAC%), event-free survival, and the effect of statin therapy on survival were all assessed. The mean follow-up duration was 56 ± 11 months. Absolute annual CAC score change was 81 ± 10 in subjects with DM and 34 ± 5 in controls (p = 0.0001). Percentage annual CAC progression was 29 ± 9% in subjects with DM and 10 ± 7% in controls (p = 0.0001). The hazard ratios of death in 3 groups of subjects with DM compared to controls without DM were 1.88 (95% confidence interval [CI] 1.51 to 2.36, p = 0.0001) for ΔCAC of 10% to 20%, 2.29 (95% CI 1.56 to 3.38, p = 0.0001) for ΔCAC of 21% to 30%, and 6.95 (95% CI 2.23 to 11.53, p = 0.0001) for ΔCAC >30%, all compared to ΔCAC <10%. The adjusted hazard ratios of all-cause mortality in subjects receiving compared to those not receiving statin therapy were 0.29 (95% CI 0.13 to 0.56, p = 0.001) in those without DM and without CAC progression, 0.51 (95% CI 0.21 to 0.73, p = 0.001) in those with DM and without CAC progression, and 0.71 (95% CI 0.25 to 0.91, p = 0.003) in those without DM and with CAC progression, with all 3 groups compared to 1.0 (reference) in those with DM, with CAC progression and without statin therapy. In conclusion, CAC progression was greater and event-free survival lower in patients with DM compared to controls in proportion to the extent of CAC progression. These results suggest that CAC progression is an independent predictor of all-cause mortality in patients with DM.

12 Article Association of coronary artery calcium score and vascular dysfunction in long-term hemodialysis patients. 2013

Zeb, Irfan / Ahmadi, Naser / Molnar, Miklos Z / Li, Dong / Shantouf, Ronney / Hatamizadeh, Parta / Choi, Taeyoung / Kalantar-Zadeh, Kamyar / Budoff, Matthew J. ·Harold Simmons Center for Chronic Disease Research & Epidemiology, Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90509-2910, USA. ·Hemodial Int · Pubmed #22962941.

ABSTRACT: Long-term hemodialysis patients are prone to an exceptionally high burden of cardiovascular disease and mortality. The novel temperature-based technology of digital thermal monitoring (DTM) of vascular reactivity appears associated with the severity of coronary artery disease in asymptomatic population. We hypothesized that in hemodialysis patients, the DTM and coronary artery calcium (CAC) score have a gradient association that follows that of subjects without kidney disease. We examined the cross-sectional DTM-CAC associations in a group of long-term hemodialysis patients, and their 1:1 matched normal counterpart. Area under the curve for temperature (TMP-AUC), the surrogate of the DTM index of vascular function, was assessed after a 5-minute arm-cuff reactive hyperemia test. Coronary calcium score was measured via electron beam computed tomography or multidetector computed tomography scan. We studied 105 randomly recruited hemodialysis patients (age: 58 ± 13 years, 47% men) and 105 age- and gender-matched controls. In hemodialysis patients vs. controls, TMP-AUC was significantly worse (114 ± 72 vs. 143 ± 80, P = 0.001) and CAC score was higher (525 ± 425 vs. 240 ± 332, P < 0.001). Hemodialysis patients were 14 times more likely to have CAC score >1000 as compared with controls. After adjustment for known confounders, the relative risk for case vs. control for each standard deviation decrease in TMP-AUC was 1.46 (95% confidence interval: 1.12-1.93, P = 0.007). Vascular reactivity measured via the novel DTM technology is incrementally worse across CAC scores in hemodialysis patients, in whom both measures are even worse than their age- and gender-matched controls. The DTM technology may offer a convenient and radiation-free approach to risk-stratify hemodialysis patients.

13 Article Comparison of coronary calcium in firefighters with abnormal stress test findings and in asymptomatic nonfirefighters with abnormal stress test findings. 2012

Pillutla, Priya / Li, Dong / Ahmadi, Naser / Budoff, Matthew J. ·Division of Cardiology, Harbor-UCLA Medical Center, Torrance, California, USA. ·Am J Cardiol · Pubmed #22105785.

ABSTRACT: Firefighters are known to have an elevated rate of sudden cardiac death compared to the general population. It is unclear whether this finding is related to underlying cardiovascular risk factors or whether firefighting inherently carries additional risk. Our objective was to determine whether Los Angeles county firefighters have higher coronary artery calcium (CAC) scores and increased atherosclerosis as determined using 64-slice cardiac, multidetector computed tomography. A total of 647 asymptomatic firefighters evaluated as a part of a wellness protocol were referred for cardiac multidetector computed tomography to evaluate abnormal exercise treadmill test findings. They were matched by age and cardiovascular risk factors, with 2,533 asymptomatic subjects undergoing cardiac computed tomography because of abnormal electrocardiographic or exercise treadmill test findings. CAC and the prevalence of obstructive coronary artery disease by vessel were derived. Finally, the predictors of CAC were analyzed using regression analysis. Of the firefighters, 49% had detectable CAC compared to 43% of controls (p = 0.015). Although the lesions were most prevalent in the left anterior descending artery in both groups, more firefighters had any left anterior descending artery stenosis compared to the controls (p <0.0001). The firefighters also had more left main coronary artery lesions than did the controls (p <0.0001). The firefighters had significantly greater CAC scores than did with the controls (p <0.001). Furthermore, the firefighters had significantly greater mean CAC scores (66 ± 8 in firefighters vs 33 ± 4 for controls, p <0.001). Firefighter status was independently associated with a 41-point increase in the CAC score (p <0.001). In conclusion, asymptomatic firefighters had more atherosclerosis and CAC than the matched controls.

14 Article Relation of subclinical left and right ventricular dysfunctions measured by computed tomography angiography with the severity of coronary artery disease. 2011

Ahmadi, Naser / Mao, Song S / Hajsadeghi, Fereshteh / Hacioglu, Yalcin / Flores, Ferdinand / Gao, Yanlin / Ebrahimi, Ramin / Budoff, Matthew. ·Los Angeles Biomedical Research Institute, Harbor UCLA Medical Center, Torrance, California 90502, USA. nahmadi@labiomed.org ·Coron Artery Dis · Pubmed #21666441.

ABSTRACT: OBJECTIVE: Ventricular dysfunction in asymptomatic patients is directly linked to the eventual development of symptomatic congestive heart failure. This study investigates whether subclinical left ventricular (LV) and right ventricular (RV) dysfunctions measured by computed tomography angiography is associated with the severity of coronary artery disease (CAD). METHODS AND RESULTS: We studied 1608 consecutive patients with suspected CAD (age 62 ± 10 years, 64% male), who underwent coronary artery calcium (CAC) scanning and computed tomography angiography. RV and LV volumes at end systole and end diastole were measured, and stroke volume and ejection fraction were calculated using the Simpson method and piecewise smooth subdivision surface (PSSS) method. Analysis by Simpson was performed on short axis and apical four-chamber views. Axial images were used to measure RV and LV volumes by the PSSS method. CAD was defined as normal, nonobstructive, and obstructive (0% stenosis, luminal stenosis 1-49 and 50%+, respectively). There was a strong agreement between PSSS and Simpson method RV ejection fraction (RVEF) and LV ejection fraction (LVEF) measurement. RVEF and LVEF decreased proportionally from CAC 0 to CAC 100+, also from normal-to-diseased coronaries (P=0.001). After adjustment for cardiovascular risk factors, the mean LVEF and RVEF decreased 2.8 and 2.4%, respectively in CAC 100+ compared with CAC 0. Similarly, LVEF and RVEF decreased significantly in nonobstructive CAD (-3.5 and -3.1%, respectively) and obstructive CAD (-5.9 and -4.5%, respectively) compared with normal coronaries, respectively (P<0.05). The relative risk of each 5% decrease in LVEF and RVEF was 1.33 and 1.29 for nonobstructive CAD and 1.54 and 1.33 for obstructive CAD, respectively. CONCLUSION: The presence and severity of coronary atherosclerosis is significantly associated with subclinical RV and LV dysfunctions.

15 Article Post-traumatic stress disorder, coronary atherosclerosis, and mortality. 2011

Ahmadi, Naser / Hajsadeghi, Fereshteh / Mirshkarlo, Hormoz B / Budoff, Matthew / Yehuda, Rachel / Ebrahimi, Ramin. ·Greater Los Angeles Veterans Administration Medical Center, University of California-Los Angeles School of Medicine, Los Angeles, California, USA. ·Am J Cardiol · Pubmed #21530936.

ABSTRACT: Post-traumatic stress disorder (PTSD) is associated with increased risk of multiple medical problems including myocardial infarction. However, a direct link between PTSD and atherosclerotic coronary artery disease (CAD) has not been made. Coronary artery calcium (CAC) score is an excellent method to detect atherosclerosis. This study investigated the association of PTSD to atherosclerotic CAD and mortality. Six hundred thirty-seven veterans without known CAD (61 ± 9 years of age, 12.2% women) underwent CAC scanning for clinical indications and their psychological health status (PTSD vs non-PTSD) was evaluated. In subjects with PTSD, CAC was more prevalent than in the non-PTSD cohort (76.1% vs 59%, p = 0.001) and their CAC scores were significantly higher in each Framingham risk score category compared to the non-PTSD group. Multivariable generalized linear regression analysis identified PTSD as an independent predictor of presence and extent of atherosclerotic CAD (p <0.01). During a mean follow-up of 42 months, the death rate was higher in the PTSD compared to the non-PTSD group (15, 17.1%, vs 57, 10.4%, p = 0.003). Multivariable survival regression analyses revealed a significant linkage between PTSD and mortality and between CAC and mortality. After adjustment for risk factors, relative risk (RR) of death was 1.48 (95% confidence interval [CI] 1.03 to 2.91, p = 0.01) in subjects with PTSD and CAC score >0 compared to subjects without PTSD and CAC score equal to 0. With a CAC score equal to 0, risk of death was not different between subjects with and without PTSD (RR 1.04, 95% CI 0.67 to 6.82, p = 0.4). Risk of death in each CAC category was higher in subjects with PTSD compared to matched subjects without PTSD (RRs 1.23 for CAC scores 1 to 100, 1.51 for CAC scores 101 to 400, and 1.81 for CAC scores ≥400, p <0.05 for all comparisons). In conclusion, PTSD is associated with presence and severity of coronary atherosclerosis and predicts mortality independent of age, gender, and conventional risk factors.

16 Article Assessment of progression of coronary atherosclerosis using multidetector computed tomography angiography (MDCT). 2011

Hamirani, Yasmin S / Kadakia, Jigar / Pagali, Sandeep R / Zeb, Irfan / Isma'eel, Hussain / Ahmadi, Naser / Sarraf, Guilda / Choi, TaeYoung / Patel, Amish / Budoff, Matthew J. ·Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, United States. Electronic address: yasminshamshuddin@yahoo.com. · Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, United States. ·Int J Cardiol · Pubmed #21419503.

ABSTRACT: -- No abstract --

17 Article Mortality in individuals without known coronary artery disease but with discordance between the Framingham risk score and coronary artery calcium. 2011

Ahmadi, Naser / Hajsadeghi, Fereshteh / Blumenthal, Roger S / Budoff, Matthew J / Stone, Gregg W / Ebrahimi, Ramin. ·Greater Los Angeles VA Medical Center, UCLA School of Medicine, Los Angeles, CA, USA. ·Am J Cardiol · Pubmed #21247539.

ABSTRACT: A risk-management approach based on the Framingham risk score (FRS), although useful in preventing future coronary artery disease (CAD) events, is unable to identify a considerable portion of patients with CAD who need aggressive medical management. Coronary artery calcium (CAC), an anatomic marker of atherosclerosis, correlates well with presence and extent of CAD. This study investigated mortality risk associated with CAC score and FRS in subjects classified as "low risk" versus "high risk" based on FRS. In total 730 veterans without known CAD (61 ± 10 years old, 12.8% women) underwent measurement of their FRS and CAC. Subjects were classified as "discordant low risk" (DLR) if their FRS was <10% and CAC score was ≥ 100 (n = 108, 14.8%) or "discordant high risk" (DHR) if their FRS was ≥ 20% and CAC score was 0 (n = 104, 14.2%). Survival analysis was used to compare mortality rates associated with FRS and CAC in DLR versus DHR subjects. Mortality rate during the mean 48-month follow-up was 7.3% (n = 53) including 18.5% (n = 20) in the DLR group and 7.7% (n = 8) in the DHR group, respectively. Adjusted relative risks of mortality were 5.46 (95% confidence interval [CI] 2.44 to 12.20, p = 0.0001) in subjects with CAC score ≥ 100 compared to CAC score 0 and 1.35 (95% CI 1.01 to 4.32, p = 0.04) in subjects with FRS ≥ 20% compared to FRS <10%. Adjusted relative risk of mortality was 3.6 (95% CI 1.57 to 8.34, p = 0.003) for DLR compared to DHR. Areas under the receiver operator curve to predict mortality were 0.72 for FRS, 0.82 for CAC score, and 0.92 for the combination. In conclusion, the prognostic value of CAC to predict future mortality is superior to the FRS. Addition of CAC score to FRS significantly improves the identification and prognostication of patients without known CAD.

18 Article Mortality incidence of patients with non-obstructive coronary artery disease diagnosed by computed tomography angiography. 2011

Ahmadi, Naser / Nabavi, Vahid / Hajsadeghi, Fereshteh / Flores, Ferdinand / French, William J / Mao, Song S / Shavelle, David / Ebrahimi, Ramin / Budoff, Matthew. ·Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, California, USA. ·Am J Cardiol · Pubmed #21146679.

ABSTRACT: It was previously reported that event-free survival rates of symptomatic patients with coronary artery disease (CAD) diagnosed by computed tomographic angiography decreased incrementally from normal coronary arteries to obstructive CAD. The aim of this study was to investigate the clinical outcomes of symptomatic patients with nonobstructive CAD with luminal stenoses of 1% to 49% on the basis of coronary plaque morphology in an outpatient setting. Among 3,499 consecutive symptomatic subjects who underwent computed tomographic angiography, 1,102 subjects with nonobstructive CAD (mean age 59 ± 14 years, 69.9% men) were prospectively followed for a mean of 78 ± 12 months. Coronary plaques were defined as noncalcified, mixed, and calcified per patient. Multivariate Cox proportional-hazards models were developed to predict all-cause mortality. The death rate of patients with nonobstructive CAD was 3.1% (34 deaths). The death rate increased incrementally from calcified plaque (1.4%) to mixed plaque (3.3%) to noncalcified plaque (9.6%), as well as from single- to triple-vessel disease (p <0.001). In subjects with mixed or calcified plaques, the death rate increased with the severity of coronary artery calcium from 1 to 9 to ≥ 400. The risk-adjusted hazard ratios of all-cause mortality in patients with nonobstructive CAD were 3.2 (95% confidence interval 1.3 to 8.0, p = 0.001) for mixed plaques and 7.4 (95% confidence interval 2.7 to 20.1, p = 0.0001) for noncalcified plaques compared with calcified plaques. The areas under the receiver-operating characteristic curve to predict all-cause mortality were 0.75 for mixed and 0.86 for noncalcified coronary lesions. In conclusion, this study demonstrates that the presence of noncalcified and mixed coronary plaques provided incremental value in predicting all-cause mortality in symptomatic subjects with nonobstructive CAD independent of age, gender, and conventional risk factors.

19 Article Non-contrast cardiac computed tomography can accurately detect chronic myocardial infarction: Validation study. 2011

Gupta, Mohit / Kadakia, Jigar / Hacioglu, Yalcin / Ahmadi, Naser / Patel, Amish / Choi, Taeyoung / Yamada, Gregg / Budoff, Matthew. ·Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, CA 90502, USA. mohit_gupta13@yahoo.com ·J Nucl Cardiol · Pubmed #21128040.

ABSTRACT: BACKGROUND: This study evaluates whether non-contrast cardiac computed tomography (CCT) can detect chronic myocardial infarction (MI) in patients with irreversible perfusion defects on nuclear myocardial perfusion imaging (MPI). METHODS: One hundred twenty-two symptomatic patients with irreversible perfusion defect (N = 62) or normal MPI (N = 60) underwent coronary artery calcium (CAC) scanning. MI on these non-contrast CCTs was visually detected based on the hypo-attenuation areas (dark) in the myocardium and corresponding Hounsfield units (HU) were measured. RESULTS: Non-contrast CCT accurately detected MI in 57 patients with irreversible perfusion defect on MPI, yielding a sensitivity of 92%, specificity of 72%, negative predictive value (NPV) of 90%, and a positive predictive value (PPV) of 77%. On a per myocardial region analysis, non-contrast CT showed a sensitivity of 70%, specificity of 85%, NPV of 91%, and a PPV of 57%. The ROC curve showed that the optimal cutoff value of LV myocardium HU to predict MI on non-contrast CCT was 21.7 with a sensitivity of 97.4% and specificity of 99.7%. CONCLUSION: Non-contrast CCT has an excellent agreement with MPI in detecting chronic MI. This study highlights a novel clinical utility of non-contrast CCT in addition to assessment of overall burden of atherosclerosis measured by CAC.

20 Article Increased epicardial, pericardial, and subcutaneous adipose tissue is associated with the presence and severity of coronary artery calcium. 2010

Ahmadi, Naser / Nabavi, Vahid / Yang, Eric / Hajsadeghi, Fereshteh / Lakis, Mustapha / Flores, Ferdinand / Zeb, Irfan / Bevinal, Manzoor / Ebrahimi, Ramin / Budoff, Matthew. ·Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, CA, USA. nahmadi@labiomed.org ·Acad Radiol · Pubmed #20947390.

ABSTRACT: RATIONALE AND OBJECTIVES: Epicardial adipose tissue (EAT), pericardial adipose tissue (PAT), and subcutaneous adipose tissue (SAT) are mediators of metabolic risk and may be involved in the pathogenesis of coronary artery disease. The aim of this study was to investigate the association of visceral and subcutaneous fat depots with the presence and severity of coronary artery calcium (CAC) in asymptomatic individuals. MATERIALS AND METHODS: One hundred eleven consecutive subjects underwent CAC assessment, and their Framingham risk scores were measured. EAT, total thoracic adipose tissue, and SAT volumes were measured from slice level 15 mm above to 30 mm below the ostium of the left main coronary artery. PAT was calculated as thoracic adipose tissue - EAT. SAT was defined as the volume of fat depot anterior to the sternum and posterior to the vertebra. CAC was defined as 0, 1 to 100, 101 to 400, or ≥ 400. Relative risk regression analysis was used to assess the association between fat depots and CAC. RESULTS: There were modest correlations between EAT (r = 0.58), PAT (r = 0.47), SAT (r = 0.34), and CAC (P < .01). EAT, PAT, and SAT increased proportionally with the severity of CAC in both genders (P < .05). After adjustment for cardiovascular risk factors and body mass index, the relative risks for each standard deviation increase in EAT, PAT, and SAT were 3.3 (95% confidence interval, 1.9-5.6), 2.7 (95% confidence interval, 1.6-3.9), and 2.6 (95% confidence interval, 1.5-4.4) for CAC ≥ 100 compared to CAC 0, respectively (P < .05). The area under the receiver-operating characteristic curve to predict CAC ≥ 100 was higher in each fat depot compared to Framingham risk score, and addition of fat depots to Framingham risk score provided maximum prognostication value to detect CAC ≥ 100. CONCLUSIONS: Increased EAT, PAT, and SAT are associated with the severity of CAC independent of risk factors.

21 Article Atherosclerotic plaque composition among patients with stenotic coronary artery disease on noninvasive CT angiography. 2010

Hamirani, Yasmin S / Nasir, Khurram / Gopal, Ambarish / Ahmadi, Naser / Pal, Raveen / Flores, Ferdinand / Blumenthal, Roger S / Budoff, Matthew J. ·Los Angeles Biomedical Research Institute, Harbor-UCLA, Torrance, California, USA. ·Coron Artery Dis · Pubmed #20418769.

ABSTRACT: INTRODUCTION: Multidetector computed tomographic angiography (MDCTA) has emerged as a promising noninvasive tool to rule out significant coronary artery disease (CAD). In addition, MDCTA also provides additional information about atherosclerotic plaque composition. In this study, we aim to assess whether differences in plaque composition exist across patients with varying degree of stenotic CAD disease. METHODS: Four hundred and sixteen patients with chest pain or shortness of breath thought to be related to CAD (64% males, mean age: 61+/-13 years), with 61 (15%) reporting type 2 diabetes mellitus, who underwent contrast-enhanced MDCTA were studied. Enrolled patients had an intermediate pretest probability of obstructive disease. RESULTS: Overall 51 patients (12%) had normal coronaries without evidence of plaque. In the remaining 365 patients, 45 (12%) and 83 (23%) were found to have stenosis 50-70% and at least 70% in at-least one coronary artery segment, respectively. Those with a higher degree of stenotic CAD showed significantly more coronary segments with exclusively calcified and mixed plaques. With increasing severity of CAD (<50 vs. 50-70% vs. >70% stenosis), the overall proportion of plaque burden was more likely to be mixed (18 vs. 38% vs. 44%) in nature as well less likely to be exclusively noncalcified (39 vs. 20 vs. 16%). Only two of 108 (2%) patients without any underlying calcification had significant CAD (stenosis> or =50%). CONCLUSION: Significant differences in plaque composition according to severity of CAD were observed in our study. Individuals with a higher likelihood of stenotic CAD were more likely to have higher underlying burden of exclusively calcified and mixed plaque. These findings should stimulate further investigations to assess the prognostic value of plaque according to their underlying composition.

22 Article Noninvasive quantitative evaluation of coronary artery stent patency using 64-row multidetector computed tomography. 2010

Abdelkarim, Murrad J / Ahmadi, Naser / Gopal, Ambarish / Hamirani, Yasmin / Karlsberg, Ronald P / Budoff, Matthew J. ·Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 West Carson Street, Box 400, Torrance, CA 90509, USA. murrad@ucla.edu ·J Cardiovasc Comput Tomogr · Pubmed #20159625.

ABSTRACT: BACKGROUND: Many studies have used multidetector computed tomography (MDCT) angiography to evaluate coronary stents qualitatively but not quantitatively. OBJECTIVES: This study sought to validate a method of quantitatively evaluating stent patency by using 64-row compared with invasive coronary angiography (ICA) and to evaluate the stent size threshold of MDCT in detecting stent patency. METHODS: Stented lesions (n=122) in 55 patients (age, 65+/-10 years; 90% men) who underwent both 64-row MDCT and ICA were studied. Density measurements in Hounsfield units (HUs) and stent diameters in millimeters were recorded in the stented segments, with the density of the ascending aorta (AO) taken as a reference. The ratio of the average of stent's proximal, middle, and distal densities to mean AO density was defined as the AS/AO HU. Threshold values for the detection of stent patency were examined by using receiver operator characteristic (ROC) curve analysis. RESULTS: One hundred six of 122 stents were interpretable. By ICA, 24 stents were found to have in-stent restenosis (22 interpretable and 2 noninterpretable with MDCT). The ROC curve showed that the optimal cutoff value of AS/AO HU to predict stent patency on MDCT was 0.81 with sensitivity of 90.9%, specificity of 95.2%, and the optimal stent diameter cutoff value was > or = 2.5 mm with a sensitivity of 91.8% and a specificity of 93.8%. CONCLUSION: With 64-row MDCT, coronary stent patency can be evaluated quantitatively with high sensitivity and specificity and with adequate diagnostic accuracy in stents > or = 2.5 mm in diameter.

23 Article Relation of oxidative biomarkers, vascular dysfunction, and progression of coronary artery calcium. 2010

Ahmadi, Naser / Tsimikas, Sotirios / Hajsadeghi, Fereshteh / Saeed, Anila / Nabavi, Vahid / Bevinal, Manzoor A / Kadakia, Jigar / Flores, Ferdinand / Ebrahimi, Ramin / Budoff, Matthew J. ·Los Angeles Biomedical Research Institute, Harbor UCLA Medical Center, Torrance, California, USA. ·Am J Cardiol · Pubmed #20152239.

ABSTRACT: The relation between oxidative stress and coronary artery calcium (CAC) progression is currently not well described. The present study evaluated the relation among the biomarkers of oxidative stress, vascular dysfunction, and CAC. Sixty asymptomatic subjects participated in a randomized trial evaluating the effect of aged garlic extract plus supplement versus placebo and underwent measurement of CAC. The postcuff deflation temperature-rebound index of vascular function was assessed using a reactive hyperemia procedure. The content of oxidized phospholipids (OxPL) on apolipoprotein B-100 (apoB) particles detected by antibody E06 (OxPL/apoB), lipoprotein(a), IgG and IgM autoantibodies to malondialdehyde-low-density lipoprotein and apoB-immune complexes were measured at baseline and after 12 months of treatment. CAC progression was defined as an annual increase in CAC >15%. Vascular dysfunction was defined according to the tertiles of temperature-rebound at 1 year of follow-up. From baseline to 12 months, a strong inverse correlation was noted between an increase in CAC scores and increases in temperature-rebound (r(2) = -0.90), OxPL/apoB (r(2) = -0.85), and lipoprotein(a) (r(2) = -0.81) levels (p <0.0001 for all). The improvement in temperature-rebound correlated positively with the increases in OxPL/apoB (r(2) = 0.81, p = 0.0008) and lipoprotein(a) (r(2) = 0.79, p = 0.0001) but inversely with autoantibodies to malondialdehyde-low-density lipoprotein and apoB-immune complexes. The greatest CAC progression was noted with the lowest tertiles of increases in temperature-rebound, OxPL/apoB and lipoprotein(a) and the highest tertiles of increases in IgG and IgM malondialdehyde-low-density lipoprotein. In conclusion, the present results have documented a strong relation among markers of oxidative stress, vascular dysfunction, and progression of coronary atherosclerosis. Increases in OxPL/apoB and lipoprotein(a) correlated strongly with increases in vascular function and predicted a lack of progression of CAC.

24 Minor Normalization of automatic plaque quantification in cardiac computed tomography (CCT). 2011

Hamirani, Yasmin S / Zeb, Irfan / Pagali, Sandeep R / Kadakia, Jigar / Saraff, Guilda / Choi, TaeYoung / Ahmadi, Naser / Isma'eel, Hussain / Budoff, Matthew J. · ·Int J Cardiol · Pubmed #21106261.

ABSTRACT: -- No abstract --