Detection of coronary artery calcium by ultrafast computed tomography and its relation to clinical evidence of coronary artery disease

doi:10.1016/0002-9149(94)90223-2

The American Journal of Cardiology

Volume 73, Issue 4, 1 February 1994, Pages 223-227

https://doi.org/10.1016/0002-9149(94)90223-2 Get rights and content

Abstract

Ultrafast computed tomography (CT) was used to evaluate the relation of coronary artery calcium, a marker of atherosclerosis, with a reported history of coronary artery disease (CAD) in 928 men and 290 women (mean age 53 ± 10 years; 11% with previous CAD). Total calcium score was calculated as the sum of each lesion-specific score, calculated as the product of pixel area and density >130 Hounsfeld units. Total score was 3 to 6 times greater (p < 0.01) and the probability of coronary artery calcium 30 to 40% greater (p < 0.01) in patients with a reported history of myocardial infarction, positive angiography, bypass surgery or angioplasty. From score cutoffs ranging from 1 to 500 for defining calcium, a negative test was accurate 93 to 98% of the time in ruling out CAD, whereas specificity increased from 43 to 93%; however, sensitivity decreased from 92 to 42%. A score cutoff of 50 showed modest sensitivity (78%) and specificity (71%); however, the predictive value for CAD from a positive test remained low (≤40%), regardless of score cutoff. From multiple logistic regression, total score was also an independent indicator of CAD after considering any effects due to age, sex and other CAD risk factors. Further study is needed to document the long-term prognostic use of coronary calcium screening, including criteria that best project future risk of CAD.

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ACR Appropriateness Criteria<sup>®</sup> Chronic Chest Pain—High Probability of Coronary Artery Disease
2017, Journal of the American College of Radiology
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In addition, general reliance on MRI in assessing chronic chest pain is hindered by the limited availability of advanced facilities and experienced personnel. MDCT as well as electron-beam CT (less commonly used) are used for detecting the presence and severity of calcification, a sign of coronary atherosclerosis [59-69]. In a large study of 10,377 patients, Shaw et al [70] showed that CCS provides independent incremental information in the prediction of all-cause mortality.
In patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD), imaging has major and diverse roles. First, imaging is valuable in determining and documenting the presence, extent, and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions. Second, imaging findings are important in determining the course of management of patients with suspected chronic myocardial ischemia and better defining those patients best suited for medical therapy, angioplasty/stenting, or surgery. Third, imaging is also necessary to determine the long-term prognosis and likely benefit from various therapeutic options by evaluating ventricular function, diastolic relaxation, and end-systolic volume. Imaging studies are also required to demonstrate other abnormalities, such as congenital/acquired coronary anomalies and severe left ventricular hypertrophy, that can produce angina in the absence of symptomatic coronary obstructive disease due to atherosclerosis. Clinical risk assessment is necessary to determine the pretest probability of CAD. Multiple methods are available to categorize patients as low, medium, or high risk for developing CAD.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
ACR Appropriateness Criteria® chronic chest pain-high probability of coronary artery disease
2011, Journal of the American College of Radiology
Imaging is valuable in determining the presence, extent, and severity of myocardial ischemia and the severity of obstructive coronary lesions in patients with chronic chest pain in the setting of high probability of coronary artery disease. Imaging is critical for defining patients best suited for medical therapy or intervention, and findings can be used to predict long-term prognosis and the likely benefit from various therapeutic options. Chest radiography, radionuclide single photon-emission CT, radionuclide ventriculography, and conventional coronary angiography are the imaging modalities historically used in evaluating suspected chronic myocardial ischemia. Stress echocardiography, PET, cardiac MRI, and multidetector cardiac CT have all been more recently shown to be valuable in the evaluation of ischemic heart disease. Other imaging techniques may be helpful in those patients who do not present with signs classic for angina pectoris or in those patients who do not respond as expected to standard management. The ACR Appropriateness Criteria^® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes
2005, Kidney International
Citation Excerpt :
Of greater concern is the development of silent myocardial infarction in diabetic subjects. Coronary artery calcium deposition is an integral part of the atherosclerotic plaque, and calcium scores obtained by electron beam computed tomography (EBCT) correlate with histologic, intravascular ultrasound, and angiographic measurements of CAD[30], [31]. Moreover, the coronary artery calcium score is an independent predictor of subsequent cardiac events in both symptomatic and asymptomatic individuals.
Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes.
Cardiovascular calcification (CVC) is common and severe in patients with end-stage renal disease on dialysis. However, the prevalence and severity of CVC is less well documented in patients with chronic kidney disease (CKD) not yet on dialysis.
Fifty-eight nondialyzed HA with type 2 diabetes and CKD were enrolled. They comprise 29 patients with stages 1 and 2 CKD (early CKD group) and 26 patients with stages 4 and 5 CKD (advanced CKD group). Coronary artery calcification (CAC) was measured by ultrafast spiral computed tomography, while peripheral artery calcification (PAC) was evaluated by plain x-ray of the chest, pelvis, thighs, and lower extremities.
The prevalence of CAC and PAC were significantly higher in the advanced CKD group compared to the early CKD group (73% vs. 38%; P < 0.01 and 85% vs. 35%; P < 0.0001, respectively). The median CAC scores were 18-fold greater in the advanced CKD group (138.9 vs. 7.8, respectively). By linear regression analysis, a strong association was found between the level of renal function and ln total volume of CAC.
Our data indicate that CAC and PAC are common and severe in HA diabetic patients with CKD not previously treated with dialysis, calcium-based phosphate binders, or vitamin D analogues. Lower level of renal function is associated with increased burden of vascular calcification in predialysis patients with CKD.
Dyslipidemia and progression of cardiovascular calcification (CVC) in patients with end-stage renal disease (ESRD)
2005, Kidney International, Supplement
Citation Excerpt :
As a result, studies have shown that more than 90% of atherosclerotic plaques in the older general population are calcified16. In the general population, coronary artery calcium scores as measured by EBCT have generally been used as an index of the atherosclerotic burden16-18. As such, calcium scores correlate with histologic, intravascular ultrasound, and angiographic measurements of CAD19-21.
Dyslipidemia and progression of cardiovascular calcification (CVC) in patients with end-stage renal disease (ESRD).Cardiovascular calcification (CVC) is commonly encountered both in the general population as well as in patients with end-stage renal disease (ESRD). The etiology of CVC in patients with ESRD is multifactorial. Despite that, current debate remains narrowly focused on the role of calcium loading from calcium-based phosphate binders (CBPB) in the pathogenesis and progression of CVC. Yet, the alleged link between these binders and CVC has not been substantiated in well-designed controlled trials. In contrast, the purported role of sevelamer, a non–calcium-based phosphate binder, in slowing the progression of CVC in dialysis patients has attracted widespread attention. The beneficial effect of sevelamer on progression of calcification was thought to be due to lower calcium loading during its use. However, an alternative and possibly more likely mechanism involves sevelamer-induced lowering of LDL cholesterol. In this context, previous studies in individuals with normal renal function have documented amelioration of coronary artery calcification (CAC) with reduction of LDL-cholesterol by treatment with HMG-CoA reductase inhibitors (statins). Given that CAC is a well-accepted marker of atherosclerosis, and that high plasma cholesterol concentration is one of the main risk factors for atherosclerosis, then it is not unreasonable to suspect that CAC may be halted or even reversed by lowering of LDL cholesterol level with statin therapy. Unfortunately, the effect of lowering the LDL-cholesterol level on CAC has not been studied in patients with ESRD. Therefore, conclusions about this important topic should await the results of well-designed clinical studies that control for all factors potentially implicated in the CVC burden of patients with ESRD. In this review, I will discuss the role of various potential mechanisms involved in the pathogenesis of CVC in patients with ESRD, and emphasize the role of dyslipidemia and its treatment in this important clinical entity.
Gender and age differences in the prevalence of coronary artery calcification in 953 Chinese subjects
2005, Heart Lung and Circulation
To investigate gender and age differences in coronary artery calcium (CAC) as determined by electron beam computed tomography (EBCT) in a Chinese population.
Consecutive patients undergoing EBCT were subdivided into groups based on gender and decades of life. They were further subdivided into three groups with respect to symptoms of coronary artery disease: typical, atypical and asymptomatic. Total calcium score was calculated for each patient and means calculated for each subgroup. Groups were then compared with respect to age, gender and symptoms.
During the study period, 953 patients (736 men and 217 female) aged 17–86 years (mean 55 ± 11 years) underwent EBCT. The prevalence of CAC increased significantly with increasing age. The mean total calcium score also increased with increasing age in males and females of each symptom subgroup. The prevalence of coronary artery calcification was significantly higher in males than females until age in excess of 69 years (p < 0.05). The prevalence of coronary artery calcification and mean calcium scores were significantly different between each symptom subgroup (p < 0.001) with higher scores and prevalence in patients with typical symptoms of coronary disease.
There is an increase in the prevalence of coronary artery calcification with age in Chinese subjects. Male subjects are more likely than female subjects to have detectable coronary calcification up until an age in excess of 69 years. Patients under the age of 70 years, with typical symptoms of coronary artery disease have a higher prevalence and mean calcium score than those with atypical or no symptoms.
Association among plasma levels of monocyte chemoattractant protein-1, traditional cardiovascular risk factors, and subclinical atherosclerosis
2004, Journal of the American College of Cardiology
Citation Excerpt :
First, we performed EBCT as the measure of atherosclerosis burden in the Dallas Heart Study. Given that age is so closely associated with coronary calcification (31–34), this relationship may have “dominated” a more subtle association between MCP-1 and CAC in multivariable models. Association studies with MCP-1 should be performed using other measures of subclinical atherosclerosis that may be less dependent on age, such as carotid intima-media thickness, magnetic resonance imaging of the vascular wall, and novel plaque imaging modalities.
We sought to evaluate the association between plasma levels of monocyte chemoattractant protein (MCP)-1 and the risk for subclinical atherosclerosis.
Monocyte chemoattractant protein is a chemokine that recruits monocytes into the developing atheroma and may contribute to atherosclerotic disease development and progression. Plasma levels of MCP-1 are independently associated with prognosis in patients with acute coronary syndromes, but few population-based data are available from subjects in earlier stages of atherosclerosis.
In the Dallas Heart Study, a population-based probability sample of adults in Dallas County ≤65 years old, plasma levels of MCP-1 were measured in 3,499 subjects and correlated with traditional cardiovascular risk factors, high-sensitivityC-reactive protein (hs-CRP), and coronary artery calcium (CAC) measured by electron beam computed tomography.
Higher MCP-1 levels were associated with older age, white race, family history of premature coronary disease, smoking, hypertension, diabetes, hypercholesterolemia, and higher levels of hs-CRP (p < 0.01 for each). Similar associations were observed between MCP-1 and risk factors in the subgroup of participants without detectable CAC. Compared with the subjects in the lowest quartile of MCP-1, the odds of prevalent CAC (CAC score ≥10) for subjects in the second, third, and fourth quartiles were 1.30 (95% confidence interval [CI] 0.99 to 1.73), 1.60 (95% CI 1.22 to 2.11), and 2.02 (95% CI 1.54 to 2.63), respectively. The association between MCP-1 and CAC remained significant when adjusted for traditional cardiovascular risk factors, but not when further adjusted for age.
In a large population-based sample, plasma levels of MCP-1 were associated with traditional risk factors for atherosclerosis, supporting the hypothesis that MCP-1 may mediate some of the atherogenic effects of these risk factors. These findings support the potential role of MCP-1 as a biomarker target for drug development.

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Detection of coronary artery calcium by ultrafast computed tomography and its relation to clinical evidence of coronary artery disease

Abstract

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Clin Radiol

Coronary arterial calcification

Am J Med Sci

Coronary calcification: relationship to clinically significant coronary lesions and race, sex and topographic distribution

Circulation