Combined presence of aortic valve calcification and mitral annular calcification as a marker of the extent and vulnerable characteristics of coronary artery plaque assessed by 64-multidetector computed tomography
Introduction
Valvular calcification is generally considered a manifestation of atherosclerosis. Particularly, aortic valve calcification (AVC) and mitral annular calcification (MAC) were reported to be independently associated with both cardiovascular risk factors [1] and coronary artery calcification (CAC) [2], [3]. Recent epidemiological studies have also demonstrated that the combined presence of AVC and MAC is independent of and incremental to traditional risk assessment for the prediction of cardiovascular events, and is more strongly associated with cardiovascular mortality than is AVC or MAC alone [4].
Recent advances in contrast-enhanced data acquisition using multidetector computed tomography (MDCT) enabled the detection of calcified coronary atherosclerotic plaque (CAP), mixed coronary atherosclerotic plaque (MCAP), and noncalcified coronary atherosclerotic plaque (NCAP), which was in good agreement with intravascular ultrasound [5], [6]. Furthermore, 64-MDCT characterizes coronary plaque in terms of vascular positive remodeling, lipid-rich plaque, and adjacent spotty calcium, which may relate to the fact that vulnerable plaque is prone to rupture with subsequent coronary events [7], [8].
Although AVC and MAC are believed to be associated with overall coronary plaque burden using invasive coronary angiography or noncontrast-enhanced CT [2], [9], the impact of multiple heart valve calcium deposits on the distribution and vulnerable characteristics of coronary plaque is unknown. Thus, this study aimed to evaluate the value of the combined presence of AVC and MAC in predicting the extent and vulnerable characteristics of coronary plaque in patients with proven or suspected coronary artery disease (CAD).
Section snippets
Study population
Between August 2007 and December 2009, we enrolled 578 consecutive patients with proven or suspected CAD who were referred for 64-MDCT for the follow-up or diagnosis of CAD at our institution. Exclusion criteria included prior percutaneous coronary intervention (n = 92) or coronary artery bypass grafting (n = 90), irregular heart rhythm including chronic atrial fibrillation (n = 25), serum creatinine >1.5 mg/dl (n = 15), prior aortic or mitral valve surgery (n = 8), acute coronary syndrome (n = 8),
Patient characteristics
There were 201 subjects (62%) with AVC and 53 (17%) with MAC. Of 17 coronary artery segments, there was an average of 4.2 ± 3.4 segments with any plaque, 3.5 ± 3.3 with CAP, 1.3 ± 1.7 with MCAP, and 0.8 ± 1.2 with NCAP. Of 201 subjects with coronary plaque burden, 84 (26%) had coronary plaque with all three vulnerable characteristics (vascular positive remodeling, low CT density, and adjacent spotty calcification).
Clinical characteristics and CT findings stratified by the presence of valvular
Discussion
Our study demonstrates the relationship between valvular calcification and the presence of coronary plaque with positive vascular remodeling, low CT density, and adjacent spotty calcium, which may represent vulnerable characteristics as previously reported [7], [8]. These data suggest the presence of a common atherosclerotic pathway for development of valvular calcification and coronary plaque, and emphasize the importance of the combined presence of AVC and MAC as a marker of subclinical CAD.
Conclusions
Our study provides the first insight into the impact of the combined presence of AVC and MAC on the presence, extent, and vulnerable characteristics of coronary plaque in patients with proven or suspected CAD. The presence of multiple calcium deposits in heart valves is a useful marker for advanced coronary atherosclerosis, and is likely to help identify appropriate patients for aggressive medical therapy to inhibit the atherosclerosis process.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgements
This study was supported by grants from the Ministry of Health, Labour and Welfare, Japan (Tokyo, Japan). The authors are grateful to Masao Kiguchi, RT and Chikako Fujioka, RT for their technical assistance.
References (20)
- et al.
Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study
J Am Coll Cardiol
(1997) - et al.
Heart valve sclerosis predicts all-cause and cardiovascular mortality
Atherosclerosis
(2010) - et al.
Comprehensive evaluation of noncalcified coronary plaque characteristics detected using 64-slice computed tomography in patients with proven or suspected coronary artery disease
Am Heart J
(2007) - et al.
Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound
J Am Coll Cardiol
(2005) - et al.
Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome
J Am Coll Cardiol
(2009) - et al.
Characterization of noncalcified coronary plaques and identification of culprit lesions in patients with acute coronary syndrome by 64-slice computed tomography
JACC Cardiovasc Imaging
(2009) - et al.
Valvular and thoracic aortic calcium as a marker of the extent and severity of angiographic coronary artery disease
Am Heart J
(2003) - et al.
Quantification of coronary artery calcium using ultrafast computed tomography
J Am Coll Cardiol
(1990) - et al.
SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography
J Cardiovasc Comput Tomogr
(2009) - et al.
Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial
J Am Coll Cardiol
(2009)
Cited by (40)
A study on the prevalence, distribution and related factors of heart valve calcification using coronary CT angiography
2020, IJC Heart and VasculatureAortic root, not valve, calcification correlates with coronary artery calcification in patients with severe aortic stenosis: A two-center study
2015, AtherosclerosisCitation Excerpt :Calcification of coronary arteries, aortic valve and aortic root was quantified using the Agatston score in both cohorts [17]. AVC was defined as calcification involving the aortic valve leaflets, points of attachment as well as the aortic wall immediately connected to the calcified leaflets, as previously described [25–28]. ARC was defined as calcification of the aortic root not immediately connected to the calcified leaflets up to the level of the sinotubular junction (STJ).
Incremental prognostic value of cardiac computed tomography angiography in asymptomatic aortic stenosis: Significance of aortic valve calcium score
2013, International Journal of CardiologyCitation Excerpt :In fact, the high-AVCS group had higher LVMI, left atrial volume index, and lateral E/e′ than the low-AVCS group, indicating impairment of LV diastolic function (Table 1). Recent studies found associations between AVC and subclinical CAD [2] and myocardial ischemia [21], especially in asymptomatic patients. In addition, LV hypertrophy was associated with prevalence, severity, and incidence of AVC independent of hypertension [3].