Elsevier

Atherosclerosis

Volume 213, Issue 1, November 2010, Pages 166-172
Atherosclerosis

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

https://doi.org/10.1016/j.atherosclerosis.2010.08.070Get rights and content

Abstract

Objective

We examined the association of aortic valve calcification (AVC) and mitral annular calcification (MAC) to coronary atherosclerosis using 64-multidetector computed tomography (MDCT).

Background

Valvular calcification is considered a manifestation of atherosclerosis. The impact of multiple heart valve calcium deposits on the distribution and characteristics of coronary plaque is unknown.

Methods

We evaluated 322 patients referred for 64-MDCT, and assessed valvular calcification and the extent of calcified (CAP), mixed (MCAP), and noncalcified coronary atherosclerotic plaque (NCAP) in accordance with the 17-coronary segments model. We assessed the vulnerable characteristics of coronary plaque with positive remodeling, low-density plaque (CT density ≤38 Hounsfield units), and the presence of adjacent spotty calcification.

Results

In 49 patients with both AVC and MAC, the segment numbers of CAP and MCAP were larger than in those with a lack of valvular calcification and an isolated AVC (p < 0.001 for both). Multivariate analyses revealed that a combined presence of AVC and MAC was independently associated with the presence (odds ratio [OR] 9.36, 95% confidence interval [95%CI] 1.55–56.53, p = 0.015) and extent (β-estimate 1.86, p < 0.001) of overall coronary plaque. When stratified by plaque composition, it was associated with the extent of CAP (β-estimate 1.77, p < 0.001) and MCAP (β-estimate 1.04, p < 0.001), but not with NCAP. Moreover, it was also related to the presence of coronary plaque with all three vulnerable characteristics (OR 4.87, 95%CI 1.85–12.83, p = 0.001).

Conclusion

The combined presence of AVC and MAC is highly associated with the presence, extent, and vulnerable characteristics of coronary plaque identified by 64-MDCT.

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)

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