Coronary artery calcium screening: current status and recommendations from the European Society of Cardiac Radiology and North American Society for Cardiovascular Imaging

Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis

OBJECTIVES

Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC.

METHODS

Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model.

RESULTS

A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports.

CONCLUSION

CAC is a common, but underreported, finding on non-gated CT with important prognostic implications.

CLINICAL RELEVANCE STATEMENT

Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT.

KEY POINTS

• Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.

The effect of non-optimal lipids on the progression of coronary artery calcification in statin-naïve young adults: results from KOICA registry

Background

Despite the importance of attaining optimal lipid levels from a young age to secure long-term cardiovascular health, the detailed impact of non-optimal lipid levels in young adults on coronary artery calcification (CAC) is not fully explored. We sought to investigate the risk of CAC progression as per lipid profiles and to demonstrate lipid optimality in young adults.

Methods

From the KOrea Initiative on Coronary Artery calcification (KOICA) registry that was established in six large volume healthcare centers in Korea, 2,940 statin-naïve participants aged 20-45 years who underwent serial coronary calcium scans for routine health check-ups between 2002 and 2017 were included. The study outcome was CAC progression, which was assessed by the square root method. The risk of CAC progression was analyzed according to the lipid optimality and each lipid parameter.

Results

In this retrospective cohort (mean age, 41.3 years; men 82.4%), 477 participants (16.2%) had an optimal lipid profile, defined as triglycerides <150 mg/dl, LDL cholesterol <100 mg/dl, and HDL cholesterol >60 mg/dl. During follow-up (median, 39.7 months), CAC progression was observed in 434 participants (14.8%), and more frequent in the non-optimal lipid group (16.5% vs. 5.7%; p < 0.001). Non-optimal lipids independently increased the risk of CAC progression [adjusted hazard ratio (aHR), 1.97; p = 0.025], in a dose-dependent manner. Even in relatively low-risk participants with an initial calcium score of zero (aHR, 2.13; p = 0.014), in their 20 s or 30 s (aHR 2.15; p = 0.041), and without other risk factors (aHR 1.45; p = 0.038), similar results were demonstrable. High triglycerides had the greatest impact on CAC progression in this young adult population.

Conclusion

Non-optimal lipid levels were significantly associated with the risk of CAC progression in young adults, even at low-risk. Screening and intervention for non-optimal lipid levels, particularly triglycerides, from an early age might be of clinical value.

Assessment of Normal Systolic Blood Pressure Maintenance with the Risk of Coronary Artery Calcification Progression in Asymptomatic Metabolically Healthy Korean Adults with Normal Weight, Overweight, and Obesity

Metabolically healthy obesity (MHO) is known to have a close association with subclinical coronary atherosclerosis. Despite recent data on the benefit of intensive systolic blood pressure (SBP) control in diverse clinical conditions, little is known regarding the association of normal SBP maintenance (SBP_maintain) with coronary artery calcification (CAC) progression in MHO. This study included 2724 asymptomatic adults (48.8 ± 7.8 years; 77.9% men) who had no metabolic abnormalities except overweight and obesity. Participants with normal weight (44.2%), overweight (31.6%), and obesity (24.2%) were divided into two groups: normal SBP_maintain (follow-up SBP < 120 mm Hg) and ≥elevated SBP_maintain (follow-up SBP ≥ 120 mm Hg). CAC progression was defined using the SQRT method, a difference of ≥2.5 between the square root (√) of the baseline and follow-up coronary artery calcium score. During a mean follow-up of 3.4 years, the proportion of normal SBP_maintain (76.2%, 65.2%, and 59.1%) and the incidence of CAC progression (15.0%, 21.3%, and 23.5%) was different in participants with normal weight, overweight, and obesity (all p < 0.05, respectively). The incidence of CAC progression was lower in the normal SBP_maintain group than in the ≥elevated SBP_maintain group in only participants with obesity (20.8% vs. 27.4%, p = 0.048). In multiple logistic models, compared to participants with normal weight, those with obesity had a higher risk of CAC progression. Normal SBP_maintain was independently associated with the decreased risk of CAC progression in participants with obesity. MHO had a significant association with CAC progression. Normal SBP_maintain reduced the risk of CAC progression in asymptomatic adults with MHO.

Coronary Artery Calcium Data and Reporting System (CAC-DRS): A Primer

The Coronary Artery Calcium Data and Reporting System (CAC-DRS) is a standardized reporting method for calcium scoring on computed tomography. CAC-DRS is applied on a per-patient basis and represents the total calcium score with the number of vessels involved. There are 4 risk categories ranging from CAC-DRS 0 to CAC-DRS 3. CAC-DRS also provides risk prediction and treatment recommendations for each category. The main strengths of CAC-DRS include a detailed and meaningful representation of CAC, improved communication between physicians, risk stratification, appropriate treatment recommendations, and uniform data collection, which provides a framework for education and research. The major limitations of CAC-DRS include a few missing components, an overly simple visual approach without any standard reference, and treatment recommendations lacking a basis in clinical trials. This consistent yet straightforward method has the potential to systemize CAC scoring in both gated and non-gated scans.

Preventive Health Screening for Women at Risk for Cardiovascular Disease: Targeting Women 40 to 64 Years of Age

Objective:

The Centers for Disease Control and Prevention (CDC) has documented that the leading cause of death in the United States is cardiovascular disease (CVD). Specifically, CVD is responsible for the death of one out of every five women in the United States. Therefore, the research question was, “What specific diagnostic tests, including a novel approach to detecting abdominal aortic calcifications (AAC), could be added to screening women for CVD?”

Materials and Methods:

A prospective cohort of 14 female volunteers, between the ages of 40 and 60 years, were consented to sonography of the aorta, collection of demographic data, as well as contributing biometric data. Each volunteer gave informed consent in compliance with the university’s Institutional Review Board. Volunteers also were provided with a Health Insurance Portability and Accountability Act (HIPAA) release that was signed prior to the collection of any data. All sonographic images were analyzed post-examination and aortic calcifications were graded using a modified scoring system derived from a dual-energy x-ray absorptiometry (DXA)-based grading system.

Results:

In this cohort of 14 females, their AAC category scores ranged from I to IIIB (grades: normal to multiple calcified atheroma). Descriptive statistics demonstrate that it is possible to document AAC on this cohort of women using sonography. Correlational statistics showed a statistically significant association between a volunteer’s posterior aortic-intimal media thickness (a-IMT) and their atherosclerotic cardiovascular disease (ASCVD) 10-year risk score.

Conclusion:

This pilot study suggests the need for further research on screening techniques to determine women’s specific CVD risk in this age group. Although the preliminary results allude to sonographic measures of a-IMT being a possible CVD screening method in the future, more research data are needed.

Progostic value of coronary artery calcium scores from 1.5 mm slice reconstructions of electrocardiogram-gated computed tomography scans in asymptomatic individuals

It is unknown whether the thinner slice reconstruction has added value relative to 3 mm reconstructions in predicting major adverse cardiac events (MACEs). This retrospective study included 550 asymptomatic individuals who underwent cardiac CT. Coronary artery calcium (CAC) scores and severity categories were assessed from 1.5 and 3 mm scans. CAC scores obtained from 1.5 and 3 mm scans were compared using Wilcoxon signed-rank tests. Cox proportional hazard models were developed to predict MACEs based on the degree of coronary artery stenosis on coronary CT angiography and the presence of CAC on both scans. Model performances were compared using the time-dependent ROC curve and integrated area under the curve (iAUC) methods. The CAC scores obtained from 1.5 mm scans were significantly higher than those from 3 mm scans (median, interquartile range 4.5[0–71] vs. 0[0–48.4]; p < 0.001). Models showed no difference in predictive accuracy of the presence of CAC between 1.5 and 3 mm scans (iAUC, 0.625 vs. 0.672). In conclusion, CAC scores obtained from 1.5 mm scans are significantly higher than those from 3 mm scans, but do not provide added prognostic value relative to 3 mm scans.

Identification of Risk Factors for Coronary Artery Disease in Asymptomatic Patients with Type 2 Diabetes Mellitus

BACKGROUND

Patients with diabetes mellitus (DM) are a high-risk group for coronary artery disease (CAD). In the present study, we investigated predictive factors to identify patients at high risk of CAD among asymptomatic patients with type 2 DM based on coronary computed tomographic angiography (CCTA) findings.

METHODS

A single-center prospective study was performed on 452 consecutive patients with type 2 DM who were provided with a weekly hospital-based diabetes education program between 3 October 2015, and 31 March 2020. A total of 161 consecutive asymptomatic patients (male/female: 111/50, age: 57.3 ± 9.3 years) with type 2 DM without any known CAD underwent CCTA. Based on conventional coronary risk factors and non-invasive examination, i.e., measurement of intima-media thickness, subcutaneous and visceral fat area, a stress electrocardiogram test, and the Agatston score, patients with obstructive CAD, CT-verified high-risk plaques (CT-HRP), and optimal revascularization within 90 days were evaluated.

RESULTS

Current smoking (OR, 4.069; 95% C.I., 1.578-10.493, p = 0.0037) and the Agatston score ≥100 (OR, 18.034; 95% C.I., 6.337-51.324, p = 0.0001) were independent predictive factors for obstructive CAD, while current smoking (OR, 5.013; 95% C.I., 1.683-14.931, p = 0.0038) was an independent predictive factor for CT-HRP. Furthermore, insulin treatment (OR, 5.677; 95% C.I., 1.223-26.349, p = 0.0266) was the only predictive factor that correlated with optimal revascularization within 90 days.

CONCLUSIONS

In asymptomatic patients with type 2 DM, current smoking, an Agatston score ≥100, and insulin treatment were independent predictive factors of patients being at high-risk for CAD. However, non-invasive examinations except for Agatston score were not independent predictors of patients being at high risk of CAD.

Usefulness of Cardiac Computed Tomography in Coronary Risk Prediction: A Five-Year Follow-Up of the SPICA Study (Secure Prevention with Imaging of the Coronary Arteries)

Accurate identification of individuals at high coronary risk would reduce acute coronary syndrome incidence and morbi-mortality. We analyzed the effect on coronary risk prediction of adding coronary artery calcification (CAC) and Segment Involvement Score (SIS) to cardiovascular risk factors. This was a prospective cohort study of asymptomatic patients recruited between 2013–2017. All participants underwent a coronary computed tomography angiography to determine CAC and SIS. The cohort was followed-up for a composite endpoint of myocardial infarction, coronary angiography and/or revascularization (median = five years). Discrimination and reclassification of the REGICOR function with CAC/SIS were examined with the Sommer’s D index and with the Net reclassification index (NRI). Nine of the 251 individuals included had an event. Of the included participants, 94 had a CAC = 0 and 85 a SIS = 0, none of them had an event. The addition of SIS or of SIS and CAC to the REGICOR risk function significantly increased the discrimination capacity from 0.74 to 0.89. Reclassification improved significantly when SIS or both scores were included. CAC and SIS were associated with five-year coronary event incidence, independently of cardiovascular risk factors. Discrimination and reclassification of the REGICOR risk function were significantly improved by both indexes, but SIS overrode the effect of CAC.

Association between blood pressure classification defined by the 2017 ACC/AHA guidelines and coronary artery calcification progression in an asymptomatic adult population

Aims

Coronary artery calcium score (CACS) is widely used for cardiovascular risk stratification in asymptomatic population. We assessed the association of new blood pressure (BP) classification using the 2017 American College of Cardiology/American Heart Association guidelines with coronary artery calcification (CAC) progression according to age in asymptomatic adults.

Methods and results

Overall, 10 839 asymptomatic Korean adults (23.4% aged ≤45 years) who underwent at least two CACS evaluations for health check-up were enrolled. Participants were categorized by age (≤45 and >45 years) and BP [normal (<120/<80 mmHg, untreated), elevated (120-129/<80 mmHg, untreated), Stage 1 hypertension (untreated BP 130-139/80-89 mmHg) or Stage 2 hypertension (BP ≥140/≥90 mmHg or anti-hypertensive use)] groups. CAC progression was defined as a difference of ≥2.5 between the square root (√) of the baseline and follow-up CACS. During a mean 3.3-year follow-up, the incidence of CAC progression was 13.5% and 36.3% in individuals aged ≤45 and >45 years, respectively. After adjustment for age, sex, diabetes, dyslipidaemia, obesity, current smoking, and baseline CACS, hazard ratios (95% confidence interval) for CAC progression in elevated BP, Stage 1 hypertension, and Stage 2 hypertension compared to normal BP were 1.43 (0.96-2.14) (P = 0.077), 1.64 (1.20-2.23) (P = 0.002), and 2.38 (1.82-3.12) (P < 0.001) in the ≤45 years group and 1.11 (0.95-1.30) (P = 0.179), 1.17 (1.04-1.32) (P = 0.009), and 1.52 (1.39-1.66) (P < 0.001) in the >45 years group, respectively.

Conclusion

Newly defined Stage 1 hypertension is independently associated with CAC progression in asymptomatic adults regardless of age.

Coronary artery calcium score and risk of cardiovascular events without established coronary artery disease: a systemic review and meta-analysis

BACKGROUND

Coronary artery calcium (CAC) is an indicator of atherosclerosis, and the CAC score is a useful noninvasive assessment of coronary artery disease.

OBJECTIVE

To compare the risk of cardiovascular outcomes in patients with CAC > 0 versus CAC = 0 in asymptomatic and symptomatic population in patients without an established diagnosis of coronary artery disease.

METHODS

A systematic search of electronic databases was conducted until January 2018 for any cohort study reporting cardiovascular events in patients with CAC > 0 compared with absence of CAC.

RESULTS

Forty-five studies were included with 192 080 asymptomatic 32 477 symptomatic patients. At mean follow-up of 11 years, CAC > 0 was associated with an increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared to a CAC = 0 in asymptomatic arm [pooled risk ratio (RR) 4.05, 95% confidence interval (CI) 2.91-5.63, P < 0.00001, I2 = 80%] and symptomatic arm (pooled RR 6.06, 95% CI 4.23-8.68, P < 0.00001, I2 = 69%). CAC > 0 was also associated with increased risk of all-cause mortality in symptomatic population (pooled RR 7.94, 95% CI 2.61-24.17, P < 0.00001, I2 = 85%) and in asymptomatic population CAC > 0 was associated with higher all-cause mortality (pooled RR 3.23, 95% CI 2.12-4.93, P < 0.00001, I2 = 94%). In symptomatic population, revascularization in CAC > 0 was higher (pooled RR 15, 95% CI 6.66-33.80, P < 0.00001, I2 = 72) compared with CAC = 0. Additionally, CAC > 0 was associated with more revascularization in asymptomatic population (pooled RR 5.34, 95% CI 2.06-13.85, P = 0.0006, I2 = 93). In subgroup analysis of asymptomatic population by gender, CAC > 0 was associated with higher MACE (RR 6.39, 95% CI 3.39-12.84, P < 0.00001).

CONCLUSION

Absence of CAC is associated with low risk of cardiovascular events compared with any CAC > 0 in both asymptomatic and symptomatic population without coronary artery disease.

Computed Tomography Screening for Early Lung Cancer, COPD and Cardiovascular Disease in Shanghai: Rationale and Design of a Population-based Comparative Study

RATIONALE AND OBJECTIVES

To describe the rational and design of a population-based comparative study. The objective of the study is to assess the screening performance of volume-based management of CT-detected lung nodule in comparison to diameter-based management, and to improve the effectiveness of CT screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), in addition to lung cancer, based on quantitative measurement of CT imaging biomarkers in a Chinese screening setting.

MATERIALS AND METHODS

A population-based comparative study is being performed, including 10,000 asymptomatic participants between 40 and 74 years old from Shanghai urban population. Participants in the intervention group undergo a low-dose chest and cardiac CT scan at baseline and 1 year later, and are managed according to NELCIN-B3 protocol. Participants in the control group undergo a low-dose chest CT scan according to the routine CT protocol and are managed according to the clinical practice. Epidemiological data are collected through questionnaires. In the fourth year from baseline, the diagnosis of the three diseases will be collected.

RESULTS

The unnecessary referral rate will be compared between NELCIN-B3 and standard protocol for managing early-detected lung nodules. The effectiveness of quantitative measurement of CT imaging biomarkers for early detection of lung cancer, COPD and CVD will be evaluated.

CONCLUSION

We expect that the quantitative assessment of the CT imaging biomarkers will reduce the number of unnecessary referrals for early detected lung nodules, and will improve the early detection of COPD and CVD in a Chinese urban population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03988322. Registered on 14 June 2019.

Automatic coronary calcium scoring in chest CT using a deep neural network in direct comparison with non-contrast cardiac CT: A validation study

PURPOSE

To evaluate deep-learning based calcium quantification on Chest CT scans compared with manual evaluation, and to enable interpretation in terms of the traditional Agatston score on dedicated Cardiac CT.

METHODS

Automated calcium quantification was performed using a combination of deep-learning convolution neural networks with a ResNet-architecture for image features and a fully connected neural network for spatial coordinate features. Calcifications were identified automatically, after which the algorithm automatically excluded all non-coronary calcifications using coronary probability maps and aortic segmentation. The algorithm was first trained on cardiac-CTs and refined on non-triggered chest-CTs. This study used on 95 patients (cohort 1), who underwent both dedicated calcium scoring and chest-CT acquisitions using the Agatston score as reference standard and 168 patients (cohort 2) who underwent chest-CT only using qualitative expert assessment for external validation. Results from the deep-learning model were compared to Agatston-scores(cardiac-CTs) and manually determined calcium volumes(chest-CTs) and risk classifications.

RESULTS

In cohort 1, the Agatston score and AI determined calcium volume shows high correlation with a correlation coefficient of 0.921(p < 0.001) and R² of 0.91. According to the Agatston categories, a total of 67(70 %) were correctly classified with a sensitivity of 91 % and specificity of 92 % in detecting presence of coronary calcifications. Manual determined calcium volume on chest-CT showed excellent correlation with the AI volumes with a correlation coefficient of 0.923(p < 0.001) and R² of 0.96, no significant difference was found (p = 0.247). According to qualitative risk classifications in cohort 2, 138(82 %) cases were correctly classified with a k-coefficient of 0.74, representing good agreement. All wrongly classified scans (30(18 %)) were attributed to an adjacent category.

CONCLUSION

Artificial intelligence based calcium quantification on chest-CTs shows good correlation compared to reference standards. Fully automating this process may reduce evaluation time and potentially optimize clinical calcium scoring without additional acquisitions.

Early imaging biomarkers of lung cancer, COPD and coronary artery disease in the general population: rationale and design of the ImaLife (Imaging in Lifelines) Study

Lung cancer, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD) are expected to cause most deaths by 2050. State-of-the-art computed tomography (CT) allows early detection of lung cancer and simultaneous evaluation of imaging biomarkers for the early stages of COPD, based on pulmonary density and bronchial wall thickness, and of CAD, based on the coronary artery calcium score (CACS), at low radiation dose. To determine cut-off values for positive tests for elevated risk and presence of disease is one of the major tasks before considering implementation of CT screening in a general population. The ImaLife (Imaging in Lifelines) study, embedded in the Lifelines study, is designed to establish the reference values of the imaging biomarkers for the big three diseases in a well-defined general population aged 45 years and older. In total, 12,000 participants will undergo CACS and chest acquisitions with latest CT technology. The estimated percentage of individuals with lung nodules needing further workup is around 1–2%. Given the around 10% prevalence of COPD and CAD in the general population, the expected number of COPD and CAD is around 1000 each. So far, nearly 4000 participants have been included. The ImaLife study will allow differentiation between normal aging of the pulmonary and cardiovascular system and early stages of the big three diseases based on low-dose CT imaging. This information can be finally integrated into personalized precision health strategies in the general population.

Non-traditional risk factors for coronary calcification and its progression in patients with type 2 diabetes: The impact of postprandial glycemia and fetuin-A

Objective

This study was performed to assess the impact of risk factors on the presence and progression of coronary calcification in patients with type 2 diabetes.

Methods

We prospectively enrolled 45 patients without cardiovascular or kidney disease. Coronary calcification was measured with multidetector computed tomography at baseline and 18 months. We also measured blood pressure; body mass index; serum levels of calcium, phosphate, and 25-hydroxyvitamin D; mineral bone density; and levels of alkaline phosphatase, parathormone, fetuin-A, high-sensitivity C-reactive protein, fibrinogen, albumin, homocysteine, lipids, HbA1c, and average preprandial and postprandial blood glucose at 18 months. Information about severe hypoglycemia and smoking was recorded. Spearman’s correlation coefficients were calculated. Multiple linear regression was used for the multivariate analysis.

Results

The median baseline calcium score was 63, and that at 18 months was 100. In the univariate analysis, albumin was significantly correlated with the baseline calcium score. Fetuin-A and postprandial glycemia were correlated with calcium score progression. In the multivariate model, postprandial glycemia and fetuin-A were independently associated with calcium score progression.

Conclusions

Fetuin-A and postprandial glycemia influence coronary calcification progression in patients with type 2 diabetes. The absence of some correlations could be due to pharmacological treatments for cardiovascular risk reduction.

Impact of Cardiovascular Risk Factors and Pharmacologic Treatments on Carotid Intraplaque Neovascularization Detected by Contrast-Enhanced Ultrasound

BACKGROUND

Neovascularization is a marker of plaque vulnerability that can be assessed noninvasively using contrast-enhanced ultrasound (CEUS). The presence and extent of plaque neovascularization and their relation to cardiovascular risk factors and treatments were assessed in asymptomatic patients with carotid stenosis of intermediate severity and no indication for revascularization.

METHODS

Sixty-six patients aged 69 ± 8 years (59% men) were prospectively enrolled. Plaque neovascularization was assessed using CEUS with sulfur hexafluoride contrast in each of the four carotid segments bilaterally (a total of 528 segments). In each plaque, the presence or absence of contrast enhancement was assessed semiquantitatively as CEUS grade 1 (no signal or signal confined to the adventitia and/or shoulder of the plaque) or CEUS grade 2 (signal within the plaque).

RESULTS

Plaques were detectable in 289 of 528 carotid segments (54.7%). CEUS grade 2 was present in at least one plaque in 48 of 66 patients (72.7%) and was not influenced by stenosis severity or morphology. The highest CEUS grade 2 prevalence was observed in patients with diabetes and the lowest in those treated with angiotensin-converting enzyme inhibitors and statins, especially when low-density lipoprotein cholesterol was <100 mg/dL. Patients with multiple CEUS grade 2 plaques (20 of 66 [30%]) had both higher low-density lipoprotein and higher C-reactive protein.

CONCLUSION

Intraplaque neovascularization is frequent in asymptomatic patients with intermediate carotid stenosis and is more prevalent in those with diabetes. Low-density lipoprotein cholesterol < 100 mg/dL and treatment with angiotensin-converting enzyme inhibitors seem to confer protection from neovascularization, although larger interventional studies are necessary to confirm these data.

Cardiac computed tomography in patients with symptomatic new-onset atrial fibrillation, rule-out acute coronary syndrome, but with intermediate pretest probability for coronary artery disease admitted to a chest pain unit

Background

Atrial fibrillation (AF) and coronary artery disease (CAD) may be encountered coincidently in a large portion of patients. However, data on coronary artery calcium burden in such patients are lacking. Thus, we sought to determine the value of cardiac computed tomography (CCT) in patients presenting with new-onset AF associated with an intermediate pretest probability for CAD admitted to a chest pain unit (CPU).

Methods

Calcium scores (CS) of 73 new-onset, symptomatic AF subjects without typical clinical, electrocardiographic, or laboratory signs of acute coronary syndrome (ACS) admitted to our CPU were analyzed. In addition, results from computed tomography angiography (CTA) were related to coronary angiography findings whenever available.

Results

Calcium scores of zero were found in 25%. Median Agatston score was 77 (interquartile range: 1–270) with gender- and territory-specific dispersal. CS scores above average were present in about 50%, high (> 400)-to-very high (> 1000) CS scores were found in 22%. Overall percentile ranking showed a relative accordance to the reference percentile distribution. Additional CTA was performed in 47%, revealing stenoses in 12%. Coronary angiography was performed in 22% and resulted in coronary intervention or surgical revascularization in 7%. On univariate analysis, CS > 50th percentile failed to serve as an independent determinant of significant stenosis during catheterization.

Conclusions

Within a CPU setting, relevant CAD was excluded or confirmed in almost 50%, the latter with a high proportion of coronary angiographies and subsequent coronary interventions, underlining the diagnostic value of CCT in symptomatic, non-ACS, new-onset AF patients when admitted to a CPU.

Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography

This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.

Cardiac Computed Tomography in Certified German Chest Pain Units

OBJECTIVE

The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients.

METHODS

For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared.

RESULTS

Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21).

CONCLUSIONS

Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

Less increase of CT-based calcium scores of the coronary arteries : Effect three years after breast-conserving radiotherapy using breath-hold

PURPOSE

The aim of this prospective longitudinal study was to compare coronary artery calcium (CAC) scores determined before the start of whole breast irradiation with those determined 3 years afterwards.

PATIENTS AND METHODS

Changes in CAC scores were analysed in 99 breast cancer patients. Three groups were compared: patients receiving left- and right-sided radiotherapy, and those receiving left-sided radiotherapy with breath-hold. We analysed overall CAC scores and left anterior descending (LAD) and right coronary artery (RCA) CAC scores. Between the three groups, changes of the value of the LAD minus the RCA CAC scores of each individual patient were also compared.

RESULTS

Three years after breath-hold-based whole breast irradiation, a less pronounced increase of CAC scores was noted. Furthermore, LAD minus RCA scores in patients treated for left-sided breast cancer without breath-hold were higher when compared to LAD minus RCA scores of patients with right-sided breast cancers and those with left-sided breast cancer treated with breath-hold.

CONCLUSION

Breath-hold in breast-conserving radiotherapy leads to a less pronounced increase of CT-based CAC scores. Therefore, breath-hold probably prevents the development of radiation-induced coronary artery disease. However, the sample size of this study is limited and the follow-up period relatively short.

Role of Coronary Artery Calcium Scoring in Detection of Coronary Artery Disease according to Framingham Risk Score in Populations with Low to Intermediate Risks

Current guidelines recommend that coronary artery calcium (CAC) screening should only be used for intermediate risk groups (Framingham risk score [FRS] of 10%-20%). The CAC distributions and coronary artery disease (CAD) prevalence in various FRS strata were determined. The benefit to lower risk populations of CAC score-based screening was also assessed. In total, 1,854 participants (aged 40-79 years) without history of CAD, stroke, or diabetes were enrolled. CAC scores of > 0, ≥ 100, and ≥ 300 were present in 33.8%, 8.2%, and 2.9% of the participants, respectively. The CAC scores rose significantly as the FRS grew more severe (P < 0.01). The total CAD prevalence was 6.1%. The occult CAD prevalence in the FRS ≤ 5%, 6%-10%, 11%-20%, and > 20% strata were 3.4%, 6.7%, 9.0%, and 11.6% (P < 0.001). In multivariate logistic regression analysis adjusting, not only the intermediate and high risk groups but also the low risk (FRS 6%-10%) group had significantly increased odds ratio for occult CAD compared to the very low-risk (FRS ≤ 5%) group (1.89 [95% confidence interval, CI, 1.09-3.29] in FRS 6%-10%; 2.48 [95% CI, 1.47-4.20] in FRS 11%-20%; and 3.10 [95% CI, 1.75-5.47] in FRS > 20%; P < 0.05). In conclusion, the yield of screening for significant CAC and occult CAD is low in the very low risk population but it rises in low and intermediate risk populations.

Long-Term Prognosis After Coronary Artery Calcification Testing in Asymptomatic Patients: A Cohort Study

BACKGROUND

The extent of coronary artery calcification (CAC) and near-term adverse clinical outcomes are strongly related through 5 years of follow-up.

OBJECTIVE

To describe the ability of CAC scores to predict long-term mortality in persons without symptoms of coronary artery disease.

DESIGN

Observational cohort.

SETTING

Single-center, outpatient cardiology laboratory.

PATIENTS

9715 asymptomatic patients.

MEASUREMENTS

Coronary artery calcification scoring and binary risk factor data were collected. The primary end point was time to all-cause mortality (median follow-up, 14.6 years). Univariable and multivariable Cox proportional hazards models were used to compare survival distributions. The net reclassification improvement statistic was calculated.

RESULTS

In Cox models adjusted for risk factors for coronary artery disease, the CAC score was highly predictive of all-cause mortality (P < 0.001). Overall 15-year mortality rates ranged from 3% to 28% for CAC scores from 0 to 1000 or greater (P < 0.001). The relative hazard for all-cause mortality ranged from 1.68 for a CAC score of 1 to 10 (P < 0.001) to 6.26 for a score of 1000 or greater (P < 0.001). The categorical net reclassification improvement using cut points of less than 7.5% to 22.5% or greater was 0.21 (95% CI, 0.16 to 0.32).

LIMITATIONS

Data collection was limited to a single center with generalizability limitations. Only binary risk factor data were available, and CAC was only measured once.

CONCLUSION

The extent of CAC accurately predicts 15-year mortality in a large cohort of asymptomatic patients. Long-term estimates of mortality provide a unique opportunity to examine the value of novel biomarkers, such as CAC, in estimating important patient outcomes.

PRIMARY FUNDING SOURCE

None.

Management of Coronary Artery Calcium and Coronary CTA Findings

Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient's risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.

Using coronary artery calcification combined with pretest clinical risk assessment as a means of determining investigation and treatment in patients presenting with chest pain in a rural setting

462 patients presenting with chest pain to a rural district general hospital underwent calcium scoring and pretest clinical risk assessment in order to stratify subsequent investigations and treatment was retrospectively reviewed. The patients were followed up for two years and further investigations and outcomes recorded. Of the 206 patients with zero calcium score, 132 patients were immediately discharged from cardiac follow-up with no further investigation on the basis of their calcium score, low pretest risk of coronary artery disease, and no significant incidental findings. After further tests, 267 patients were discharged with no further cardiac therapy, 88 patients were discharged with additional medical therapy, and 19 patients underwent coronary artery by-pass grafting or percutaneous intervention. 164 patients with incidental findings on the chest CT (computed tomography) accompanying calcium scoring were reviewed, of which 88 patients underwent further tests and follow-up for noncardiac causes of chest pain. The correlations between all major risk factors and calcium scores were weak except for a combination of diabetes and hypertension in the male gender (P = 0.012), The use of calcium scoring and pretest risk appeared to reduce the number of unnecessary cardiac investigations in our patients: however, the calcium scoring test produced a high number of incidental findings on the associated CT scans.

Non-invasive molecular imaging of vulnerable atherosclerotic plaques

The growing discoveries coming from clinical and basic research during the past decades have revolutionized our knowledge regarding pathophysiologic mechanisms underlying the atherosclerotic process and its thrombotic complications. The traditional view focusing on the severity of stenosis of atherosclerotic plaque has given way to the evidence that the clinical complications of atherosclerotic vascular disease, particularly the propensity to develop thrombotic complications, are determined mainly by the biological composition of the plaque. This paradigm shift has reinforced the need to move from the sole anatomical assessment toward combined anatomic and functional imaging modalities enabling the molecular and cellular characterization of the disease on top of its structural properties. Together, the progress to identify molecular targets related to plaque vulnerability and the improvement of imaging techniques for the detection of such molecular targets have allowed us to obtain new important pathophysiological information. This might allow better patient stratification for the identification of subjects at high risk to develop premature atherosclerosis who might need an aggressive therapeutic approach. Nuclear techniques, magnetic resonance imaging, computed tomography angiography, and contrast-enhanced ultrasound represent the currently available non-invasive imaging modalities for molecular imaging which can provide different and complementary insights into the biological features of the atherosclerotic process. This clinical review will discuss the evidence and potential translational applications of the individual imaging techniques particularly concerning their ability to detect the main atherosclerotic features related to plaque vulnerability, such as plaque inflammation and intertwined neovascularization.

Can nontriggered thoracic CT be used for coronary artery calcium scoring? A phantom study

PURPOSE

Coronary artery calcium score, traditionally based on electrocardiography (ECG)-triggered computed tomography (CT), predicts cardiovascular risk. However, nontriggered CT is extensively utilized. The study-purpose is to evaluate the in vitro agreement in coronary calcium score between nontriggered thoracic CT and ECG-triggered cardiac CT.

METHODS

Three artificial coronary arteries containing calcifications of different densities (high, medium, and low), and sizes (large, medium, and small), were studied in a moving cardiac phantom. Two 64-detector CT systems were used. The phantom moved at 0-90 mm∕s in nontriggered low-dose CT as index test, and at 0-30 mm∕s in ECG-triggered CT as reference. Differences in calcium scores between nontriggered and ECG-triggered CT were analyzed by t-test and 95% confidence interval. The sensitivity to detect calcification was calculated as the percentage of positive calcium scores.

RESULTS

Overall, calcium scores in nontriggered CT were not significantly different to those in ECG-triggered CT (p>0.05). Calcium scores in nontriggered CT were within the 95% confidence interval of calcium scores in ECG-triggered CT, except predominantly at higher velocities (≥50 mm∕s) for the high-density and large-size calcifications. The sensitivity for a nonzero calcium score was 100% for large calcifications, but 46%±11% for small calcifications in nontriggered CT.

CONCLUSIONS

When performing multiple measurements, good agreement in positive calcium scores is found between nontriggered thoracic and ECG-triggered cardiac CT. Agreement decreases with increasing coronary velocity. From this phantom study, it can be concluded that a high calcium score can be detected by nontriggered CT, and thus, that nontriggered CT likely can identify individuals at high risk of cardiovascular disease. On the other hand, a zero calcium score in nontriggered CT does not reliably exclude coronary calcification.

Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals

OBJECTIVES

To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT).

METHODS

This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT.

RESULTS

Participants' mean age was 54.6 years (SD ± 12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD ± 277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008).

CONCLUSION

CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factors.

The Prevalence and Extent of Coronary Atherosclerosis among Patients with a Zero Calcium Score and the Influence of Patient Characteristics

<p><b>Purpose:</b> Coronary artery calcium (CAC) is a specific indicator of and an independent risk factor for atherosclerosis; however, calcium scoring may miss noncalcified plaques, which may have clinical importance. The aim of this study was both to identify the presence and extent of coronary plaques during computed tomography coronary angiography (CTCA) in patients with a zero CAC score and to evaluate the effect of risk factors and symptom status on the presence of noncalcified plaques.</p><p><b>Materials and Methods:</b> In this retrospective study, we analyzed the cases of 842 consecutive patients between October 2006 and November 2011. Of these patients, we included 357 with a zero calcium score in the study. Information regarding patient age, sex, coronary risk factors, and symptom status were recorded. Coronary calcium-scoring scans were followed by CTCA. The calcium scores were calculated, and the presence of noncalcified plaques and significant stenoses (>50% of vessel diameter) was evaluated.</p><p><b>Results:</b> Of the 357 patients with a zero calcium score, 37 (10.36%) had atherosclerotic plaques; 9 patients (2.52%) had significant coronary stenosis. Among coronary risk factors, only diabetes mellitus was significantly correlated with any risk factors (presence of atherosclerosis and obstructive coronary artery disease; <i>P</i> = .030 and .013, respectively).</p><p><b>Conclusion:</b> Although CAC scoring is a safe and a reliable test to exclude obstructive coronary artery disease, the absence of CAC does not definitively exclude the presence of atherosclerosis. CTCA is a more appropriate method for determining the atheroma burden.</p>

Validation and Prognosis of Coronary Artery Calcium Scoring in Nontriggered Thoracic Computed Tomography

Background—

Coronary calcium score (CS), traditionally based on electrocardiography-triggered computed tomography (CT), predicts cardiovascular risk. Currently, nontriggered thoracic CT is extensively used, such as in lung cancer screening. The purpose of the study was to determine the correlation in CS between nontriggered and electrocardiography-triggered CT, and to evaluate the prognostic performance of the CS derived from nontriggered CT.

Methods and Results—

PubMed, Embase, and Web of Knowledge were searched until November 2012. Two reviewers independently screened 2120 records to identify studies reporting the CS in nontriggered CT and extracted information. Study quality was evaluated by standardized assessment tools. Cohen κ was extracted for agreement of CS categories between nontriggered and electrocardiography-triggered CT (validation). Hazard ratio (HR) was extracted for prognostic performance. Five studies about validation comprising 1316 individuals were included. Five studies about prognosis comprising 34 028 cardiac asymptomatic individuals, mainly from lung cancer screening trials, were included. All studies were of high quality. Meta-analysis could only be performed for validation studies because studies on prognostic performance were highly heterogeneous. Pooled Cohen κ for agreement between the 2 techniques was 0.89 (95% confidence interval, 0.83–0.95) for increasing CS categories. Increasing CS categories were associated with increasing risk of cardiovascular death or events. Nontriggered CT yielded false-negative CS in 8.8% of individuals and underestimated high CS in 19.1% of individuals.

Conclusions—

Our analysis shows the prognostic value and potential role of nontriggered assessment of coronary calcium, but it does not suggest that electrocardiography-triggered CT should be replaced by nontriggered examinations.

A head-to-head comparison of the coronary calcium score by computed tomography with myocardial perfusion imaging in predicting coronary artery disease

Objectives

The coronary artery calcium (CAC) score has been shown to predict future cardiac events. However the extent to which the added value of a CAC score to the diagnostic performance of myocardial perfusion imaging (MPI) by single photon emission computed tomography (SPECT) is unclear. The purpose of this study is to investigate the correlation between CAC score and SPECT in patients with suspected coronary artery disease.

Methods

A retrospective review of the CAC scores by use of the Agatston calcium scoring method and cardiac SPECT diagnostic reports was conducted in 48 patients, who underwent both coronary computed tomography (CT) and SPECT examinations due to suspected coronary artery disease. A Pearson correlation test was used to determine the relation between CAC scores and MPI-SPECT assessments with regard to the evaluation of the extent of disease.

Results

Forty-seven percent of the patients had CAC scores more than 100, while 42% of these patients demonstrated abnormal, or probably abnormal, MPI-SPECT. Of the 23% of patients with a zero CAC score, only 7% had normal MPI-SPECT findings. No significant correlation was found between the CAC scores and MPI-SPECT assessments (r value ranged from 0.012 to 0.080), regardless of the degree of coronary calcification.

Conclusions

There is a lack of correlation between the CAC scores and the MPI-SPECT findings in the assessment of the extent of coronary artery disease. CAC scores and MPI-SPECT should be considered complementary approaches in the evaluation of patients with suspected coronary artery disease.

Coronary artery calcium scoring: Influence of adaptive statistical iterative reconstruction using 64-MDCT

OBJECTIVE

Assessment of coronary artery calcification is increasingly used for cardiovascular risk stratification. We evaluated the reliability of calcium-scoring results using a novel iterative reconstruction algorithm (ASIR) on a high-definition 64-slice CT scanner, as such data is lacking.

METHODS AND RESULTS

In 50 consecutive patients Agatston scores, calcium mass and volume score were assessed. Comparisons were performed between groups using filtered back projection (FBP) and 20-100% ASIR algorithms. Calcium score was measured in the coronary arteries, signal and noise were measured in the aortic root and left ventricle. In comparison with FBP, use of 20%, 40%, 60%, 80%, and 100% ASIR resulted in reduced image noise between groups (7.7%, 18.8%, 27.9%, 39.86%, and 48.56%, respectively; p<0.001) without difference in signal (p=0.60). With ASIR algorithms Agatston coronary calcium scoring significantly decreased compared with FBP algorithms (837.3 ± 130.3; 802.2 ± 124.9, 771.5 ± 120.7; 744.7 ± 116.8, 724.5 ± 114.2, and 709.2 ± 112.3 for 0%, 20%, 40%, 60%, 80%, and 100% ASIR, respectively, p<0.001). Volumetric score decreased in a similar manner (p<0.001) while calcium mass remained unchanged. Mean effective radiation dose was 0.81 ± 0.08 mSv.

CONCLUSION

ASIR results in image noise reduction. However, ASIR image reconstruction techniques for HDCT scans decrease Agatston coronary calcium scores. Thus, one needs to be aware of significant changes of the scoring results caused by different reconstruction methods.

Improvement of cardiovascular risk prediction using coronary imaging: subclinical atherosclerosis: the memory of lifetime risk factor exposure

Deaths from diseases of the heart are decreasing. Cardiovascular diseases (CVD) will be the main cause of morbidity and mortality in 2015 according to a WHO report. The main problem is related to the long-time delay between the start of the development of atherosclerosis in young adults and the manifestation many decades later. Despite a recent decline in a CVD mortality rate in men and women, the main problem is related to the acute manifestation as the acute coronary syndrome, which leads 30-50% of subjects to sudden and fatal outcomes. In addition, about 20% of first and recurrent acute myocardial infarctions are silent. The lifetime risk of coronary artery disease after 40 years is 49% for men and 32% for women. That means, we are confronted with a major health care problem. This is even more obvious, when the rate of coronary heart disease deaths out of the hospital are taken into account which amount to 70% in 2007. These data are confirmed for Europe despite a strong decline of hospital deaths. Another problem is related to the fact that the number of sudden cardiac death amounts to >300 000 in the general US population. It is about 10 times higher than in those patients who are defined as prone to sudden death due to low ejection fraction, ventricular arrhythmias, and acute myocardial infarction. For cardiologists, this general topic becomes even more obvious, because even well-known cardiologists experienced early (≤65 years) sudden cardiac deaths such as RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline again what has been emphasized 15 years ago by the MONICA study that two-thirds of patients die outside the hospital and that we have to concentrate on primary and secondary prevention, also in memory of these colleagues. This review will demonstrate the potential value of coronary artery calcification screening which can be used as a sign of subclinical coronary arteriosclerosis for improved risk prediction, the first step to prevention. Subclinical atherosclerosis represents the vessel memory of risk factor exposure.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM)

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.