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Abdul-Rahman T, Bliss ZSB, Lizano-Jubert I, Muñoz MJS, Garg N, Pachchipulusu VK, Ashinze P, Miteu GD, Baig R, Omar DA, Badawy MM, Bukhari SMA, Wireko AA, Aborode AT, Atallah O, Mahmoud HA, Aldosoky W, Abohashem S. Beyond symptoms: Unlocking the potential of coronary calcium scoring in the prevention and treatment of coronary artery disease. Curr Probl Cardiol 2024; 49:102378. [PMID: 38185434 DOI: 10.1016/j.cpcardiol.2024.102378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
Coronary Artery Disease (CAD) represents a persistent global health menace, particularly prevalent in Eastern European nations. Often asymptomatic until its advanced stages, CAD can precipitate life-threatening events like myocardial infarction or stroke. While conventional risk factors provide some insight into CAD risk, their predictive accuracy is suboptimal. Amidst this, Coronary Calcium Scoring (CCS), facilitated by non-invasive computed tomography (CT), emerges as a superior diagnostic modality. By quantifying calcium deposits in coronary arteries, CCS serves as a robust indicator of atherosclerotic burden, thus refining risk stratification and guiding therapeutic interventions. Despite certain limitations, CCS stands as an instrumental tool in CAD management and in thwarting adverse cardiovascular incidents. This review delves into the pivotal role of CCS in CAD diagnosis and treatment, elucidates the involvement of calcium in atherosclerotic plaque formation, and outlines the principles and indications of utilizing CCS for predicting major cardiovascular events.
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Affiliation(s)
| | | | | | | | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, United States
| | | | - Patrick Ashinze
- Department of Medical Services, Saint Francis Catholic Hospital, Okpara Inland, Delta, Nigeria
| | - Goshen David Miteu
- Department of Biomedical Science, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rusab Baig
- Shadan Institute of Medical Sciences, Hyderabad, India
| | | | | | | | | | | | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | | | - Wesam Aldosoky
- Massachusetts General Hospital and Harvard Medical School, Boston, United States
| | - Shady Abohashem
- Massachusetts General Hospital and Harvard Medical School, Boston, United States.
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2
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Lehker A, Mukherjee D. Coronary Calcium Risk Score and Cardiovascular Risk. Curr Vasc Pharmacol 2021; 19:280-284. [PMID: 32242784 DOI: 10.2174/1570161118666200403143518] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 12/21/2022]
Abstract
The association between the presence of coronary artery calcium (CAC) and the risk of coronary artery disease (CAD) has been appreciated for decades. In this review, we critically appraise the role of CAC based on computerized tomography in contemporary risk stratification. Available evidence suggests that the measurement of CAC is a useful modality in many patients for more precise risk stratification and prognostic determination. Whether newer CAC score incorporating extra coronary calcification will add incremental value, especially for stroke and other non-coronary vascular outcomes, needs a prospective study.
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Affiliation(s)
- Angelica Lehker
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas 79905, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas 79905, United States
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3
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Cheong BYC, Wilson JM, Spann SJ, Pettigrew RI, Preventza OA, Muthupillai R. Coronary artery calcium scoring: an evidence-based guide for primary care physicians. J Intern Med 2021; 289:309-324. [PMID: 33016506 DOI: 10.1111/joim.13176] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/24/2020] [Indexed: 12/12/2022]
Abstract
Primary care physicians often must decide whether statin therapy would be appropriate (in addition to lifestyle modification) for managing asymptomatic individuals with borderline or intermediate risk for developing atherosclerotic cardiovascular disease (ASCVD), as assessed on the basis of traditional risk factors. In appropriate subjects, a simple, noninvasive measurement of coronary artery calcium can help clarify risk. Coronary atherosclerosis is a chronic inflammatory disease, with atherosclerotic plaque formation involving intimal inflammation and repeated cycles of erosion and fibrosis, healing and calcification. Atherosclerotic plaque formation represents the prognostic link between risk factors and future clinical events. The presence of coronary artery calcification is almost exclusively an indication of coronary artery disease, except in certain metabolic conditions. Coronary artery calcification can be detected and quantified in a matter of seconds by noncontrast electrocardiogram-gated low-dose X-ray computed tomography (coronary artery calcium scoring [CACS]). Since the publication of the seminal work by Dr. Arthur Agatston in 1990, a wealth of CACS-based prognostic data has been reported. In addition, recent guidelines from various professional societies conclude that CACS may be considered as a tool for reclassifying risk for atherosclerotic cardiovascular disease in patients otherwise assessed to have intermediate risk, so as to more accurately inform decisions about possible statin therapy in addition to lifestyle modification as primary preventive therapy. In this review, we provide an overview of CACS, from acquisition to interpretation, and summarize the scientific evidence for and the appropriate use of CACS as put forth in current clinical guidelines.
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Affiliation(s)
- B Y C Cheong
- From the, Department of Cardiovascular Radiology, Texas Heart Institute, Houston, TX, USA.,Department of Diagnostic and Interventional Radiology, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA.,Department of Cardiology, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA
| | - J M Wilson
- Department of Cardiology, HCA Houston Healthcare Medical Center, Houston, TX, USA
| | - S J Spann
- The University of Houston College of Medicine, Houston, TX, USA
| | - R I Pettigrew
- College of Medicine and Department of Biomedical Engineering, Texas A&M University, Houston, TX, USA
| | - O A Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - R Muthupillai
- From the, Department of Cardiovascular Radiology, Texas Heart Institute, Houston, TX, USA.,Department of Diagnostic and Interventional Radiology, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA
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4
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Neleman T, Liu S, Tovar Forero MN, Hartman EMJ, Ligthart JMR, Witberg KT, Cummins P, Zijlstra F, Van Mieghem NM, Boersma E, van Soest G, Daemen J. The Prognostic Value of a Validated and Automated Intravascular Ultrasound-Derived Calcium Score. J Cardiovasc Transl Res 2021; 14:992-1000. [PMID: 33624259 PMCID: PMC8575752 DOI: 10.1007/s12265-021-10103-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/11/2021] [Indexed: 01/15/2023]
Abstract
Background Coronary calcification has been linked to cardiovascular events. We developed and validated an algorithm to automatically quantify coronary calcifications on intravascular ultrasound (IVUS). We aimed to assess the prognostic value of an IVUS-calcium score (ICS) on patient-oriented composite endpoint (POCE). Methods We included patients that underwent coronary angiography plus pre-procedural IVUS imaging. The ICS was calculated per patient. The primary endpoint was a composite of all-cause mortality, stroke, myocardial infarction, and revascularization (POCE). Results In a cohort of 408 patients, median ICS was 85. Both an ICS ≥ 85 and a 100 unit increase in ICS increased the risk of POCE at 6-year follow-up (adjusted hazard ratio (aHR) 1.51, 95%CI 1.05–2.17, p value = 0.026, and aHR 1.21, 95%CI 1.04–1.41, p value = 0.014, respectively). Conclusions The ICS, calculated by a validated automated algorithm derived from routine IVUS pullbacks, was strongly associated with the long-term risk of POCE. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12265-021-10103-1.
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Affiliation(s)
- Tara Neleman
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Shengnan Liu
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria N Tovar Forero
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline M J Hartman
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jurgen M R Ligthart
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karen T Witberg
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul Cummins
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gijs van Soest
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Hwang IC, Lee H, Yoon YE, Choi IS, Kim HL, Chang HJ, Lee JY, Choi JA, Kim HJ, Cho GY, Park JB, Lee SP, Kim HK, Kim YJ, Sohn DW. Risk stratification of non-obstructive coronary artery disease for guidance of preventive medical therapy. Atherosclerosis 2019; 290:66-73. [DOI: 10.1016/j.atherosclerosis.2019.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 12/14/2022]
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Nakao YM, Miyamoto Y, Higashi M, Noguchi T, Ohishi M, Kubota I, Tsutsui H, Kawasaki T, Furukawa Y, Yoshimura M, Morita H, Nishimura K, Kada A, Goto Y, Okamura T, Tei C, Tomoike H, Naito H, Yasuda S. Sex differences in impact of coronary artery calcification to predict coronary artery disease. Heart 2018; 104:1118-1124. [PMID: 29331986 PMCID: PMC6031260 DOI: 10.1136/heartjnl-2017-312151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/17/2017] [Accepted: 11/28/2017] [Indexed: 01/01/2023] Open
Abstract
Objective To assess sex-specific differences regarding use of conventional risks and coronary artery calcification (CAC) to detect coronary artery disease (CAD) using coronary CT angiography (CCTA). Methods The Nationwide Gender-specific Atherosclerosis Determinants Estimation and Ischemic Cardiovascular Disease Prospective Cohort study is a prospective, multicentre, nationwide cohort study. Candidates with suspected CAD aged 50–74 years enrolled from 2008 to 2012. The outcome was obstructive CAD defined as any stenosis ≥50% by CCTA. We constructed logistic regression models for obstructive CAD adjusted for conventional risks (clinical model) and CAC score. Improvement in discrimination beyond risks was assessed by C-statistic; net reclassification index (NRI) for CAD probability of low (<30%), intermediate (30%–60%) and high (≥60%); and risk stratification capacity. Results Among 991 patients (456 women, 535 men; 65.2 vs 64.4 years old), women had lower CAC scores (median, 4 vs 60) and lower CAD prevalence (21.7% vs 37.0%) than men. CAC significantly improved model discrimination compared with clinical model in both sexes (0.66–0.79 in women vs 0.61–0.83 in men). The NRI for women was 0.33, which was much lower than that for men (0.71). Adding CAC to clinical model had a larger benefit in terms of moving an additional 43.3% of men to the most determinant categories (high or low risk) compared with −1.4% of women. Conclusions The addition of CAC to a prediction model based on conventional variables significantly improved the classification of risk in suspected patients with CAD, with sex differences influencing the predictive ability. Trial registration number UMIN-CTR Clinical Trial: UMIN000001577.
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Affiliation(s)
- Yoko M Nakao
- Department of Preventive Medicine and Epidemiologic informatics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic informatics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medicine Kagoshima University, Kagoshima, Japan
| | - Isao Kubota
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hideaki Morita
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Kunihiro Nishimura
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Chuwa Tei
- Waon Therapy Research Institute, Tokyo, Japan
| | | | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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8
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Mordi I, Tzemos N. The prognostic value of CT coronary angiography in patients attending hospital with troponin-negative acute chest pain and inconclusive exercise treadmill tests. Eur Heart J Cardiovasc Imaging 2015; 17:542-9. [PMID: 26705484 DOI: 10.1093/ehjci/jev319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/13/2015] [Indexed: 12/13/2022] Open
Abstract
AIMS Once acute coronary syndrome (ACS) is excluded in patients presenting to hospital with acute chest pain, usual practice is to stratify future risk of adverse cardiovascular events. Commonly this is performed by pre-discharge exercise treadmill testing (ETT). Often however, patients are unable to perform the test for various reasons, or the final result is inconclusive. This potentially could lead to uncertainty and to unnecessary invasive coronary angiography. We wished to evaluate the potential prognostic significance of CT coronary angiography (CTCA) in patients with prior inconclusive ETTs. METHODS AND RESULTS Two hundred and thirty-two consecutive patients underwent CTCA and calcium scoring following hospital attendance with acute chest pain and following exclusion of ACS. All patients were followed up for a combined primary outcome of death, non-fatal myocardial infarction, and late revascularization. The mean follow-up period was 2.5 ± 0.9 years. The combined primary outcome occurred in 26 patients (11.2%). Calcium score (HR 1.16; 95% CI 1.02-1.31, P = 0.023 per 100 Agatston unit increase), the presence of coronary artery disease (CAD) on CTCA (non-obstructive CAD, HR 4.52; 95% CI 1.30-15.73, P = 0.018; obstructive CAD, HR 17.00; 95% CI 4.60-62.85, P < 0.001), and ≥3 segments with non-calcified plaque (HR 3.30; 95% CI 1.24-8.76, P = 0.017) were significant univariable predictors of the primary outcome. CTCA was the only significant multivariable predictor of adverse outcome. CONCLUSIONS The presence of CAD assessed by CTCA is a strong predictor of adverse events in patients with troponin-negative acute chest pain and could potentially be used as an alternative, non-invasive risk stratifier in patients with inconclusive exercise tests.
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Affiliation(s)
- Ify Mordi
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Nikolaos Tzemos
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
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Yamamoto H, Kitagawa T, Kihara Y. Clinical implications of the coronary artery calcium score in Japanese patients. J Atheroscler Thromb 2014; 21:1101-8. [PMID: 25263530 DOI: 10.5551/jat.26427] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Coronary artery calcification (CAC) is a well-established surrogate marker of the total burden of coronary atherosclerosis. The CAC score, as measured on coronary computed tomography (CT), is associated with the prevalence of coronary artery disease (CAD) as well as cardiovascular morbidity and mortality. The CAC score is used to reclassify coronary risks in asymptomatic individuals with intermediate risks. However, there are few clinical data regarding the usefulness of the CAC score for identifying high-risk Japanese patients. In this review article, we describe our previous studies of the prognostic value of the CAC score in patients with proven or suspected CAD. In addition, we reanalyzed our previous data for 723 patients with suspected CAD and found both all-cause and cardiovascular disease mortality to be significantly higher among the patients with a CAC score of ≥100 than among those with a CAC score of <100. Several studies from Japan have also shown that the CAC score is associated with the prevalence of obstructive CAD, as demonstrated on invasive coronary angiography or stress myocardial perfusion imaging. Furthermore, the CAC score provides useful information for performing coronary CT angiography, as asymptomatic patients without CAC are expected to have favorable outcomes. In contrast, the diagnostic accuracy is decreased in patients with a high CAC score (>400 or 600). In conclusion, the CAC score may have useful clinical applications in symptomatic and asymptomatic Japanese individuals. However, further studies are required to evaluate the prognostic value of this parameter for predicting cardiovascular morbidity and mortality in population-based analyses of asymptomatic Japanese subjects.
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Affiliation(s)
- Hideya Yamamoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
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Exploring the Complementary Role of CAC and Coronary CT in the Primary CVD Prevention Setting. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0398-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
As laparoscopic surgery is replacing open surgery, similarly computed tomography angiography is replacing invasive conventional cardiac angiography. In the last century, marvelous efforts in research have improved strategies for cure, diagnosis and prevention of fatal human diseases; however, coronary artery disease, as the most prevalent cause of mortality and morbidity in the world, has remained a great challenge. Due to advancements in technology and research, it has become more simple and robust to diagnose and treat coronary artery disease (CAD) with minimal or no intervention, promising to not only diagnosis at an early stage but potential prevention altogether. While most with obvious CAD can be diagnosed easily and quickly with ECG, those identified as 'low risk' require more extensive testing to diagnose or rule out CAD. For example in emergency departments, low-risk patients with chest pain are diagnosed solely depending on history, ECG and blood testing for biomarkers. This approach has resulted in either delayed or miss-diagnosis of Acute coronary syndrome. To prevent this, many emergency departments now use protocols for low-risk heart patients that include cardiac stress tests and/or CT heart imaging. This review provides an overview of the current literature on the value of Computed tomography angiography and discusses how prognostic information obtained with Computed tomography angiography can be used to further integrate the technique into clinical practice.
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Affiliation(s)
- Muhammad A Latif
- St. John Cardiovascular Research Center, Los Angeles Biomedical Research Institute, Torrance, CA, USA
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Cheezum MK, Bittencourt MS, Hulten EA, Scirica BM, Villines TC, Blankstein R. Coronary computed tomographic angiography in the emergency room: state of the art. Expert Rev Cardiovasc Ther 2014; 12:241-53. [PMID: 24417341 DOI: 10.1586/14779072.2014.877345] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Chest pain is a common complaint in the emergency department often necessitating testing to exclude underlying obstructive coronary artery disease. While the traditional evaluation of patients with suspected acute coronary syndrome often consists of serial electrocardiograms and cardiac biomarkers, followed by selective use of stress testing for further risk stratification, this approach is costly and inefficient. Recently, coronary computed tomographic angiography (CTA) has offered an alternative approach with a high sensitivity and negative predictive value to exclude obstructive coronary artery disease that can rapidly identify patients with low rates of downstream major adverse cardiac events. In this review, the authors provide an overview of available data on the use of CTA for evaluating acute chest pain, while emphasizing its advantages and disadvantages compared to existing strategies. In addition, we provide a suggested algorithm to identify how CTA can be incorporated into the evaluation of acute chest pain and discuss tips for successful implementation of CTA in the emergency department.
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Affiliation(s)
- Michael K Cheezum
- Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Non-Invasive Cardiovascular Imaging Program, Boston, MA, USA
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