A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques

Coronary Calcium Is Elevated in Patients with Myocardial Infarction without Standard Modifiable Risk Factors

Objectives: Recent reports have highlighted myocardial infarction (MI) patients without standard modifiable risk factors (SMRF), noting them to be surprisingly common and to have a substantial risk of adverse outcomes. The objective of this study was to address the challenge of identifying at-risk patients without SMRF and providing preventive therapy. Methods: Patients presenting between 2001 and 2021 to Intermountain Health catheterization laboratories with a diagnosis of MI were included if they also had a coronary artery calcium (CAC) scan by computed tomography within 2 years. SMRF were defined as a clinical diagnosis or treatment of hypertension, hyperlipidemia, diabetes, or smoking. The co-primary endpoints in SMRF-less patients were: (1) proportion of patients with an elevated (>50%ile) CAC score, and (2) an indication for statin therapy (i.e., CAC ≥ 100 AU or ≥75%ile). The 60-day and long-term major adverse cardiovascular events were determined. A comparison set included MI patients with SMRF. Results: We identified 429 MI patients with a concurrent CAC scan, of which 60 had no SMRF. SMRF status did not distinguish most risk factors or interventions. No-SMRF patients had a high CAC prevalence and percentile (82% ≥ 50%ile; median, 80%ile), and 77% met criteria for preventive therapy. As expected, patients with SMRF had high CAC scores and percentiles. Outcomes were more favorable for No-SMRF status and for lower CAC scores. Conclusions: Patients without SMRF presenting with an MI have a high prevalence and percentile of CAC. Wider application of CAC scans, including in those without SMRF, is promising as a method to identify an additional at-risk population for MI and to provide primary preventive therapy.

Predictors of long-term absence of coronary artery calcium in individuals with high blood pressure: results from the MESA study

BACKGROUND & AIMS

Individuals with high blood pressure (BP) have varying risks of cardiovascular events due to other coexisting factors. We aimed to identify the predictors of long-term absence of coronary artery calcium (CAC) in individuals with high BP, which is an indicator of healthy arterial aging and can guide preventive strategies.

METHODS

We analyzed data from participants with high BP (≥120/80 mm Hg) in the Multi-Ethnic Study of Atherosclerosis who had baseline CAC = 0 and underwent a second CAC scanning after 10 years. We used multivariable logistic regression to evaluate the association between various risk factors for atherosclerotic cardiovascular disease (ASCVD) and long-term CAC = 0. We also calculated the area under the receiver operating characteristic curve (AUC) to predict the phenotype of healthy arterial aging in this population.

RESULTS

We included 830 participants (37.6% male, mean ± SD age of 59.4 ± 8.7 years). During follow-up, 46.5% of participants (n = 386) had CAC = 0, and they were younger and had fewer metabolic syndrome components. Adding ASCVD risk factors to the demographic model (age, sex, and ethnicity) moderately increased the predictive value for long-term CAC = 0 (AUC: demographic model + ASCVD risk factors vs. demographic model alone, 0.653 vs. 0.597, p < .001; category net reclassification improvement = 0.104, p = .044; integrated discrimination improvement = 0.040, p < .001).

CONCLUSION

In individuals with high BP and initial CAC = 0, over 40% maintained CAC = 0 during a 10-year follow-up, which was associated with fewer ASCVD risk factors. These findings may have implications for preventive strategies in individuals with high BP.Clinical Trial registration number: The MESA was registered at clinical trials. gov as NCT00005487.KEY MESSAGESNearly half (46.5%) of individuals with high blood pressure (BP) maintained a long-term absence of coronary artery calcium (CAC) during a 10-year follow-up, and this was associated with a 66.6% lower risk of atherosclerotic cardiovascular disease (ASCVD) events compared to those who developed incident CAC.Individuals with high BP, who are usually assumed to have an increased risk of ASCVD, exhibit significant heterogeneity in their ASCVD risk; those who maintain CAC = 0 have a lower ASCVD risk.Adding overall ASCVD risk factors to demographic information resulted in a moderate improvement in predicting long-term CAC = 0.

Comparison of coronary artery calcium scores among patients referred for cardiac imaging tests

BACKGROUND

While coronary artery calcium (CAC) can now be evaluated by multiple imaging modalities, there is presently scant study regarding how CAC scores may vary among populations of varying clinical risk.

METHODS

We evaluated the distribution of CAC scores among three patient groups: 18,941 referred for CAC scanning, 5101 referred for diagnostic coronary CT angiography (CCTA), and 3307 referred for diagnostic positron emission tomography (PET) myocardial perfusion imaging (MPI). We assessed the relationship between CAC score and myocardial ischemia, obstructive coronary artery disease (CAD), and all-cause mortality across imaging modalities.

RESULTS

Within each age group, the frequency of CAC abnormalities were relatively similar across testing modalities, despite an annualized mortality rate which varied from 0.5%/year among CAC patients to 3.8%/year among PET-MPI patients (p < 0.001). Among CCTA and PET-MPI patients, a zero CAC score was common, occurring in ~70% of patients <50 years, ~40% of patients 50-59 years, and ~ 25% of patients 60-69 years. Among CCTA patients, zero CAC was associated with a normal coronary angiogram with high frequency, ranging from 92.2% among patients <50 years to 87.9% among patients ≥70 years. Among PET-MPI patients, zero CAC was associated with a very low frequency of inducible ischemia across all age groups, ranging from 1.5% among patients <50 years to 0.9% among patients ≥70 years.

CONCLUSIONS

In our study, relatively similar CAC scores were noted among patients varying markedly in mortality risk. Clinically, zero CAC scores predicted both a low likelihood of obstructive CAD and inducible myocardial ischemia in all age groups and were observed with high frequency across diagnostic testing modalities.

Early outcomes following integration of computed tomography (CT) coronary angiography service in an established cardiology practice in disease management

BACKGROUND

Computed tomography coronary angiography (CTCA) is an established modality for the diagnosis and assessment of cardiovascular disease. However, price and space pressure have mostly necessitated outsourcing CTCA to external radiology providers. Advara HeartCare has recently integrated CT services within local clinical networks across Australia. This study examined the benefits of the presence (integrated) or absence (pre-integrated) of this "in-house" CTCA service in real-world clinical practice.

METHODS

De-identified patient data from electronic medical records were used to create an Advara HeartCare CTCA database. Data analysis included clinical history, demographics, CTCA procedure, and 30-day outcomes post-CTCA from two age-matched cohorts: integrated (n ​= ​495) and pre-integrated (n ​= ​456).

RESULTS

Data capture was more comprehensive and standardised across the integrated cohort. There was a 21% increase in referrals for CTCA from cardiologists observed for the integration cohort vs. pre-integration [n ​= ​332 (72.8%) pre-integration vs. n ​= ​465 (93.9%) post-integration, p ​< ​0.0001] with a parallel increase in diagnostic assessments including blood tests [n ​= ​209 (45.8%) vs. n ​= ​387 (78.1%), respectively, p ​< ​0.0001]. The integrated cohort received lower total dose length product [Median 212 (interquartile range 136-418) mGy∗cm vs. 244 (141.5, 339.3) mGy∗cm, p ​= ​0.004] during the CTCA procedure. 30-days after CTCA scan, there was a significantly higher use of lipid-lowering therapies in the integrated cohort [n ​= ​133 (50.5%) vs. n ​= ​179 (60.6%), p ​= ​0.04], along with a significant decrease in the number of stress echocardiograms performed [n ​= ​14 (10.6%) vs. n ​= ​5 (11.6%), p ​= ​0.01].

CONCLUSION

Integrated CTCA has salient benefits in patient management, including increased pathology tests, statin usage, and decreased post-CTCA stress echocardiography utilisation. Our ongoing work will examine the effect of integration on cardiovascular outcomes.

Associations of Arterial Stiffness and Bone Mineral Density in Postmenopausal Women

Aim. To study associations  between arterial stiffness and bone mineral density in postmenopausal women.

Material and methods. The intima-media thickness  (IMT), the presence  and  number  of atherosclerotic  plaques  (AP) were studied  using  duplex scanning. Pulse wave velocity (PWV), augmentation index (AI) were measured by applanation. The Bone mineral density (BMD) of the spine, hip neck (HN) and proximal hip (PH) was measured using double energy x-ray absorptiometry.

Results. A significant  correlation  of PWV  with  age,  duration  of menopause was  revealed,  a more pronounced correlation  was  noted  with  blood pressure (BP), maximum IMT thickness.  There was no significant  correlation  between  PWV  and BMD.  AI showed  a statistically  significant but weak negative  correlation  with  the HN  (rs=0.12, p<0.05); a more  pronounced negative  correlation  was  obtained  for BMD  (rs=0.16, p<0.01). For indicators characterizing the degree of bone mass increased,  there is a significant  correlation with age (rs=-0.4, p<0.01), weight (rs=0.4, p<0.01), Quetelet index (rs=0.3, p<0.01) and the presence of AP (rs=-0.12, p<0.05). According to the results of multivariate regression  analysis,  the most significant  predictors of arterial stiffness were indicators  reflecting  obesity and diastolic BP. The relationship  between BMD and age-adjusted vascular stiffness was not statistically significant.

Conclusion. In our study, postmenopausal women have increased arterial stiffness,  suggesting a higher risk of cardiovascular disease. The relationship between  bone mineral density and vascular  wall stiffness  was insignificant. To a greater extent,  arterial stiffness  depended  on age,  increased  blood pressure, and the presence of atherosclerotic  changes.

Relationship Between Cardio-Ankle Vascular Index And Coronary Artery Calcification In A Population Sample Of Southwestern Siberia

Objective — To examine associations between cardio-ankle vascular index (CAVI) and coronary artery calcium (CAC) score a population sample of southwestern Siberia. Methods — From the sample of 1,620 people the final analysis included 1,316 participants 25 to 64 years of age who were enrolled in an observational cross-sectional study, Epidemiology of Cardiovascular Diseases and Their Risk Factors in the Russian Federation (ESSE-RF). Study participants were split among two groups: Group 1 with CAVI≥9.0 (n=128) and Group 2 with CAVI<9.0 (n=1,188). Prevalence of coronary artery calcification in both groups was analyzed via the Agatston method. We compared main demographic and clinical data between the groups, as well as CAC scores. Results — Elevated CAVI (≥9.0) was present in 9.7% of people included in a population sample from southwestern Siberia, and coronary artery calcification was found in 33.5% of the sample. While similar rates of minimum, mild, moderate and severe CAC score were observed in the participants with elevated and normal CAVI values, CAVI as a continuous variable was statistically significantly associated with moderate and severe CAC scores (OR 1.20, 95% CI 1.06-1.37, p=0.004). CAC score values were higher in individuals at the age of ≥50 years with pathological CAVI values (116±489 vs. 75±425 in normal CAVI, p=0.035), but not in patients under the age of 50 years (64±227 and 85±475, p=0.343). Conclusion — CAVI could possibly be used as a feasible marker before assessing the CAC score in some asymptomatic Caucasian subjects, but identifying the most appropriate methods and participants, whom it could be clearly applicable to, requires further studying.

There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness

Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.

The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis

BACKGROUND

There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing.

OBJECTIVES

The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA).

METHODS

The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP.

RESULTS

In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate).

CONCLUSIONS

Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.

Preventive cardiology advances in the 2021 AHA/ACC chest pain guideline

A core principle of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline is the importance of preventive therapies among patients with nonobstructive or obstructive coronary artery disease (CAD). Accordingly, this editorial provides unique insights that emphasize the role of preventive cardiology throughout the new guideline. For the first time, CAD was defined to also include nonobstructive plaque. This definition was based on the fact that individuals who have nonobstructive plaque are at an increased risk of atherosclerotic events compared with those who do not. Herein, we highlight guideline recommendations related to the diagnosis and management of nonobstructive CAD. We also highlight recommendations which emphasize the importance of preventive therapies. Adoption of these recommendations have the potential to lead to enhanced preventive therapies and improve patient outcomes.

ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update

Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Evaluating the Coronary Artery Disease Consortium Model and the Coronary Artery Calcium Score in Predicting Obstructive Coronary Artery Disease in a Symptomatic Mixed Asian Cohort

Background

The utility of a given pretest probability score in predicting obstructive coronary artery disease (CAD) is population dependent. Previous studies investigating the additive value of coronary artery calcium (CAC) on pretest probability scores were predominantly limited to Western populations. This retrospective study seeks to evaluate the CAD Consortium (CAD2) model in a mixed Asian cohort within Singapore with stable chest pain and to evaluate the incremental value of CAC in predicting obstructive CAD.

Methods and Results

Patients who underwent cardiac computed tomography and had chest pain were included. The CAD2 clinical model comprised of age, sex, symptom typicality, diabetes, hypertension, hyperlipidemia, and smoking status and was compared with the CAD2 extended model that added CAC to assess the incremental value of CAC scoring, as well as to the corresponding locally calibrated local assessment of the heart models. A total of 522 patients were analyzed (mean age 54±11 years, 43.1% female). The CAD2 clinical model obtained an area under the curve of 0.718 (95% CI, 0.668–0.767). The inclusion of CAC score improved the area under the curve to 0.896 (95% CI, 0.867–0.925) in the CAD2 models and from 0.767 (95% CI, 0.721–0.814) to 0.926 (95% CI, 0.900–0.951) in the local assessment of the heart models. The locally calibrated local assessment of the heart models showed better discriminative performance than the corresponding CAD2 models (P<0.05 for all).

Conclusions

The CAD2 model was validated in a symptomatic mixed Asian cohort and local calibration further improved performance. CAC scoring provided significant incremental value in predicting obstructive CAD.

Is a novel diagnostic pathway for cardiology outpatient clinics in Singapore lower cost than existing practice: a cost modelling study

OBJECTIVE

To evaluate the potential for change to costs from a decision to adopt a novel diagnostic pathway for referrals to cardiology outpatients with symptoms of chest pain.

DESIGN

Costs modelling study using existing observational data, with a cost year of 2018.

SETTING

Specialist Heart Centre in Singapore.

PARTICIPANTS

All new referrals (n=10 622) to the outpatient clinics for investigation between January 2017 and December 2017.

INTERVENTIONS

Two competing testing regimes are compared in a decision tree model. Current practice includes classification of patients by their risk and the use of treadmill tests, calcium scores, functional testing and CT angiogram. New practice offers a fundamental difference in use of diagnostics for patients, with some offered angiogram directly and for low-risk patients a calcium score is used to refine risk stratification.

OUTCOME MEASURES

The expected cost difference between testing alternatives.

RESULTS

The expected cost saving from 'New Practice' as compared with 'Current Practice' is $S764 per patient. There is a 50% probability the savings per patient range between $S764 and $S824 and a 90% probability they are between $S616 and $S912. The expected savings to Singapore national health services are $S26.8 million annually, with a range of $S16.2 to $S41.1 million.

CONCLUSIONS

We find some evidence that using a coronary calcium score, which can be performed with a fraction of the time and cost of a CT coronary angiogram, saves costs to health services.

The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review

Background  Non-contrast computed tomography (CT) scanning allows for reliable coronary calcium score (CCS) calculation at a low radiation dose and has been well established as marker to assess the future risk of coronary artery disease (CAD) events in asymptomatic individuals. However, the diagnostic and prognostic value in symptomatic patients remains a matter of debate. This narrative review focuses on the available evidence for CCS in patients with stable chest pain complaints.

Method  PubMed, Embase, and Web of Science were searched for literature using search terms related to three overarching categories: CT, symptomatic chest pain patients, and coronary calcium. The search resulted in 42 articles fulfilling the inclusion and exclusion criteria: 27 articles (n = 38 137 patients) focused on diagnostic value and 23 articles (n = 44 683 patients) on prognostic value of CCS. Of these, 10 articles (n = 21 208 patients) focused on both the diagnostic and prognostic value of CCS.

Results  Between 22 and 10 037 patients were included in the studies on the diagnostic and prognostic value of CCS, including 43 % and 51 % patients with CCS 0. The most evidence is available for patients with a low and intermediate pre-test probability (PTP) of CAD. Overall, the prevalence of obstructive CAD (OCAD, defined as a luminal stenosis of ≥ 50 % in any of the coronary arteries) as determined with CT coronary angiography in CCS 0 patients, was 4.4 % (n = 703/16 074) with a range of 0–26 % in individual studies. The event rate for major adverse cardiac events (MACE) ranged from 0 % to 2.1 % during a follow-up of 1.6 to 6.8 years, resulting in a high negative predictive value for MACE between 98 % and 100 % in CCS 0 patients. At increasing CCS, the OCAD probability and MACE risk increased. OCAD was present in 58.3 % (n = 617/1058) of CCS > 400 patients with percentages ranging from 20 % to 94 % and MACE occurred in 16.7 % (n = 175/1048) of these patients with percentages ranging from 6.9 % to 50 %.

Conclusion  Accumulating evidence shows that OCAD is unlikely and the MACE risk is very low in symptomatic patients with CCS 0, especially in those with low and intermediate PTPs. This suggests a role of CCS as a gatekeeper for additional diagnostic testing. Increasing CCS is related to an increasing probability of OCAD and risk of cardiac events. Additional research is needed to assess the value of CCS in women and patient management in a primary healthcare setting.

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Citation Format

Age and the power of zero CAC in cardiac risk assessment: overview of the literature and a cautionary case

The coronary artery calcium (CAC) score is a marker of advanced coronary atherosclerosis. Numerous prospective cohorts have validated CAC as an independent marker that improves prognostication in atherosclerotic cardiovascular disease (ASCVD) beyond traditional risk factors. Accordingly, CAC is now incorporated into international cardiovascular guidelines as a tool to inform medical decision-making. Particular interest concerns the significance of zero CAC score (CAC=0). While many studies report CAC=0 to virtually exclude obstructive coronary artery disease (CAD), non-negligible rates of obstructive CAD despite CAC=0 are reported in certain populations. Overall, the current literature supports the power of zero CAC as a strong downward risk classifier in older patients, whose CAD burden predominantly involves calcified plaque. However, with their higher burden of non-calcified plaque, CAC=0 does not reliably exclude obstructive CAD in patients under 40 years. Illustrating this point, we present a cautionary case of a 31-year-old patient found to have severe two-vessel CAD despite CAC=0. We highlight the value of coronary computed tomography angiography (CCTA) as the gold-standard non-invasive imaging modality when the diagnosis of obstructive CAD is in question.

Coronary Artery Calcium Versus Pooled Cohort Equations Score for Primary Prevention Guidance: Randomized Feasibility Trial

OBJECTIVES

This study sought to determine the feasibility of performing an extensive randomized outcomes trial comparing a coronary artery calcium (CAC)- versus a pooled cohort equations (PCE) risk score-based strategy for initiating statin therapy for primary atherosclerotic cardiovascular disease (ASCVD) prevention.

BACKGROUND

Statin therapy is standard for the primary prevention of ASCVD in subjects at increased risk. National guidelines recommend using the American College of Cardiology/American Heart Association PCE risk score to guide a statin recommendation. Whether guidance by a CAC score is equivalent or superior is unknown.

METHODS

CorCal (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events) was a randomized trial consenting 601 patients without known ASCVD, diabetes, or prior statin therapy recruited from primary care clinics and randomized to CAC- (n = 302) or PCE guidance (n = 299) of statin initiation for primary prevention. Enrolled subjects and their physicians made final treatment decisions. Primary outcomes compared the proportion of statin recommendations received and subject adherence over 1 year between CAC- and PCE-arm subjects. Modeled medical costs, adverse effects, and low-density lipoprotein-cholesterol (LDL-C) were additional measures of interest.

RESULTS

Subjects were well matched, and 540 (89.9%) completed entry testing and received a protocol-based recommendation. A statin was recommended in 101 (35.9%) CAC- and 124 (47.9%) PCE-arm subjects (P = 0.005). Compared to PCE-based recommendations, CAC-arm subjects were reclassified from statin to no statin in 36.0% and from no statin to statin in 5.6% of cases, resulting in a total reclassification of 20.6%. Physicians accepted the study-dictated recommendation to start a statin in 88.1% of CAC- vs 75.0% of PCE-arm subjects (P = 0.01). Patient-reported adherence to this recommendation at 3 months was 62.2% vs 42.2%, respectively (P = 0.009). At 1 year, statin adherence remained superior, LDL-C levels were lower, estimated costs were similar or reduced in CAC subjects, and few events occurred.

CONCLUSIONS

CAC guidance may be a more efficient, personalized, cost-effective, and motivating approach to statin initiation and maintenance in primary prevention. This feasibility phase of CorCal should be regarded as hypothesis-generating with respect to cardiovascular outcomes, which is being addressed in a large, longer-term outcomes trial. (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events [CorCal]; NCT03439267).

Comparison of guidelines for diagnosing suspected stable angina and the additional value of the calcium score

Background The performance of current diagnostic algorithms of the American College of Cardiology/American Heart Association (ACC/AHA), National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) in patients with stable chest pain and coronary artery calcium (CAC) remains a matter of debate. We compared their merits in patients with CAC and investigated the additional value of the CAC score to improve diagnostic accuracy and risk stratification. Methods and results Patient data were obtained from a prospective registry of 642 consecutive patients. Mean age 63 (SD 11) years, 50% male. According to the guidelines, low and intermediate/high pre-test probability groups were constructed. Patients were reclassified based on their CAC score. Obstructive coronary artery disease (CAD) was observed in 14%. All models performed modestly in accurately predicting CAD (c-statistic <0.65). After addition of the CAC score, the c-statistic of the NICE model increased to 0.75 (95% confidence interval (CI) 0.73-0.78) which was just non-significant compared to the ESC model (0.71 95% CI 0.67-0.74) and performed significantly better than ACC/AHA (0.68 (95% CI 0.64-0.72)). After reclassification more than 50% of patients were classified low risk in NICE and ESC, while the prevalence of obstructive CAD (4.8% and 5.2% respectively) did not increase. Conclusions Addition of the CAC score to the studied models improved the ability to safely rule-out obstructive CAD and identified other patients at high risk for future coronary artery events. These results suggest that incorporating CAC score will lead to substantially less downstream testing and lower costs.

Association of Age With the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Coronary Stenosis in Symptomatic Patients

Importance

The diagnostic value is unclear of a 0 coronary artery calcium (CAC) score to rule out obstructive coronary artery disease (CAD) and near-term clinical events across different age groups.

Objective

To assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD and to assess the implications of such a CAC score and obstructive CAD across different age groups.

Design, Setting, and Participants

This cohort study obtained data from the Western Denmark Heart Registry and had a median follow-up time of 4.3 years. Included patients were aged 18 years or older who underwent computed tomography angiography (CTA) between January 1, 2008, and December 31, 2017, because of symptoms that were suggestive of CAD. Data analysis was performed from April 5 to July 7, 2021.

Exposures

Obstructive CAD, which was defined as 50% or more luminal stenosis.

Main Outcomes and Measures

Proportion of individuals with obstructive CAD who had a CAC score of 0. Risk-adjusted diagnostic likelihood ratios were used to assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD beyond clinical variables. Risk factors associated with myocardial infarction and death were estimated.

Results

A total of 23 759 symptomatic patients, of whom 12 771 (54%) had a CAC score of 0, were included. This cohort had a median (IQR) age of 58 (49-65) years and was primarily composed of women (13 160 [55%]). Overall, the prevalence of obstructive CAD was relatively low across all age groups, ranging from 3% (39 of 1278 patients) in those who were younger than 40 years to 8% (52 of 619) among those who were 70 years or older. In patients with obstructive CAD, 14% (725 of 5043) had a CAC score of 0, and the prevalence varied across age groups from 58% (39 of 68) among those who were younger than 40 years, 34% (192 of 562) among those aged 40 to 49 years, 18% (268 of 1486) among those aged 50 to 59 years, 9% (174 of 1963) among those aged 60 to 69 years, to 5% (52 of 964) among those who were 70 years or older. The added diagnostic value of a CAC score of 0 decreased at a younger age, with a risk factor-adjusted diagnostic likelihood ratio of a CAC score of 0 ranging from 0.68 (approximately 32% lower likelihood of obstructive CAD than expected) in those who were younger than 40 years to 0.18 (approximately 82% lower likelihood than expected) in those who were 70 years or older. The presence of obstructive vs nonobstructive CAD among those with a CAC score of 0 was associated with a multivariable adjusted hazard ratio of 1.51 (95% CI, 0.98-2.33) for myocardial infarction and all-cause death; however, this hazard ratio varied from 1.80 (95% CI, 1.02-3.19) in those who were younger than 60 years to 1.24 (95% CI, 0.64-2.39) in those who were 60 years or older.

Conclusions and Relevance

This cohort study found that the diagnostic value of a CAC score of 0 to rule out obstructive CAD beyond clinical variables was dependent on age, with the added diagnostic value being smaller for younger patients. In symptomatic patients who were younger than 60 years, a sizable proportion of obstructive CAD occurred among those without CAC and was associated with an increased risk of myocardial infarction and all-cause death.

Coronary artery calcium score: pivotal role as a predictor for detecting coronary artery disease in symptomatic patients

Chest pain and dyspnea are common presentations for symptomatic individuals with suspected coronary artery disease (CAD) in the primary care office and cardiology clinics. However, it is imperative to properly diagnose who should undergo further evaluation for cardiac etiologies of chest pain, with either noninvasive or invasive imaging tests. The purpose of this review is to highlight the role of coronary artery calcium (CAC) score as a screening tool for symptomatic patients to detect CAD. The purpose of CAC scoring is to establish the presence and severity of coronary atherosclerosis that can play a vital role in symptomatic patients. The use of CAC testing in symptomatic patients has traditionally been limited due to fundamental concerns, including the occurrence of coronary calcification relatively late in the atherosclerotic process and high prevalence of CAC in the population. Further issue relates to its low specificity for obstructive CAD, as well as demonstration of significant ethnic variability in plaque composition and calcification patterns. CAC testing gained attention as an inexpensive, rapid, reproducible and a well-tolerated alternative to exclude CAD in symptomatic patients and defer further invasive imaging tests. This article will review the available literature in regard to the use of CAC in symptomatic populations.

Coronary artery calcium score above 250 confirms the presence of significant stenosis in coronary CT angiography of symptomatic patients

OBJECTIVES

Evaluation of coronary artery calcium score (CACS) at multiple low and high cutoff values for the detection of significant coronary stenosis at two different cutoffs (50 and 70%) in a large number of symptomatic patients was not investigated previously in one study. This study aims to investigate if there are a correlation and statistical significance between different CACS cutoffs and the severity of coronary artery stenosis by coronary CT angiography (CCTA) in symptomatic patients.

METHODS

This is a retrospective study that included all symptomatic patients who had CCTA in a tertiary care hospital over a period of 7 years.

RESULTS

CCTA of 502 patients was evaluated (406 included, mean age 56.2 years); 230 were males (56.7%). The prevalence of stenosis at any percentage was 53.7%, ≥50% was 26.6% and ≥70% was 12.3%. The mean CACS was 84.5 (range 0-1860), for males was 124.5 and for females was 32.1. Patients with CACS of zero (59%) and CACS of ≥1 (41%) had a mean stenosis of 8.9% (range 0-75%) and 52.6% (range 0-100%), respectively. All patients with a CACS of ≥250 were found to have ≥50% stenosis (100% specificity and positive predictive value, 35.2% sensitivity, 81% negative predictive value and 82.6% accuracy). The percentage of stenosis increased as CACS increased with strong statistical significance (P value < 0.0001) and a positive correlation (r = 0.58).

CONCLUSIONS

CACS is a valuable diagnostic tool to predict the severity of coronary artery stenosis. A cutoff value of 250 confirmed the presence of at least 50% stenosis in symptomatic patients.

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.

Prevention of Coronary Artery Disease-Related Heart Failure: The Role of Computed Tomography Scan

During the past decade, coronary computed tomography angiography has emerged as the primary modality to noninvasively detect and rule out coronary artery disease. Therefore, this technique could play an important role in identifying patients at high risk of heart failure, considering the high prevalence of coronary artery disease in these patients. The latest technologies have also increased diagnostic accuracy, helping to close the gap with the other functional imaging modalities.

Performance of the coronary calcium score in an outpatient chest pain clinic and strategies for risk stratification

Background

Coronary artery calcium score (CAC) is an objective marker of atherosclerosis. The primary aim is to assess CAC as a risk classifier in stable coronary artery disease (CAD).

Hypothesis

CAC improves CAD risk prediction, compared to conventional risk scoring, even in the absence of cardiovascular risk factor inputs.

Methods

Outpatients presenting to a cardiology clinic (n = 3518) were divided into two cohorts: derivation (n = 2344 patients) and validation (n = 1174 patients). Adding logarithmic transformation of CAC, we built two logistic regression models: Model 1 with chest pain history and risk factors and Model 2 including chest pain history only without risk factors simulating patients with undiagnosed comorbidities. The CAD I Consortium Score (CCS) was the conventional reference risk score used. The primary outcome was the presence of coronary artery disease defined as any epicardial artery stenosis≥50% on CT coronary angiogram.

Results

Area under curve (AUC) of CCS in our validation cohort was 0.80. The AUC of Models 1 and 2 were significantly improved at 0.88 (95%CI 0.86–0.91) and 0.87 (95%CI 0.84–0.90), respectively. Integrated discriminant improvement was >15% for both models. At a pre‐specified cut‐off of ≤10% for excluding coronary artery disease, the sensitivity and specificity were 89.3% and 74.7% for Model 1, and 88.1% and 71.8% for Model 2.

Conclusion

CAC helps improve risk classification in patients with chest pain, even in the absence of prior risk factor screening.

Association of type D personality and level of coronary artery calcification

OBJECTIVE

To evaluate the association of the type D personality and the level of coronary arteries calcification in population-based sample.

METHODS

1595 residents aged 25 to 64 years were recruited in a observational cross-sectional study in the period from 2012 to 2013. In addition to the ESSE-RF study protocol, we assessed the presence of a Type D personality and quantified coronary artery calcium (CAC) using multispiral computed tomography. The obtained data was analyzed by the Agatston method. The patients were divided into two groups: patients with type D personality (n = 231) and without type D (n = 1379).

RESULTS

CAC score differed significantly between the groups: 689.3 ± 53.7 in patients with type D and 546.5 ± 47 without type D (p = 0.04). The greatest differences of calcium score were found in the left coronary artery system, namely left anterior descending artery (p = 0.01) and circumflex artery (p = 0.03). Patients with type D had higher levels of clinically significant anxiety (p = 0.04) and depression (p = 0.02). Type D personality is associated with high levels of CAC score independently from age, sex, diabetes mellitus status, smoking, alcohol consumption, body mass index, arterial hypertension status, cholesterol level, history of brain stroke, myocardial infarction, coronary artery disease, HADS-A and HADS-D scores.

CONCLUSIONS

Type D personality is associated with higher average values of the CAC score, and type D may represent a potentially modifiable risk factor CAD. But it is unclear whether type D can affect the progression of CAC score.

Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis

AIMS

The European Society of Cardiology recommends coronary computed tomography (CCT) for the assessment of low-risk patients with suspected stable angina. We aimed to assess in a real-life setting the relative clinical value of stress echocardiography (SE)- and CCT-guided management in this population.

METHODS AND RESULTS

Patients with stable chest pain and no prior history of coronary artery disease (CAD) who underwent CCT or SE as the initial investigative strategy were propensity-matched (990 patients each group-age: 59 ± 13.2 years, males: 47.9%) to account for baseline differences in cardiovascular risk factors. Inconclusive tests were 6% vs. 3% (P < 0.005) in CCT vs. SE. Severe (≥70% stenosis) on CCT and inducible ischaemia on SE detected obstructive CAD by invasive coronary angiography in 63% vs. 57% patients (P = 0.33). Over the follow-up period (median 717, interquartile range 93-1069 days) more patients underwent invasive coronary angiography (21.5% vs. 7.3%, P < 0.005), revascularization (7.3% vs. 3.5%, P < 0.005), further functional testing 33.4% vs. 8.7% (P < 0.005), but more patients were prescribed statins 8.8% vs. 3.8% (P < 0.005) in the CCT vs. the SE arm, respectively. Combined all-cause mortality and acute myocardial infarction was low-CCT-2.3% and SE-3.3%-with no significant difference (P = 0.16).

CONCLUSION

Initial SE-guided management was similar for the detection of obstructive CAD, demonstrated better resource utilization, but was associated with reduced prescription of statins although with no difference in medium-term outcome compared to CCT in this very low-risk population. However, a randomized study with longer follow-up is needed to confirm the clinical value of our findings.

Coronary artery calcium testing in low-intermediate risk symptomatic patients with suspected coronary artery disease: An effective gatekeeper to further testing?

Computed tomography for quantification of coronary artery calcium (CAC) is a simple non-invasive tool to assess atherosclerotic plaque burden. CAC is highly correlated with coronary atherosclerosis and is a robust predictor of cardiovascular outcomes. Recently, the 2018 ACC/AHA Cholesterol Guidelines endorsed the use of CAC scores in asymptomatic, intermediate risk individuals where the decision to initiate stain therapy is uncertain. However, whether quantification of CAC may play a role in the assessment of symptomatic individuals remains a matter of debate. In this review, we examine the evidence for the use of CAC in low-intermediate risk patients with chest pain. This appraisal places a particular focus on the growing body of literature supporting the negative predictive value of a CAC score of zero to rule out significant coronary artery disease in those without high-risk features. We also evaluate current guidelines, limitations, and future research directions for CAC scoring in this important subgroup of patients.

A Coronary Artery Calcium Score of Zero in Patients Who Have Undergone Coronary Computed Tomography Angiography Is Associated With Freedom From Major Adverse Cardiovascular Events

Background

The coronary artery calcification score (CACS) is a good marker of future cardiovascular risk. We determined the association between the CACS and the prognosis in patients who have undergone coronary computed tomography angiography (CCTA).

Methods

We performed a prospective cohort study and enrolled 502 consecutive patients who underwent CCTA for screening of coronary artery disease (CAD) at Fukuoka University Hospital (FU-CCTA Registry) and either were clinically suspected of having CAD or had at least one cardiovascular risk factor with a follow-up of up to 5 years. The patients were divided into CACS = 0 and CACS > 0 groups. Using CCTA, ≥ 50% coronary stenosis was diagnosed as CAD, and the number of significantly stenosed coronary vessels (VD), Gensini score and CACS were quantified. The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization).

Results

%CAD, the number of VD and the Gensini score in the CACS = 0 group were significantly lower than those in the CACS > 0 group. %MACE in the CACS = 0 group was also significantly lower than that in the CACS > 0 group. Kaplan-Meier curves indicated that the CACS = 0 group showed significantly greater freedom from MACE than the CACS > 0 group (P = 0.008). Finally, only CACS = 0 was independently associated with MACE (odd ratio: 0.41, 95% confidence interval: 0.17 - 0.97, P = 0.041).

Conclusions

A CACS of 0 in patients who underwent CCTA was associated with a good prognosis.

Association of Bone Mineral Density and Coronary Artery Calcification in Patients with Osteopenia and Osteoporosis

The aim of this study was to investigate the association between bone mineral density (BMD) and coronary artery calcification (CAC) in adults with osteopenia or osteoporosis. A retrospective medical review study was conducted in a regional hospital in southern Taiwan. Medical records of patients who underwent both a coronary computed tomography scan and a BMD measurement were identified. Multinomial logistic regression analyses were used to assess the association between BMD and CAC levels in patients with osteopenia or osteoporosis. Of the 246 patients, 119 were female and 42.3% had CAC. For patients with osteopenia, after adjusting for the significant factors of CAC, no significant association was observed between BMD with either moderate CAC (0 < CAC score ≤ 100) or high CAC (CAC score > 100). However, in patients with osteoporosis, after adjusting for the significant factors of CAC, BMD in the lumbar spine was inversely associated with moderate CAC (odds ratio = 0.38, p = 0.035). In conclusion, a lower BMD in the lumbar spine was associated with an increased risk of moderate CAC in patients with osteoporosis. It is crucial to take action to maintain bone health, particularly in those who already have osteoporosis, to reduce the risk of developing CAC and its associated morbidity and mortality.

Natural course of coronary artery calcium progression in Asian population with an initial score of zero

Background

We aimed to investigate the natural course of coronary artery calcium progression in an Asian population with a baseline coronary artery calcium (CAC) score of zero, and to determine subclinical coronary atherosclerosis.

Methods

Four hundred fifty-nine subjects with at least two CAC scans with an initial score of zero were included. CAC progression (+) was defined by the development of any CAC (i.e., CAC > 0) during subsequent CT scans. Clinical characteristics and Framingham risk profiles were also recorded.

Results

Among 459 subjects, 106 (23.09%) experienced CAC progression during the average follow-up period of 5.71 ± 2.68 years. Older age, male gender, HDL-C, total cholesterol and higher Framingham risk score were independently associated with CAC progression. Framingham risk score had the better discriminative ability (AUC = 0.660) to predict CAC progression compared to the other parameters with a sensitivity of 75.24% and specificity of 53.95%. For the double zero score with coronary artery atherosclerosis prediction, older age, triglycerides, hypertension, and Framingham risk score were significantly associated with these events. Among these parameters, Framingham risk score may be a relatively acceptable parameter with high negative predictive (NPV = 96.4%) value to rule out double zero score with obstructive coronary artery atherosclerosis scenario with an optimum cut-off value of <16.9 (AUC =0.652, sensitivity of 57.69%; specificity of 68.82%).

Conclusions

A baseline zero CAC score in asymptomatic Chinese population with low to intermediate risk have a low incidence for CAC progression within the 5-years period. For CAC progression prediction, Framingham risk score with the cutoff < 11.1 may help confirm subjects at low risk to improve cardiovascular risk stratification and reclassification in the field of preventive cardiology.