Coronary Artery Calcium Scanning Research Articles

The impact of nonoptimal lipids on the progression of coronary artery calcification in asymptomatic young adults: results from the KOICA registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Recently, as cumulative exposure of lipids for a lifetime has become important to prevent and predict atherosclerotic cardiovascular disease (ASCVD), it is recommended to obtain the optimal lipid levels from a young age. However, questions remain regarding the vascular changes in young adulthood by nonoptimal lipid levels. Purpose We aimed to investigate the progression of coronary artery calcification (CAC) according to lipid profiles in Korean young adults. Methods From the KOrea Initiative on Coronary Artery calcification registry, we collected 2,940 statin-naïve adults under 45-year-old, undergoing serial coronary artery calcium scans for the purpose of routine health check-ups between 2002 and 2017. CAC progression was assessed according to the optimality of lipid levels and each lipid variable. Results In this cohort (mean age, 41.3 years; man 82.4%), only 477 subjects (16.2%) had the optimal lipid profile, defined as triglycerides <150 mg/dl, LDL cholesterol <100 mg/dl, and HDL cholesterol ≥45 mg/dl. During follow-up (median 39.7 months), CAC progression was observed in 438 participants (14.8%) and more frequent in nonoptimal lipid group (16.5% vs 5.9%; p<0.001). Nonoptimal lipid levels during young adulthood increased the risk of CAC progression after adjusting for other cardiovascular risk factors (adjusted HR, 2.36; p=0.001), with a stepwise risk increase according to lipid levels. In particular, in the subjects with an initial calcium score of zero (adjusted HR, 2.13; p=0.014), those in their 20s or 30s (adjusted HR 2.70; p=0.029), and those without any other risk factors (adjusted HR 2.51; p=0.025), deemed as very low-risk groups, nonoptimal lipid levels more than doubled the risk of CAC progression, respectively. Among lipid variables, high triglycerides appeared to provide the greatest impact on CAC progression of young adults. Conclusions The proportion of young adults with optimal lipid levels was lower than expected. Nonoptimal lipid level was significantly associated with the risk of CAC progression in young adults, even with low-risk. Triglycerides had the strongest association with the risk of CAC progression. Screening and intervention for nonoptimal lipid levels, particularly triglycerides, from an early age might be of clinical value.

Risk stratification using coronary artery calcium scoring based on low tube voltage computed tomography

To determine if coronary artery calcium (CAC) scoring using computed tomography at 80 kilovolt-peak (kVp) and 70-kVp and tube voltage-adapted scoring-thresholds allow for accurate risk stratification as compared to the standard 120-kVp protocol. We prospectively included 170 patients who underwent standard CAC scanning at 120-kVp and 200 milliamperes and additional scans with 80-kVp and 70-kVp tube voltage with adapted tube current to normalize image noise across scans. Novel kVp-adapted thresholds were applied to calculate CAC scores from the low-kVp scans and were compared to those from standard 120-kVp scans by assessing risk reclassification rates and agreement using Kendall’s rank correlation coefficients (Τb) for risk categories bounded by 0, 1, 100, and 400. Interreader reclassification rates for the 120-kVp scans were assessed. Agreement for risk classification obtained from 80-kVp and 70-kVp scans as compared to 120-kVp was good (Τb = 0.967 and 0.915, respectively; both p < 0.001) with reclassification rates of 7.1% and 17.2%, respectively, mostly towards a lower risk category. By comparison, the interreader reclassification rate was 4.1% (Τb = 0.980, p < 0.001). Reclassification rates were dependent on body mass index (BMI) with 7.1% and 13.6% reclassifications for the 80-kVp and 70-kVp scans, respectively, in patients with a BMI < 30 kg/m2 (n = 140), and 2.9% and 7.4%, respectively, in patients with a BMI < 25 kg/m2 (n = 68). Mean effective radiation dose from the 120-kVp, the 80-kVp, and 70-kVp scans was 0.54 ± 0.03, 0.42 ± 0.02, and 0.26 ± 0.02 millisieverts. CAC scoring with reduced tube voltage allows for accurate risk stratification if kVp-adapted thresholds for calculation of CAC scores are applied.ClinicalTrials.gov NCT03637231.

Calcium scoring in low-dose ungated chest CT scans using convolutional long-short term memory networks.

We aimed to develop a novel deep-learning based method for automatic coronary artery calcium (CAC) quantification in low-dose ungated computed tomography attenuation correction maps (CTAC). In this study, we used convolutional long-short -term memory deep neural network (conv-LSTM) to automatically derive coronary artery calcium score (CAC) from both standard CAC scans and low-dose ungated scans (CT-attenuation correction maps). We trained convLSTM to segment CAC using 9543 scans. A U-Net model was trained as a reference method. Both models were validated in the OrCaCs dataset (n=32) and in the held-out cohort (n=507) without prior coronary interventions who had CTAC standard CAC scan acquired contemporarily. Cohen's kappa coefficients and concordance matrices were used to assess agreement in four CAC score categories (very low: <10, low:10-100; moderate:101-400 and high >400). The median time to derive results on a central processing unit (CPU) was significantly shorter for the conv-LSTM model- 6.18s (inter quartile range [IQR]: 5.99, 6.3) than for UNet (10.1s, IQR: 9.82, 15.9s, p<0.0001). The memory consumption during training was much lower for our model (13.11Gb) in comparison with UNet (22.31 Gb). Conv-LSTM performed comparably to UNet in terms of agreement with expert annotations, but with significantly shorter inference times and lower memory consumption.

Relation of Progression of Coronary Artery Calcium to Dementia (from the Multi-Ethnic Study of Atherosclerosis)

Baseline coronary artery calcification has been shown to be associated with dementia. However, the value of coronary artery calcium (CAC) progression in the prediction of dementia remains unclear. In this study, we examined the association between CAC progression and dementia in the Multi-Ethnic Study of Atherosclerosis. The Multi-Ethnic Study of Atherosclerosis is a prospective study consisting of 6,814 participants 45 to 84years of age, free of overt cardiovascular disease at baseline. A total of 5,570 subjects had baseline and follow-up CAC scans approximately 2.5years apart and were included this analysis. A total of 4,173 of these participants completed cognitive testing with the Cognitive Abilities Screening Instrument (CASI) approximately 10years after the baseline CAC scan. Dementia diagnoses were identified using International Classification of Diseases codes from hospitalizations, death certificates, and medications used to treat dementia. The absolute change between baseline and follow-up CAC was used to assess CAC progression. Cox proportional hazards and multivariable linear regression models were used to examine the association of CAC progression with incident dementia and with CASI score. Over a median follow-up of 13.2 (interquartile range: 11.2 to 15.3) years, 350 participants developed incident dementia. CAC progression showed no association with dementia risk after adjustment for age, gender, race/ethnicity, vascular risk factors, and baseline CAC score. There was no association of CAC progression with CASI score in any adjusted model. In conclusion, progression of CAC over approximately 2.5years was not associated with increased risk of dementia after adjustment for demographic variables, vascular risk factors, and baseline CAC.

Artificial intelligence and imaging: Opportunities in cardio-oncology

Cardiovascular disease is a leading cause of death in cancer survivors. It is critical to apply new predictive and early diagnostic methods in this population, as this can potentially inform cardiovascular treatment and surveillance decision-making. We discuss the application of artificial intelligence (AI) technologies to cardiovascular imaging in cardio-oncology, with a particular emphasis on prevention and targeted treatment of a variety of cardiovascular conditions in cancer patients. Recently, the use of AI-augmented cardiac imaging in cardio-oncology is gaining traction. A large proportion of cardio-oncology patients are screened and followed using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), currently obtained using echocardiography. This use will continue to increase with new cardiotoxic cancer treatments. AI is being tested to increase precision, throughput, and accuracy of LVEF and GLS, guide point-of-care image acquisition, and integrate imaging and clinical data to optimize the prediction and detection of cardiac dysfunction. The application of AI to cardiovascular magnetic resonance imaging (CMR), computed tomography (CT; especially coronary artery calcium or CAC scans), single proton emission computed tomography (SPECT) and positron emission tomography (PET) imaging acquisition is also in early stages of analysis for prediction and assessment of cardiac tumors and cardiovascular adverse events in patients treated for childhood or adult cancer. The opportunities for application of AI in cardio-oncology imaging are promising, and if availed, will improve clinical practice and benefit patient care.

Radiation Doses in Patients Undergoing Computed Tomographic Coronary Artery Calcium Evaluation With a 64-Slice Scanner Versus a 256-Slice Scanner.

Computed tomographic coronary artery calcium scanning enables cardiovascular risk stratification; however, exposing patients to high radiation levels is an ongoing concern. New-generation computed tomographic systems use lower radiation doses than older systems do. To quantify comparative doses of radiation exposure, we prospectively acquired images from 220 patients with use of a 64-slice GE LightSpeed VCT scanner (control group, n=110) and a 256-slice GE Revolution scanner (study group, n=110). The groups were matched for age, sex, and body mass index; statistical analysis included t tests and linear regression. The mean dose-length product was 21% lower in the study group than in the control group (60.2 ± 27 vs 75.9 ± 22.6 mGy·cm; P <0.001) and also in each body mass index subgroup. Similarly, the mean effective radiation dose was 21% lower in the study group (0.84 ± 0.38 vs 1.06 ± 0.32 mSv) and lower in each weight subgroup. After adjustment for sex, women in the study group had a lower dose-length product (50.4 ± 23.4 vs 64.7 ± 27.6 mGy·cm) than men did and received a lower effective dose (0.7 ± 0.32 vs 0.9 ± 0.38 mSv) (P=0.009). As body mass index and waist circumference increased, so did doses for both scanners. Our study group was exposed to radiation doses lower than the previously determined standard of 1 mSv, even after adjustment for body mass index and waist circumference. In 256-slice scanning for coronary artery calcium, radiation doses are now similar to those in lung cancer screening and mammography.

Preventing Heart Disease via Coronary Artery Calcium Scoring to Make a Definitive Diagnosis of Atherosclerosis

Purpose: Cardiovascular disease is the number one cause of death in the Western world. The purpose of this manuscript is to compare the benefits and deficiencies of coronary artery calcium scanning versus computer generated risk equations in identifying atherosclerotic cardiovascular disease. These two approaches provide significantly different cardiovascular risk assessments and often lead to therapeutic differences in recommendations from the physician to the patient. Methods: Pertinent medical literature is reviewed concerning both risk assessment approaches (i.e., coronary artery scanning and computer generated risk equations). The strengths and weaknesses of both approaches are discussed, and recommendations are provided based upon available data. Results: Cardiovascular risk equations are simple and readily obtained at no charge by physicians. However, their drawbacks are several, including non-applicability to specific populations, disagreements among different cardiovascular society risk equations, wide ranges of risk outputs (e.g., intermediate 10-year risk is between 5% and 20%), inability to definitively identify coronary artery plaques, and lack of definitive anatomical coronary disease. Alternatively, coronary artery calcium scanning costs approximately $100/scan (if not covered by insurance), requires time and effort by the patient, and exposes the patient to a minimal amount of radiation. However, coronary calcium scanning identifies specific atherosclerotic coronary disease and provides additional information about the anatomical location (i.e., coronary artery) of the atherosclerotic plaque. Conclusion: Based on the published literature, coronary artery calcium scanning is the preferred approach for identifying atherosclerotic cardiovascular disease. Although there are minor drawbacks, overall it provides superior clinical information compared with computer generated risk equations.

Guidelines for the Prevention of Symptomatic Cardiovascular Disease, Based upon the Presence of Coronary Artery Calcified Plaque—Provided by the Society for the Prevention of Symptomatic Heart Disease

Introduction: The epidemic of atherosclerotic cardiovascular disease in the Western World accounts for the majority of morbidity and mortality in adults. This disease is on the increase, and previous recommendations using “risk equations” to prescribe preventive treatment have not been successful in reducing the prevalence of cardiovascular disease. Furthermore, compliance with statin medication has been limited, with approximately 50% of individuals being non-compliant within five years. This situation is unacceptable since atherosclerosis is both preventable and reversible. Methods: The guidelines presented in this article utilize coronary artery calcium scanning as the basis for preventative therapeutic decisions and identifying the presence of asymptomatic cardiovascular disease. This radiographic technique is superior to “risk equations” in predicting future cardiovascular events. It provides a comprehensive assessment of the lifelong insults to the coronary artery vascular endothelium and the resulting inflammation. Coronary artery calcium scanning is widely available, inexpensive, safe, and reproducible. It has the major advantage of increasing treatment compliance in patients with positive coronary artery calcium scores. Results: All suggested guidelines are supported by published scientific data. Citations are provided to allow the reader to obtain further information. The authors are available for further consultation. Each guideline provides specific recommendations that the primary caregiver can discuss with the patient. Patient involvement in decision-making is strongly recommended. Both treatment costs and adverse effects are minimal. Conclusion: It is anticipated that the early identification of asymptomatic cardiovascular disease and its aggressive treatment will result in regression of subclinical atherosclerosis. Adoption of these guidelines will stop the epidemic of symptomatic heart disease and result in healthier and more satisfied patients.

Predictors for coronary artery calcium score and differences in its distributions between populations with and without diabetes

Background and aims Coronary artery calcium (CAC) scoring is a method of measure coronary plaque burden and has been shown as an excellent predictor for atherosclerotic cardiovascular disease (ASCVD). Diabetes mellitus (DM) is an established risk factor for ASCVD, but a certain portion of patients with DM do not have CAC (score = 0). We conducted a study to identify predictors of the CAC score other than DM and to compare distributions of the score between populations with and without DM. Methods We included participants who were referred to receive CAC scanning at a large imaging center from July 1992 to July 2020. The distribution of the CAC scores and baseline characteristics were compared between participants with and without DM. Univariate logistic regressions followed by multivariate analysis were performed using CAC score &gt; 0 as outcome to identify independent factors contributing to the score. Results A total of 35,086 participants (mean age 58.9 ± 11.9 years, 63% male, 69% white) were included in the analysis. Of them, 11.8% had DM, 56% had hyperlipidemia, 38% had hypertension, and 7% were current smokers. A higher proportion of participants in the DM group had CAC score &gt; 0 (82% vs 62%, p &lt;0.01), but a substantial portion (18%) of DM patients had no CAC. Distribution of CAC score was also variable among participants with and without DM. Multivariate analysis showed that DM, age, male, hyperlipidemia, hypertension, and smoking were all independent predictors of CAC, and DM was associated with the second highest odds ratio (2.05, 95% confidence interval 1.87- 2.25) behind male (4.55, 95% confidence interval 4.17-4.76). Conclusions While DM was the second strongest predictor of CAC, nearly one fifth of persons with DM had no detectable CAC. Among DM patients, there is significant heterogeneity of scores, so an individualized approach to primary prevention for these patients is warranted.

Prevention of Coronary Heart Disease: A Translational Clinical Challenge

Introduction: Atherosclerotic cardiovascular disease is a dysmetabolic medical condition resulting in the #1 cause of morbidity and mortality in the United States. Coronary Artery Calcium (CAC) CT non-invasively identifies atherosclerosis in asymptomatic individuals. This translational study tested the hypothesis that clinically overtcardiovascular disease can be prevented in asymptomatic individuals in a medical clinic. Methods: Two hundred and six asymptomatic adults requested a CAC scan to identify subclinical heart disease. Individuals with a positive CAC score > 1 (n = 125) were prescribed targeted medical therapy to reverse their atherosclerosis. The goal was to achieve an LDL Cholesterol (LDL-C) ≤ 60 mg/dl. One hundred and ten individuals reached this goal (67 male, 43 female) receiving 10 mg/d of rosuvastatin and 10 mg/d of ezetimibe plus a low cholesterol diet. Other fifteen individuals with positive CAC scores did not achieve this LDL-C goal. Results: In the group following medical therapy and achieving an LDL-C ≤ 60 mg/dl, no cardiovascular events were observed during a maximum observation period of 5 years (mean observation time = 3.6 years). Based on previously published CVD outcome data in individuals with similar CAC scores, 12.6 cardiovascular events were expected. Two of fifteen individuals with positive CAC scores not following medical therapy had a cardiovascular event. None of the 81 individuals with a zero score had a cardiovascular event during follow-up. No adverse effects of therapy occurred. Conclusion: In a medical clinic, adult population with positive CAC scores and an LDL-C ≤ 60 mg/dl, targeted medical therapy prevented overt cardiovascular disease. These results should encourage other physicians to aggressively treat atherosclerotic cardiovascular disease in their clinic populations.

Abstract 9891: Are CAC Scores Less Valuable for Patients of Low Socioeconomic Status? A Dallas Heart Study Analysis

Background: Low socioeconomic status (SES) is associated with atherosclerotic cardiovascular disease (ASCVD) and possible underestimation of risk by the pooled cohort equations (PCE). Whether coronary artery calcium (CAC) scores can improve risk discrimination in those with low SES is unknown. Methods: Individuals from the Dallas Heart Study free of ASCVD and with CAC scanning were evaluated. Low SES was defined as an annual income &lt;$16,000 or an educational attainment level ≤11 years. Unadjusted and adjusted analyses assessing the relationships between SES and 1) CAC scores and 2) ASCVD events (fatal or non-fatal MI or stroke) were performed. The incremental predictive value of CAC in those at low and higher SES was assessed using c-statistics (PCE alone vs PCE + CAC). Results: Among 2246 individuals (mean age 44 yrs, 55% women, 45% Black), 115 ASCVD events occurred over a median of 12.5 years. Low SES by income (n=451) was associated with increased risk of ASCVD after adjustment for risk factors (HR 2.16, 95% CI 1.37-3.42), but was not independently associated with CAC. Higher CAC scores (0, 1-99, ≥100) tracked with increased 10-year ASCVD event rates in those at low (5, 10, and 22%) and higher SES (0.002, 4, and 11%), with low SES groups carrying greater ASCVD risk for every stratum of CAC, including with CAC=0. In multivariable models compared with CAC=0, those with CAC 1-99 and ≥100 had a greater risk of ASCVD events for individuals at higher SES [HR 3.40 (1.5-7.8), and 4.8 (1.9-12.6)], but not for those with low SES [HR 1.00 (0.4-2.4), and 1.6 (0.6-4.6)], (p-interaction CAC x SES=0.002). Similar results were found for low SES defined by education. The addition of CAC to PCE improved risk discrimination for individuals at higher SES, but not for individuals at low SES (Table 1). Conclusion: Individuals at low SES have significantly increased risk of ASCVD, however, CAC scores are not independently associated with ASCVD in this population and may be less useful in risk discrimination.

Abstract 9550: Sex and Ethnicity Specific Burden of Coronary Artery Calcium Among Middle-Aged and Older Adults: Multi-Ethnic Study of Atherosclerosis

Introduction: Detection of coronary artery calcium (CAC) at a low score is the ideal phase of the atherosclerotic process to start primary prevention therapies. A better understanding of how the proportion of individuals with zero, low, or moderate/high CAC changes with age, sex, and race/ethnicity may aid in determining the optimal age to perform general CAC scoring before there is a severe burden of atherosclerosis. Methods: We calculated the proportion of individuals with 1) CAC ≥1 and CAC ≥100 based on population percentiles from 6,110 participants without diabetes from the Multi-Ethnic Study of Atherosclerosis (MESA) who had a CAC scan at Visit 1 (2000-02). Results: There was an approximately 12 year age difference for when 25% of men had CAC ≥1 compared to CAC ≥100 (&lt;45-51 years old vs 58-63 years old) compared to an approximately 14 year age difference for women (54-59 years old vs 69-75 years old). Women had a 50% prevalence of CAC ≥1 by age 69 years old (71 for Black women vs 67 for White women) compared to age 57 years old for men (62 for Black men vs 53 for White men). White men had a 50% prevalence of CAC ≥100 at age 68 years old, which was between 8-15 years younger than men of other races/ethnicities while women did not have a 50% prevalence of CAC ≥100 until age 80 years or older. In order to have at least a 25 to 50% probability of CAC ≥100, testing should be considered at ages of 55-64 for White men, 65-74 for men of other races/ethnicities and White women, and 75-84 years old for women of other races/ethnicities. Conclusion: Women developed CAC ≥1 approximately 12 years later in life than men. White men developed CAC ≥100 at a much younger age than men of other races/ethnicities, while a majority of women did not develop CAC ≥100 until age ≥80 years old. These findings may provide additional information to aid in the clinician-patient decision making process on the ideal age to perform CAC scoring, especially for those individuals who wish to rule out the presence of a moderate or high CAC score.

Abstract 13748: Feasibility Of Quantitation Coronary And Aortic Valve Calcification In Virtual Non-contrast Images From Dual-energy Delayed Ct Scans In Patients With Severe Aortic Stenosis

Introduction: Increased extracellular volume (ECV), is a prognostically important marker of myocardial fibrosis in patients with severe aortic stenosis (AS). ECV can be assessed during transcatheter aortic valve replacement planning CT (TAVR CT) scan by adding a dual-energy CT (DECT) delayed image. TAVR CT scans routinely include a traditional non-contrast scan (TNC) for coronary artery calcium (CAC) and aortic valve calcium (AVC) scoring. Virtual non-contrast (VNC) images, derived from the DECT could replace TNC for CAC and AVC scoring, and reducing radiation and scan time. We examined the adaptability of VNC as a substitute for TNC by comparing CAC and AVC scoring based on VNC from delayed DECT scans compared to TNC in severe AS patients. Methods: We enrolled 27 severe AS patients who underwent TNC CAC scan and delayed DECT scan as part of TAVR CT using a dual-source scanner (Somatom Flash, Siemens). VNC was reconstructed with postprocessing software (Syngo Dual Energy, Siemens). CAC was categorized as 0, 1-99, 100-399, 400-999 and ≥1,000. Severe AVC was defined as &gt;2,200 for men and &gt;1,200 for women. Results: Both CAC and AVC scores in VNC demonstrated excellent correlation with TNC (r=0.975 and 0.982). The CAC score was significantly lower in VNC compare to TNC (745.2 ± 923.6 vs. 1006.4 ± 1116.9, p&lt;0.001). AVC score did not significantly differ between VNC and TNC (2000.8 ± 2791.6 vs. 1911.5 ± 2186.8, p=0.567). Three patients (3/27) were categorized to a CAC category one grade lower than TNC by VNC DECT (Figure). One patient with non-severe AVC by TNC was misclassified as having severe AVC by VNC (1/27) (Figure). Conclusions: VNC DECT underestimates CAC compared to TNC, but the differences in CAC score rarely resulted in categorical discordance in severe AS patients. VNC from DECT delayed scan for ECV assessment can assign patients to the correct cardiovascular risk categories based on CAC and performs adequately for clinically meaningful AVC scoring in severe AS patients.

Deep learning for automatic calcium scoring in population based cardiovascular screening

Abstract Background High volumes of standardized coronary artery calcium (CAC) scans are generated in screening that need to be scored accurately and efficiently to risk stratify individuals. Purpose To evaluate the performance of deep learning based software for automatic coronary calcium scoring in a screening setting. Methods Participants from the Robinsca trial that underwent low-dose ECG-triggered cardiac CT for calcium scoring were included. CAC was measured with fully automated deep learning prototype and compared to the original manual assessment of the Robinsca trial. Detection rate, positive Agatston score and risk categorization (0–99, 100–399, ≥400) were compared using McNemar test, ICC, and Cohen's kappa. False negative (FN), false positive (FP) rate and diagnostic accuracy were determined for preventive treatment initiation (cut-off ≥100 AU). Results In total, 997 participants were included between December 2015 and June 2016. Median age was 61.0 y (IQR: 11.0) and 54.4% was male. A high agreement for detection was found between deep learning based and manual scoring, κ=0.87 (95% CI 0.85–0.89). Median Agatston score was 58.4 (IQR: 12.3–200.2) and 61.2 (IQR: 13.9–212.9) for deep learning based and manual assessment respectively, ICC was 0.958 (95% CI 0.951–0.964). Reclassification rate was 2.0%, with a very high agreement with κ=0.960 (95% CI: 0.943–0.997), p&amp;lt;0.001. FN rate was 0.7% and FP rate was 0.1% and diagnostic accuracy was 99.2% for initiation of preventive treatment. Conclusion Deep learning based software for automatic CAC scoring can be used in a cardiovascular CT screening setting with high accuracy for risk categorization and initiation of preventive treatment. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Robinsca trial was supported by advanced grant of European Research Council

Modeling the Recommended Age for Initiating Coronary Artery Calcium Testing Among At-Risk Young Adults

BackgroundThere are currently no recommendations guiding when best to perform coronary artery calcium (CAC) scanning among young adults to identify those susceptible for developing premature atherosclerosis. ObjectivesThe purpose of this study was to determine the ideal age at which a first CAC scan has the highest utility according to atherosclerotic cardiovascular disease (ASCVD) risk factor profile. MethodsWe included 22,346 CAC Consortium participants aged 30-50 years who underwent noncontrast computed tomography. Sex-specific equations were derived from multivariable logistic modeling to estimate the expected probability of CAC >0 according to age and the presence of ASCVD risk factors. ResultsParticipants were on average 43.5 years of age, 25% were women, and 34% had CAC >0, in whom the median CAC score was 20. Compared with individuals without risk factors, those with diabetes developed CAC 6.4 years earlier on average, whereas smoking, hypertension, dyslipidemia, and a family history of coronary heart disease were individually associated with developing CAC 3.3-4.3 years earlier. Using a testing yield of 25% for detecting CAC >0, the optimal age for a potential first scan would be at 36.8 years (95% CI: 35.5-38.4 years) in men and 50.3 years (95% CI: 48.7-52.1 years) in women with diabetes, and 42.3 years (95% CI: 41.0-43.9 years) in men and 57.6 years (95% CI: 56.0-59.5 years) in women without risk factors. ConclusionsOur derived risk equations among health-seeking young adults enriched in ASCVD risk factors inform the expected prevalence of CAC >0 and can be used to determine an appropriate age to initiate clinical CAC testing to identify individuals most susceptible for early/premature atherosclerosis.

Coronary Calcium Scanning and Cardiovascular Risk Assessment Among Firefighters

Sudden cardiac death is the main cause of death among firefighters. The goal of this study is to identify firefighters at risk for cardiovascular disease using coronary artery calcium screening. Asymptomatic firefighters aged ≥40 years without known cardiovascular disease or diabetes (N=487) were recruited from fire departments in 3 Maryland counties from 2016 to 2018, with data analysis from 2018 to 2019. The cardiovascular disease prevention program included an evaluation of blood pressure, cholesterol, BMI, fasting glucose, medications, and a coronary calcium scan. A subset (n=100) was evaluated in more detail, including family history, metabolic syndrome, diet, exercise, smoking, and atherosclerotic cardiovascular disease risk score. Results indicated that 191 (39%) firefighters had a coronary artery calcium score >0, of which 91% were above the average for age, sex, and ethnicity. On univariable logistic regression, older age, male sex, hypertension, BMI, and glucose were significantly (p<0.05) associated with a higher likelihood of having any coronary artery calcium. Multiple logistic regression found that older age; male sex; taking lipid-lowering or antihypertensive medications; and higher low-density lipoprotein cholesterol, BMI, and fasting blood glucose were significantly associated with a higher likelihood of having coronary artery calcium. Of those with coronary artery calcium, 141 (74%) were not on lipid-lowering medication. In addition, 47 (94%) of those on lipid-lowering medication had a low-density lipoprotein cholesterol >70 mg/dL. In the detailed subset, 30 (30%) had coronary artery calcium. Among these, 28 (93%) had an atherosclerotic cardiovascular disease risk score <7.5%. Thus, if atherosclerotic cardiovascular disease scores alone were used to assess risk in this subset, an opportunity would have been missed to identify and treat firefighters who may have benefited from more aggressive treatment. A coronary artery calcium scan may identify the firefighters at increased risk for cardiovascular disease. A comprehensive cardiovascular disease prevention program implemented early in a firefighter's career may help reduce cardiovascular disease risk and thus death and disability in this high-risk population.

Modeling The Recommended Age To Initiate Coronary Artery Calcium Testing Among At-risk Young Adults: The CAC Consortium

Introduction: There are currently no recommendations guiding when best to perform coronary artery calcium (CAC) scanning among young adults to identify those susceptible for developing premature atherosclerosis. This study explored the ideal age at which a first CAC scan has the highest utility according to atherosclerotic cardiovascular disease (ASCVD) risk factor profile.

Racial/ethnic Differences In Vertebral Bone Mineral Density (BMD) Assessed By Cardiac Computed Tomography (CT): Results From The Multi-ethnic Study Of Atherosclerosis (MESA)

Introduction: Each year an estimated 1.5 million individuals suffer a fracture due to bone disease. The risk of bone fractures increases with age and is greatest in women, who have represented the focus of most of the previous published studies. However, racial and ethnic differences in BMD are important factors as well, since people of certain races/ethnicities might normally exhibit lower BMDs than others. We investigated the ethnic/racial differences in vertebral BMD in the general population using gated coronary artery calcium scans.

Feasibility of Using an Ultrashort Lifestyle Questionnaire to Predict Future Mortality Risk among Patients with Suspected Heart Disease

Adverse health behaviors are potent drivers of chronic disease and premature mortality. This has led to the development of various lifestyle scores to predict clinical risk, but their complexity makes them impractical for use in clinical settings. Thus, there is a need to develop a brief lifestyle score that can assess factors such as exercise and diet within the constraints of routine medical practice. Accordingly, we assessed 19,081 patients undergoing coronary artery calcium (CAC) scanning between September 1, 1998 and December 30, 2016. Each patient completed a questionnaire that included a two-item lifestyle scale regarding patients' frequency of exercise and adherence to a low saturated fat diet. Patients' responses were used to generate a lifestyle score which ranged from very low risk to high risk. Patients were followed for a median of 11.0 years for all-cause mortality. A stepwise relationship was noted between worse lifestyle scores and increased frequency of hypertension, diabetes, smoking, obesity, waist/hip ratio, and resting heart rate and blood pressure. Among patients with zero CAC scores, mortality risk was low regardless of lifestyle score, but as CAC abnormality increased, a stepwise relationship emerged between worse lifestyle scores and mortality. The lifestyle score was more predictive of mortality than conventional CAD risk factors according to multivariable Chi-square analysis. Thus, our results establish the practicality of an ultrashort lifestyle questionnaire that could be employed in nearly all clinical settings. Within our study, our two-item lifestyle scale showed a stepwise relationship to known CAD risk factors and predicted future mortality.

Simplifying the ISCHEMIA trial algorithm for clinical practice: Identifying left main coronary artery disease using coronary artery calcium scans

Several recent trials have evaluated invasive versus medical therapy for stable ischemic heart disease. Importantly, patients with significant left main coronary stenosis (LMCS) were excluded from these trials. In the ISCHEMIA trial, these patients were identified by a coronary CT angiogram (CCTA), which adds time, expense, and contrast exposure. We tested whether a coronary artery calcium scan (CACS), a simpler, less expensive test, could replace CCTA to exclude significant LMCS. We hypothesized that patients with ≥50% LMCS would have a LM CACS score > 0. As a corollary, we postulated that a LM CACS=0 would exclude patients with LMCS. To test this, we searched Intermountain Healthcare's electronic medical records database for all adult patients who had undergone non-contrast cardiac CT for quantitative CACS scoring prior to invasive coronary angiography (ICA). Patients aged <50 and those with a heart transplant were excluded. Cases with incomplete (qualitative) angiographic reports for LMCS and those with incomplete or discrepant LM CACS results were reviewed and reassessed blinded to CACS or ICA findings, respectively. Among 669 candidate patients with CACS followed by ICA, 36 qualifying patients were identified who had a quantitative CACS score and LMCS ≥ 50%. Their age averaged 71.8 years, and 81% were men. Angiographic LMCS averaged 72% (range 50%-99%). Median time between CACS and ICA was 6 days. Total CACS score averaged 2,383 Agatston Units (AU), range 571-6,636. LM CACS score averaged 197 AU, range 31-610. Importantly, no LMCS patient had a LM CACS score of 0 vs 57% (362/633) of non-LMCS controls (P < .00001). Our results support the hypothesis that an easily administered, inexpensive, low radiation CACS can identify a large subset of patients with a very low risk of LMCS who would not have the need for routine CCTA. Using CACS to exclude LMCS may efficiently allow for safe implementation of an initial medical therapy strategy of patients with stable ischemic heart disease in clinical practice. These promising results deserve validation in larger data sets.