Coronary Artery Calcium Score Of Zero Research Articles

Abstract 4131815: The Prevalence of Normal Coronary Arteries as Determined by a Coronary Artery Calcium Score of Zero Amongst Subjects with Diabetes Mellitus

Background: The CDC reports that in 2021, 11.6% of the American population had diabetes mellitus (DM). Past literature has shown diabetes to be a significant risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). Research Question/Goal: Using data obtained through Computed Tomography Angiography (CTA), we aim to distinguish the risk factors associated with a coronary artery calcium (CAC) score of zero in subjects with DM and to identify the prevalence of non-calcified plaque in individuals with this score. Methods: We performed a retrospective study of patients with DM, who underwent CAC and CTA screenings from October 2004 to January 2024 at our center in Torrance, California to examine CTA outcomes in those with CAC Score of zero and greater than zero. Results: Among the cohort of 2,763 subjects with DM, the average age was 63.8±12.2 years, 62% male. Within this cohort, 465 (17%) subjects had a CAC Score of zero compared to 2,298 subjects with a CAC Score greater than zero with a median score of 428 (Interquartile range (IQR) 91-1267). DM subjects with CAC Score of zero were significantly younger (53.0±13.9 versus 66.0±10.6: p<0.001), were more likely to be female and had significantly lower rates of hypertension (57% versus 76%: p<0.001), and hyperlipidemia (63% versus 76%: p<0.001). In DM subjects with CAC Score of zero, 133 (29%) had a total plaque severity score of 1 or greater (median 1, IQR 1-2) while 332 (71%) had normal coronaries on CTA. Conclusions: A significant percentage of subjects with DM were determined to have a CAC score of zero. Subjects with normal coronary arteries were more likely to be younger, female, and/or absent of other chronic diseases such as hypertension and hyperlipidemia. Although age and sex are nonmodifiable risk factors of ASCVD, limiting the comorbid conditions associated with DM may be beneficial in preventing ASCVD in individuals with diabetes.

Abstract 4136403: Impact of Coronary Artery Calcium Scores on Cardiovascular Risk and Preventive Therapies: A Systematic Review and Meta-Analysis

Introduction: Coronary artery calcium (CAC) serves as a key marker of atherosclerosis and is widely utilized in the noninvasive evaluation of coronary artery disease. We aim to compare cardiovascular risk outcomes and the likelihood of initiating or continuing pharmacological and lifestyle preventive therapies in asymptomatic and symptomatic patients with a CAC score greater than zero and those with a CAC score of zero with no established diagnosis of coronary artery disease. Methods: We performed systematic searches of PubMed, Scopus, Google Scholar, Cochrane Central, and ClinicalTrials.gov from inception to May 2024. Our search focused on randomized controlled trials and observational studies comparing outcomes between patients with a CAC score greater than zero and those with a CAC score of zero. Results: We included 53 observational studies, incorporating data from 210,672 asymptomatic and 32,477 symptomatic patients. Over a mean follow-up duration of 8.6 years, we observed that a CAC score greater than zero significantly correlated with an elevated risk of major adverse cardiovascular events (MACE) (OR: 5.58; 95% CI: 4.05–7.69; P < 0.00001). This association extended to all-cause mortality (OR: 3.90; 95% CI: 2.78–5.48; P < 0.00001), myocardial infarction (OR: 4.01; 95% CI: 3.45–4.65; P < 0.00001), and the need for revascularization (OR: 11.90; 95% CI: 6.82–20.78; P < 0.00001). Patients with a CAC score greater than zero were more likely to commence and continue aspirin therapy (OR: 2.45; 95% CI: 1.56–3.83; P < 0.0001 for initiation and OR: 1.71; 95% CI: 1.31–2.23; P < 0.0001 for continuation). Similar trends were noted for lipid-lowering medications (OR: 2.44; 95% CI: 1.57–3.79; P < 0.0001 for initiation and OR: 2.48; 95% CI: 1.53–4.01; P = 0.0002 for continuation), as well as the initiation of blood pressure medications (OR: 1.94; 95% CI: 1.61–2.33; P < 0.00001). Furthermore, a CAC score greater than zero was linked to increased adoption of lifestyle modifications, including enhanced physical activity (OR: 1.84; 95% CI: 1.41–2.41; P < 0.00001) and dietary changes (OR: 1.94; 95% CI: 1.52–2.49; P < 0.00001). Conclusion: Patients with elevated CAC scores are more likely to initiate and continue preventive pharmacological therapies and adopt beneficial lifestyle modifications. These findings underscore the importance of CAC scoring in guiding the management and prevention of cardiovascular disease in both asymptomatic and symptomatic populations.

Relationship between coronary artery calcium score and plaque vulnerability in patients with established coronary artery disease

Abstract Introduction Coronary artery calcium (CAC) score is widely used for risk stratification. However, in patients with established coronary artery disease (CAD), its clinical implication and relationship with plaque vulnerability have not been fully investigated. Purpose We sought to investigate the relationship between CAC score and plaque vulnerability assessed by optical coherence tomography (OCT). Methods Patients with CAD who had both CAC score and OCT prior to percutaneous coronary intervention were included. The patients with a prior history of coronary revascularization were excluded. Patients were divided into five groups based on CAC score; CAC score of 0, 1-99, 100-399, 400-999, and over 1000. Vulnerable features in culprit plaque assessed by OCT were compared among these five groups. Results In 460 patients, the prevalence of lipid-rich plaque, macrophage, and cholesterol crystal significantly differed among the five groups: lowest in the patients with a CAC score of zero. The prevalence of thin-cap fibroatheroma (TCFA) tended to be lower in those with a CAC score of zero (Figure). In the two-group comparison between the group with a CAC score of zero and the other four groups, the prevalence of lipid-rich plaque (60.5 vs. 85.9%, p < 0.001), macrophage (48.8 vs. 74.1%, p < 0.001), TCFA (16.3 vs. 35.0%, p = 0.013), and cholesterol crystal (11.6 vs. 32.9%, p = 0.004) was significantly lower in the patients with CAC score of zero. No significant difference in vulnerable features was observed among the four groups with CAC scores > 0. CAC score of zero was independently negatively associated with the lipid-rich plaque (odds ratio [OR] 0.246, p < 0.001), macrophage (OR 0.348, p = 0.003), TCFA (OR 0.285, p = 0.006), and cholesterol crystal (OR 0.273, p = 0.010) after adjustment with patient characteristics. Conclusion This is the first study that investigated the relationship between CAC score and plaque vulnerability assessed by OCT in patients with known CAD. Patients with CAC score of zero have a significantly lower prevalence of vulnerable plaque features compared to those with CAC score > 0.

Prevalence of high-risk plaque features on cardiac computed tomography scans in patients with a coronary artery calcium score of zero

Abstract Introduction Coronary artery calcium (CAC) score of zero (so-called "power of zero") is associated with a very low rate of major adverse cardiac events (MACE), especially during short and midterm follow-up. However, a CAC score of zero does not definitively exclude the presence of atherosclerotic plaques or obstructive coronary artery disease (CAD). The composition of atherosclerotic plaques and the frequency of high-risk plaque features in this population are not well described. Purpose We sought to characterize the composition of atherosclerotic plaques and assess the frequency of high-risk plaque features on contrast-enhanced computed tomography (CT) images in patients with a zero CAC score. Methods The study enrolled patients with stable chest pain suspected of CAD referred for coronary CT imaging and having a CAC score of zero. Coronary CT angiography images were assessed by an expert reader to identify atherosclerotic plaques and high-risk plaque features in all coronary arteries with a diameter ≥1.5mm. The coronary artery lumen and plaques were manually segmented, and the degree of stenosis was evaluated following the Coronary Artery Disease Reporting and Data System (CAD-RADS) criteria. The presence of four high-risk plaque features was identified: positive remodeling, spotty calcification, low-attenuation plaque, and napkin ring sign. Total plaque volume, percent atheroma volume, and plaque composition were quantified using dedicated software (Figure 1). Results A total of 145 patients (mean age 54.2±12.1 years, 35.9% males) were included in the analysis. At least one coronary artery plaque was identified in 30 individuals (20.7%). 22 (15.2%), 7 (4.8%), and 1 (0.7%) patients were categorized into CAD-RADS 1, CAD-RADS 2, and CAD-RADS 3 categories, respectively. Among 30 patients with any coronary artery plaque, at least one high-risk feature was found in 10 individuals (33.3%), while 3 individuals (10.0%) had two features. Positive remodeling was found in 7 (23.3%), spotty calcification in 3 (10.0%), low-attenuation plaque in 3 (10.0%), and napkin ring sign in 0 patients, respectively (Figure 1). The mean total plaque volume was 48.2±54.3mm³, and the mean percent atheroma volume was 1.2±0.8%. Total plaque volume comprised low-attenuation (0.4%), fibro-fatty (58.9%), fibrous (39.4%), and calcified (1.3%) plaque volumes. Notably, in 3 (10.0%) individuals, the presence of calcified plaque was identified, which on non-contrast CT images did not meet the Agatston criteria for the CAC score. Conclusions Our study demonstrates a significant prevalence of atherosclerotic plaques and high-risk plaque features in patients with a CAC score of zero. Specifically, one in every five study participants had identifiable atherosclerotic plaque, with one in every three of those exhibiting one or more high-risk plaque features. The prognostic significance of these findings warrants further evaluation in studies with longitudinal follow-up.

Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent - an Experience from a Tertiary Care Center in Pakistan.

The absence of CAC in asymptomatic individuals is associated with a very low incidence of cardiovascular events. Of symptomatic patients, 1-2% with zero CAC score have non-calcified coronary artery atherosclerosis, and at least one third of cardiovascular events occur in individuals with zero CAC. South Asians (SA) have proportionally higher case fatality rates for CVD, relatively younger age of presentation, and accelerated rate of atherosclerosis when compared with other ethnic groups. All consecutive patients who underwent a CTCA to evaluate angina or angina-equivalent symptoms during the study duration were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. MACE was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization. A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. On a mean follow-up of 96.6 months ± 49.8 (range 21-194 months), all-cause MACE was observed in 8.8% of patients. The most common MACE was angina (3.96%) and all-cause mortality (3%). The baseline characteristics and MACE did not differ in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE. The incidence of soft plaque in this SA cohort is higher than that reported in international studies. However, in symptomatic SA, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.

The role of coronary artery calcium score and european score2 in primary prevention of cardiovascular disease

Abstract Background There is limited evidence about the role of using coronary artery calcium (CAC) score in conjunction with the European SCORE2 (systematic coronary risk evaluation) for the identification of individuals at higher risk of cardiovascular disease. Purpose To evaluate the relationship between CAC score and the European SCORE2 for cardiovascular risk stratification in an asymptomatic population in primary prevention. Methods This is a preliminary analysis from a single-centre, prospective, randomised 1:1, controlled trial assessing the use of CAC score vs standard preventive strategies in asymptomatic individuals undergoing primary cardiovascular prevention. The 10-year risk of cardiovascular events was assessed with either SCORE2 (ages 45-69) or SCORE2-OP (ages 70-89). Subjects were classified as 1) low to moderate risk, 2) high risk, and 3) very high risk according to SCORE2/SCORE2-OP. CAC score was assessed by ECG gated low-dose computed tomography with no contrast administration. A CAC score of zero was considered to reclassify risk one level downward in high or very-high risk patients. CAC score ≥ 100 was used to reclassify risk one level upward in patients with low to moderate risk and a CAC score > 1000 to reclassify risk upward in subjects with high risk. Results A total of 1,252 participants: 627 in the CAC group and 625 in the control group, median age 55 yrs, 25th-75th 50-61 yrs, with availability of SCORE2 and SCORE2-OP were included in this analysis. SCORE2/SCORE 2-OP was similar in the CAC and control groups. Among the subjects in the CAC group, there was a highly significant difference in SCORE2/SCORE 2-OP between participants with CAC score = zero and those with CAC > zero (median 5.6, 25th-75th 3.6-8.55 vs 2.9, 1.8-4.6, p< 0.001) as well as between those with CAC ≥ 100 and those with CAC score < 100 [median 6.8, 25th-75th (10.3-4.5) vs 3.3 (2.0-5.3), p<0.001]. The prevalence of CAC score = zero was 75% in the low to moderate risk group, 47% in the high risk, and 20% in the very high risk, p<0.001. By contrast the prevalence of CAC score ≥ 100 was 7% in the low to moderate risk group, 24% in the high risk, and 45% in the very high risk, p< 0.001. The proportion of patients classified as low to moderate risk group was 72% with CAC score vs 59% without CAC score, high risk 23% with CAC score vs 35% without CAC score, very high risk 5% vs 6% respectively, p<0.001. Using CAC score risk reclassification occurred in 48% downward and 2% upward in originally classified high risk subjects, 7% upward in originally classified low to moderate risk, and 20% downward in originally classified very high risk subjects. Conclusions CAC score may lead to risk reclassification in a substantial proportion of individuals, in particular among those originally classified as high risk by the SCORE2/SCORE2-OP. The cardiovascular risk prediction accuracy of adding CAC score to SCORE2/SCORE2-OP awaits validation at long-term follow-up.

Impact of optimal cholesterol levels on subclinical atherosclerosis in the absence of risk factors in young adults

Background and aimsWe aimed to assess the association of blood lipids with the prevalence, incidence, and progression of subclinical atherosclerosis among young individuals without dyslipidemia and other traditional cardiovascular risk factors (CVRFs). MethodsA total of 1270 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study aged 32–46 years free of cardiovascular disease, diabetes, hypertension, current smoking, and dyslipidemia (total cholesterol [TC] ≥ 240 mg/dL, triglycerides [TG] ≥ 150 mg/dL, low-density lipoprotein cholesterol [LDL-C] ≥ 160 mg/dL, high-density lipoprotein cholesterol [HDL-C] < 40 mg/dL, or taking lipid-lowering medications) were included. A subgroup with optimal lipids within the low-CVRF group was defined with TC < 200 mg/dL, LDL-C < 100 mg/dL, non-HDL-C < 130 mg/dL, and women with HDL-C ≥ 50 mg/dL. Results1-SD higher TC (25.9 mg/dL), LDL-C (24.7 mg/dL), and non-HDL-C (26.6 mg/dL) were associated with a greater risk of presence (hazard ratios: 1.30–1.36), incidence (1.30–1.32), and progression (1.31–1.35) of coronary artery calcium (CAC) and a 42–44% greater odds of composite mean carotid intima-media thickness (CIMT) ≥ 75th percentile [780 μm] (p < 0.05). Repeating the analyses in a subset of participants with a CAC score of zero did not alter the association of TC, LDL-C, and non-HDL-C with CIMT. In the subgroup with optimal lipids, these lipid indices remained associated with an increased risk of presence and incidence of CAC and greater CIMT measures. ConclusionsAmong adults aged 32–46 years, in the absence of traditional CVRFs, elevated cholesterol levels, even within what is considered optimal, are associated with atherosclerosis and arteriopathy.

Relation between Coronary Artery Calcium Score and Cardiovascular Events in Hodgkin Lymphoma Survivors: A Cross-Sectional Matched Cohort Study.

Thoracic radiotherapy is one of the corner stones of HL treatment, but it is associated with increased risk of cardiovascular events. As HL is often diagnosed at a young age, long-term follow-up including screening for coronary artery disease (CAD) is recommended. This study aims to evaluate the presence of coronary artery calcium score (CACS) in relation to cardiovascular events in HL patients treated with thoracic radiotherapy compared to a non-cancer control group. Consecutive HL patients who underwent evaluation for asymptomatic CAD with coronary computed tomography angiography > 10 years after thoracic irradiation were included. The study population consisted of 97 HL patients matched to 97 non-cancer patients on gender, age, cardiovascular risk factors, and statin use. Mean age during CT scan in the HL population was 45.5 ± 9.9 and in the non-cancer population 45.5 ± 10.3 years. CACS was elevated (defined as >0) in 49 (50.5%) HL patients and 30 (30.9%) control patients. HL survivors had an odds ratio of 2.28 [95% CI: 1.22-4.28] for having a CACS > 0 compared to the matched population (p = 0.006). Prevalence of CACS > 90th percentile differed significantly: 17.1% in HL survivors vs. 4.6% in the matched population (p = 0.009). Non-obstructive coronary artery stenosis was more prevalent in the HL population than in the control population (45.7% vs. 28.4%, respectively, p = 0.01). During follow-up of 8.5 [5.3; 9.9] years, nine HL patients experienced an event including two patients with a CACS of zero. No events occurred in the control population. In a matched study population, HL survivors have a higher prevalence of a CACS > 0 and an increased risk of cardiovascular events after thoracic irradiation compared to a matched non-cancer control group.

Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent – An Experience From a Tertiary Care Center in Pakistan

Objectives: To estimate the prevalence of non-calcified coronary artery disease in patients with chest pain and a zero coronary artery calcium score, and to assess the prognostic significance of a zero coronary artery calcium score in these symptomatic patients.&#x0D; Methodology: All consecutive patients who underwent a CT coronary angiogram (CTCA) for evaluation of angina or angina-equivalent symptoms from 2009 to December 2020 were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. Follow-up data was collected by using the hospital's electronic patient record system and telephone communication. The endpoint, major-adverse cardiovascular events (MACE) was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization.&#x0D; Results: A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). Chest pain was the most common presenting complaint (97.4%) followed by dyspnea. At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (&gt;50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. The mean follow-up duration was 96.6 months ± 49.8 (range 21 – 194 months). All-cause Major Adverse Cardiovascular Event (MACE) was observed in 8.8% of patients. The most common MACE outcome was angina (3.96%) and all-cause mortality (3%). Only 2.7% required revascularization on follow-up with 1.2% having myocardial infarction and non-urgent revascularization. The baseline characteristics, all-cause MACE (p = 0.79), mortality (0.82), angina (p = 0.765), revascularization (p = 0.45), non-fatal MI, and non-elective revascularization (p = 0.6) did not differ significantly in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE.&#x0D; Conclusion: The incidence of soft plaque in this South Asian cohort is higher than that reported in international studies. However, in symptomatic South Asians, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.

Relation between coronary artery calcium score and cardiovascular events in Hodgkin lymphoma survivors: a cross-sectional matched cohort study

Abstract Introduction Long-term survival after Hodgkin lymphoma (HL) has improved significantly over the past years, due to enhanced treatment options. Thoracic radiotherapy is still one of the corner stones of HL treatment, but is associated with increased risk of cardiovascular events. As HL is often diagnosed at young age, long-term follow-up including screening for coronary artery disease (CAD) is recommended. Purpose This study aims to evaluate the presence and distribution of coronary artery calcium in relation to cardiovascular events in HL patients treated with thoracic radiotherapy compared to a non-cancer control group. Methods Consecutive HL patients treated with thoracic radiotherapy, who underwent evaluation for asymptomatic CAD with coronary computed tomography angiography (CCTA) &amp;gt; 10 years after irradiation between 2002 and 2022 were included. HL patients were matched 1:1 to non-cancer patients on gender, age, cardiovascular risk factors and statin use. Differences in coronary artery calcium score (CACS), stenosis severity and cardiovascular events between the two groups were compared. Results The total study population consisted of 194 patients of whom 97 patients had a prior HL diagnosis and 97 patients had no history of cancer. Elevated CACS was seen in 50.5% of the HL patients (N=49) and 30.9% of the control patients (N=30). HL survivors had an odds ratio of 2.28 [95% CI: 1.22 – 4.28] for having a CACS &amp;gt; 0 compared to the matched non-cancer population (p=0.006). Distribution pattern of coronary calcium differed significantly with the prevalence of a CACS above the 90th percentile (17.5% in HL survivors versus 4.7% in the matched population, p=0.005). Also coronary artery stenosis was more prevalent in the HL population than in the control population (39.2% versus 15.5% respectively, p=&amp;lt;0.001). Nine HL patients experienced an event during the follow-up period including two patients with a CACS of zero. No events were observed in the control population. Conclusion This study shows that in a matched study population, HL survivors have a higher prevalence of a CACS &amp;gt; 0 and an increased risk of cardiovascular events after thoracic irradiation compared to a matched non-cancer control group.Distribution of CACS percentiles

Using Coronary Artery Calcium Score as Diagnostic Tool in Symptomatic Chronic Coronary Syndrome Patients in a Real-Life Setting.

The coronary artery calcium (CAC) score can be used to increase (CAC score > 0) or decrease (CAC score = 0) the likelihood of coronary artery disease (CAD). We compared the CAC score with the pre-test probability (PTP) for CAD (low, intermediate, and high). Furthermore, we compared the CAC score with exercise electrocardiography (ECG) and compared both tests with coronary angiography. We retrospectively identified patients with angina and/or dyspnea for whom CAC score was used to increase or decrease the likelihood of CAD. Of 882 patients, majority had low (45%) or intermediate (44%) PTP. Patients with higher PTP had significantly higher CAC scores (Cramer's V = 0.29, p < 0.0001). Most patients (57%) had a CAC score of zero, especially those with low (73%) and intermediate (49%) PTP. However, 20% of patients with high PTP had CAC score of zero. Higher CAC scores were observed in patients with abnormal exercise ECG, but association was weak and not significant (Cramer's V = 0.13, p = 0.08). Moreover, more than 40% of patients with an abnormal exercise ECG had CAC score of zero. Higher CAC scores were associated with more severe abnormalities on coronary angiography (Cramer's V = 0.43, p < 0.0001), whereas there was no association between results of exercise ECG and coronary angiography (Cramer's V = 0.11, p = 0.91). CAC score can be used in addition to PTP to increase or decrease the likelihood of CAD, and it might be more useful than exercise ECG in the diagnostic work-up of chest pain.

Coronary Artery Calcium Scoring by Computed Tomography and the GRACE Risk Score as Predictors of Obstructive Coronary Artery Disease in Patients with Non-ST Segment Elevation Acute Coronary Syndrome: A Comparative Study

Abstract Aim and objectives The aim of our study is to enhance patient risk stratification which can potentially influence the treatment strategy. Our objective is to evaluate the correlation of the Global Registry of Acute Coronary Events (GRACE) risk score, the coronary artery calcium (CAC) score and their use combined with the extent and severity of obstructive coronary artery disease (CAD) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Patients and Methods This study included two hundred and two patients who presented with NSTE-ACS and were planned for coronary angiography in Ain Shams University hospitals during the period from September 2020 to February 2021. The GRACE score was calculated for all patients and they were divided into 3 groups according to the predicted in-hospital and post-discharge to 6 months mortality risk. Patients then underwent coronary artery calcium scoring (CACS) using computed tomography (CT) and were divided into 4 groups according to their Agatston score. Following invasive coronary angiography, patients were divided into 2 groups depending on whether or not there was at least one significant stenosis. Patients who had significant stenosis were then divided into 4 subgroups according to the number of vessels affected; one-vessel disease, two-vessel disease, multi-vessel disease and left main CAD. A receiveroperating characteristic (ROC) curve was plotted for the CAC score, the GRACE score and for the CAC score combined with the GRACE score. It was used to suggest a cut-off value for each score below which obstructive CAD can be excluded in patients presenting with NSTE-ACS. Results The CAC score and the GRACE score were significantly higher in patients with obstructive CAD detected on invasive coronary angiography. Both, the CAC score and the GRACE score positively correlated with the number of affected coronaries. It was also detected that a CAC score of zero had a highly significant relationship with the absence of significant stenosis on invasive coronary angiography (p value &amp;lt;0.001). A CAC score of zero had a negative predictive value of 84.8% [95% Confidence Interval (CI): 72.4% to 92.2%], a positive predictive value of 73.7(95% CI: 69.3% to 77.7%), a sensitivity of 94.3 %( 95% CI: 88.5% to 97.7 %), and a specificity of 48.8% (95% CI: 37.4% to 60.2%). In addition, tested the use of zero CAC to exclude obstructive CAD in patients with low inhospital and post discharge mortality risk had a higher sensitivity, specificity, positive and negative predictive values. From the ROC curve, it could be concluded that the use of CACS in combination with the GRACE score improves the sensitivity, specificity, positive and negative predictive value in comparison to the use of the GRACE score alone. Conclusion CAC score as detected by CT is predictive of obstructive CAD and correlates with its extent or in other words, the number of affected coronaries. The low radiation dose and absence of contrast exposure in CACS make it an attractive candidate for the on-going research regarding the noninvasive tools for prediction of CAD. In addition to the role of GRACE score in predicting the risk of mortality in ACS, it can be also used to predict the severity and extent of obstructive CAD. It can be hypothesized that its combination with CAC score improves its reliability as a predictor of obstructive CAD.

Coronary Artery Stenosis Severity in Patients With Different Coronary Artery Calcium Scores on Coronary Computed Tomography Angiography.

Background In this study, we aimed to determine coronary artery stenosis severity in patients with different coronary artery calcium (CAC) scores. Methodology A total of 145 patients were included in the study. All patients were given beta-blockers 12 hours and two hours before the test to keep their heart rate between 55 and 65 beats per minute. Computed tomography angiography was done from the pulmonary hilum up to the base of the heart and the patients were asked to hold their breath. The CAC score and stenosis were assessed. Results The mean age of the patients was 41.35 ± 4.95 years. In total, 112 (77.24%) patients were male and 33 (22.76%) were female. Regarding the frequency of the CAC score, a score of 0-9 was observed in 43 (29.66%) patients, 10-99 was observed in 55 (37.93%) patients, and 100-400 was observed in 47 (32.41%) patients. The CAC score was 0-9 in 86.4% of patients having normal coronary arteries. Two (5.2%) patients with a CAC score of 100-400 had mild coronary artery stenosis, 11 (32.3%) patients had moderate coronary artery disease, and 33 (66.0%) patients had severe coronary artery disease (p < 0.00001). Conclusions There is a strong association between CAC scores and the severity of coronary artery stenosis. A CAC score of zero is associated with a very low risk of having coronary artery stenosis.

Changes in metabolic syndrome burden and risk of coronary artery calcification progression in statin-naïve young adults

Background and aimsWe aimed to investigate the association between metabolic syndrome (MetS) and coronary artery calcium (CAC) progression in statin-naïve young adults. MethodsFrom the KOrea Initiatives on Coronary Artery calcification registry, we included asymptomatic young adults aged 20–45 years who underwent serial CAC scans for routine health check-ups. The primary endpoint was CAC progression. We estimated the risk of CAC progression based on the presence and burden of MetS. Among participants with MetS, the temporal relationship between changes in metabolic burden and CAC progression was evaluated. ResultsOf 2151 young adults (mean age 41.3 ± 3.8 years; male 85.4%), 488 (22.7%) had MetS. The mean CAC score was 10.8 and 81.3% of them had a CAC score of zero at baseline. During follow-up (median, 2.1 years), CAC progression was observed in 325 (15.1%) adults. MetS was associated with an approximately 1.8-fold increased risk of CAC progression (adjusted hazard ratio [aHR] 1.83, p < 0.001). The risk of CAC progression was directly proportional to the metabolic burden. Elevated blood pressure and elevated triglyceride levels were independent components related to CAC progression, with the strongest contribution being made by elevated blood pressure (aHR 2.00, p < 0.001). A reduction in at least two metabolic burdens was associated with a halved risk of CAC progression in young adults having MetS (odds ratio 0.41, p = 0.018). ConclusionsIn statin-naïve young adults, the metabolic burden was associated with a risk of CAC progression in a dose-dependent manner. Improvement in metabolic imbalance may have a preventive effect on CAC progression.

Diagnostic value of clinical risk scores for predicting normal stress myocardial perfusion imaging in subjects without coronary artery calcium

BackgroundWe evaluated if risk scores commonly used to predict the absence of significant stenosis at coronary computed tomography (CT) angiography are useful to predict a normal stress myocardial perfusion imaging (MPI) study. MethodsOur cohort included a total of 1422 consecutive patients with zero coronary artery calcium score (ZCS) who underwent 82Rb PET/CT for evaluation of suspected coronary artery disease (CAD). Predictive models were constructed as reported by Genders et al. and Alshahrani et al., and the probability of abnormal summed stress score (SSS) and of reduced myocardial perfusion reserve (MPR) based on these risk scores was assessed. ResultsIn the overall population, the prevalence of abnormal SSS was 0.10 and the prevalence of reduced MPR was 0.17 (both P < .001).The observed frequencies of abnormal SSS and reduced MPR vs the probabilities predicted by the Genders and Alshahrani models were above the diagonal identity line, highlighting an underestimation of the observed occurrence by these models. The areas under the receiver operating characteristic curve of the Genders and Alshahrani models indicated lack of discriminative ability for predicting abnormal SSS (0.547 and 0.527) and reduced MPR (0.509 and 0.538). The Hosmer–Lemeshow test revealed that both models underestimated the observed occurrence of abnormal SSS and reduced MPR. ConclusionsAvailable models were unable to identify among patients with ZCS those with a low probability of a normal stress MPI study. Thus, an optimal approach to rule out from MPI patients without detectable coronary calcium still needs to be improved.

Soluble Tumor Necrosis Factor Receptor 1 is Associated With Cardiovascular Risk in Persons With Coronary Artery Calcium Score of Zero.

Background:A coronary artery calcium (CAC) score of zero confers a low but nonzero risk of atherosclerotic cardiovascular events (CVD) in asymptomatic patient populations, and additional risk stratification is needed to guide preventive interventions. Soluble tumor necrosis factor receptors (sTNFR-1 and sTNFR-2) are shed in the context of TNF-alpha signaling and systemic inflammation, which play a role in atherosclerosis and plaque instability. We hypothesized that serum sTNFR-1 concentrations may aid in cardiovascular risk stratification among asymptomatic patients with a CAC score of zero.Methods:We included all participants with CAC=0 and baseline sTNFR-1 measurements from the prospective cohort Multi-Ethnic Study of Atherosclerosis (MESA). The primary outcome was a composite CVD event (myocardial infarction, stroke, coronary revascularization, cardiovascular death).Results:The study included 1471 participants (mean age 57.6 years, 64% female), with measured baseline sTNFR-1 ranging from 603 pg/mL to 5544 pg/mL (mean 1294 pg/mL ±378.8 pg/mL). Over a median follow-up of 8.5 years, 37 participants (2.5%) experienced a CVD event. In multivariable analyses adjusted for Framingham Score, doubling of sTNFR-1 was associated with a 3-fold increase in the hazards of CVD (HR 3.0, 95% CI: 1.48-6.09, P = 0.002), which remained significant after adjusting for traditional CVD risk factors individually (HR 2.29; 95% CI: 1.04-5.06, P=0.04). Doubling of sTNFR-1 was also associated with progression of CAC >100, adjusted for age (OR 2.84, 95% CI: 1.33-6.03, P=0.007).Conclusions:sTNFR-1 concentrations are associated with more CVD events in participants with a CAC score of zero. Utilizing sTNFR-1 measurements may improve cardiovascular risk stratification and guide primary prevention in otherwise low-risk individuals.

Prognostic value of coronary artery calcium score in hospitalized COVID-19 patients

Abstract Background The association between known cardiovascular risk factors and poor prognosis of patients diagnosed with coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score assessed by computed tomography (CT) is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2). Purpose We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients. Methods We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded.Low dose non-contrast chest CT was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1–3 (mild), 4–5 (moderate) and ≥6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in–hospital treatment and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all-cause mortality and cardiovascular events (heart failure, myocarditis, arrhythmia, acute coronary syndrome, stroke, pulmonary embolism). Results Two-hundred eighty patients (63.2±16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of zero. MACE-rate was 24.2% (68 patients). Multivariate logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.264, 95% 0.071–0.981, p=0.047), with a negative predictive value (NPV) of 81.4%, sensitivity 70%, specificity 55%, independent of age, risk factors or disease severity (Table 1). Conclusion The absence of CAC translated into a low risk for MACE in COVID-19 patients, even in the presence of cardiac risk factors, which reinforces the idea that the assessment of CAC score in COVID-19 patients could be a useful marker for patients risk stratification and management. Future directions should focus on the implementation of CAC score into mid-term and long-term follow-up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk Funding Acknowledgement Type of funding sources: None. Figure 1Table 1

Long-term prognosis of zero coronary artery calcium score in symptomatic low to intermediate risk patients

Abstract Funding Acknowledgements Type of funding sources: None. Purpose/background Absence of coronary artery calcium (CAC) has shown an excellent long-term prognosis with a low number of events in asymptomatic patients. However, long-term prognosis in stable symptomatic patients undergoing SPECT MPI with a zero CAC score remains unknown. Methods We retrospectively analyzed 1600 low- to intermediate risk symptomatic patients referred for clinically indicated cardiac SPECT/CT imaging with a CAC score of zero. Long-term follow-up data were collected for the occurrence of all-cause mortality and major adverse cardiac events (MACE: any revascularization, non-fatal myocardial infarction or cardiac death). Results The mean age was 54.7 ± 11 years and 71% were female. More than half of the patients (51%) had 2 or more traditional risk factors, mainly a positive family history (55%) and/or hypertension (49%). Overall 12% had perfusion abnormalities, 98% of them were mild. During a mean follow-up of 8.6 ± 1.9 years MACE occurred in 42 patients (0.3% per year) and 85 patients died (0.6% per year). The predominant cause of death was cancer (40%). Cox proportional hazard model revealed that increasing age (HR: 1.05, 95% CI: 1.02-1.09) and current smoking status (HR: 3.58, 95% CI: 1.72-7.37) were independent predictors of MACE. Pre-test probability (HR: 1.52, 95% CI: 0.82-2.82) and abnormal SPECT result (HR: 1.72, 95% CI: 0.88-3.37) were not associated with an increased risk of MACE. Conclusion Overall, stable symptomatic patients with a low-to intermediate risk and a CAC score of 0 have a) low likelihood of abnormal SPECT, and b) excellent long-term prognosis of 0.3%/year irrespective of baseline pre-test probability and SPECT abnormalities. These findings support notion of CAC as gatekeeper for appropriate patient selection to avoid un-necessary downstream testing.

The Prognostic Value Of Coronary Artery Calcium Score Of Zero For Major Adverse Cardiovascular Events In Middle Eastern Populations

Introduction: Computed tomographic measurements of coronary artery calcium (CAC) have emerged as a useful tool for the estimation of cardiovascular disease risk in several ethnic groups and populations. Multiple studies have shown that a CAC score of zero is associated with freedom from future major adverse cardiovascular events (MACE). This study aimed to estimate the incidence of MACE including myocardial infarction (MI), cerebrovascular accidents, coronary revascularizations, and cardiovascular death among patients with CAC score of zero.

The Predictive Value Of A Zero Calcium Score For Excluding Obstructive Coronary Artery Disease In A Symptomatic Asian Cohort

Introduction: Coronary artery calcium (CAC) is pathognomonic of coronary atherosclerosis. A CAC score of zero helps exclude obstructive coronary artery disease (CAD) in asymptomatic subjects, serving as a gatekeeper to unnecessary investigations and treatment. CAC scoring also provides incremental value to CAD risk scoring models such as the CAD Consortium model (CAD2). However, indications for CAC assessment in individuals presenting with stable chest pain are less well established. The overall aim of this study was to evaluate the incremental value of CAC scoring as well as the use of zero CAC as a negative risk marker for obstructive CAD in a symptomatic Asian population.