Coronary Artery Calcium Testing Research Articles

Subclinical Atherosclerosis to Guide Treatment in Dyslipidemia and Diabetes Mellitus.

Dyslipidemia and type 2 diabetes mellitus are two common conditions that are associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we aimed to provide an in-depth and contemporary review of non-invasive approaches to assess subclinical atherosclerotic burden, predict cardiovascular risk, and guide appropriate treatment strategies. We focused this paper on two main imaging modalities: coronary artery calcium (CAC) score and computed tomography coronary angiography. Recent longitudinal studies have provided stronger evidence on the relationship between increased CAC, thoracic aorta calcification, and risk of cardiovascular events among those with primary hypercholesterolemia, highlighting the beneficial role of statin therapy. Interestingly, resilient profiles of individuals not exhibiting atherosclerosis despite dyslipidemia have been described. Non-conventional markers of dyslipidemia have also been associated with increased subclinical atherosclerosis presence and burden, highlighting the contribution of apolipoprotein B-100 (apoB)-rich lipoprotein particles, such as remnant cholesterol and lipoprotein(a), to the residual risk of individuals on-target for low-density lipoprotein cholesterol (LDL-C) goals. Regarding type 2 diabetes mellitus, variability in atherosclerotic burden has also been found, and CAC testing has shown significant predictive value in stratifying cardiovascular risk. Non-invasive assessment of subclinical atherosclerosis can help reveal the continuum of ASCVD risk in those with dyslipidemia and diabetes mellitus and can inform personalized strategies for cardiovascular disease prevention in the primary prevention setting.

Contemporary attitudes and beliefs on coronary artery calcium from social media using artificial intelligence

Coronary artery calcium (CAC) is a powerful tool to refine atherosclerotic cardiovascular disease (ASCVD) risk assessment. Despite its growing interest, contemporary public attitudes around CAC are not well-described in literature and have important implications for shared decision-making around cardiovascular prevention. We used an artificial intelligence (AI) pipeline consisting of a semi-supervised natural language processing model and unsupervised machine learning techniques to analyze 5,606 CAC-related discussions on Reddit. A total of 91 discussion topics were identified and were classified into 14 overarching thematic groups. These included the strong impact of CAC on therapeutic decision-making, ongoing non-evidence-based use of CAC testing, and the patient perceived downsides of CAC testing (e.g., radiation risk). Sentiment analysis also revealed that most discussions had a neutral (49.5%) or negative (48.4%) sentiment. The results of this study demonstrate the potential of an AI-based approach to analyze large, publicly available social media data to generate insights into public perceptions about CAC, which may help guide strategies to improve shared decision-making around ASCVD management and public health interventions.

Impact of coronary artery calcium on mortality and cardiovascular events in metabolic syndrome and diabetes among younger adults.

Whether coronary artery calcium (CAC) testing in younger individuals with metabolic syndrome (MetS) and diabetes mellitus (DM) helps predict cardiovascular disease (CVD) and death independent of traditional risk factors (RFs) remains less clear. We pooled data obtained from 5174 individuals aged 38-55 years from the CARDIA (Coronary Artery Risk Development in Young Adults; n = 3047, year 20) and MESA (Multi-Ethnic Study of Atherosclerosis; n = 2127, Visit 1) studies who completed computed tomography of CAC. The mean age (SD) of participants (44.7% men) was 47.3 (4.2) years. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) of CVD, coronary heart disease (CHD), and all-cause death. There were 1085 participants (21.0%) with prevalent CAC at baseline. A total of 461 (8.9%) had DM, 1025 (19.8%) had MetS without DM, and 3688 (71.3%) had neither condition. Over a median follow-up of 14.2 years, 256 (5.0%) participants died, and 304 (5.9%) CVD and 188 (3.6%) CHD events occurred. The CAC score was independently associated with incident CVD in those with DM (HR: 95% CI; 1.22: 1.08-1.38), MetS (1.18: 1.08-1.31), and neither condition (1.36: 1.26-1.46). The corresponding HRs for CAC ≥ 100 were 2.70 (1.25-5.83), 3.29 (1.87-5.79), and 6.30 (4.02-9.86), respectively. Similar associations for CHD and death were found. The impact of CAC ≥ 100 on CVD and CHD was lower in the presence of DM (P interaction < 0.05). The association of CAC with all outcomes in individuals with DM remained significant after adjusting with haemoglobin A1c levels. Coronary artery calcium score is independently associated with cardiovascular events and death over nearly 15 years after screening at ages 38-55 years, with a less pronounced impact on CVD and CHD events in the presence of DM.

Coronary Atherosclerosis Across the Glycemic Spectrum Among Asymptomatic Adults: The Miami Heart Study at Baptist Health South Florida.

The contemporary burden and characteristics of coronary atherosclerosis, assessed using coronary computed tomography angiography (CCTA), is unknown among asymptomatic adults with diabetes and prediabetes in the United States. The pooled cohort equations and coronary artery calcium (CAC) score stratify atherosclerotic cardiovascular disease risk, but their association with CCTA findings across glycemic categories is not well established. Asymptomatic adults without atherosclerotic cardiovascular disease enrolled in the Miami Heart Study were included. Participants underwent CAC and CCTA testing and were classified into glycemic categories. Prevalence of coronary atherosclerosis (any plaque, noncalcified plaque, plaque with ≥1 high-risk feature, maximal stenosis ≥50%) assessed by CCTA was described across glycemic categories and further stratified by pooled cohort equations-estimated atherosclerotic cardiovascular disease risk and CAC score. Adjusted logistic regression was used to evaluate the associations between glycemic categories and coronary outcomes. Among 2352 participants (49.5% women), the prevalence of euglycemia, prediabetes, and diabetes was 63%, 30%, and 7%, respectively. Coronary plaque was more commonly present across worsening glycemic categories (euglycemia, 43%; prediabetes, 58%; diabetes, 69%), and similar pattern was observed for other coronary outcomes. In adjusted analyses, compared with euglycemia, prediabetes and diabetes were each associated with higher odds of any coronary plaque (OR, 1.30 [95% CI, 1.05-1.60] and 1.75 [1.17-2.61], respectively), noncalcified plaque (OR, 1.47 [1.19-1.81] and 1.99 [1.38-2.87], respectively), and plaque with ≥1 high-risk feature (OR, 1.65 [1.14-2.39] and 2.53 [1.48-4.33], respectively). Diabetes was associated with stenosis ≥50% (OR, 3.01 [1.79-5.08]; reference=euglycemia). Among participants with diabetes and estimated atherosclerotic cardiovascular disease risk <5%, 46% had coronary plaque and 10% had stenosis ≥50%. Among participants with diabetes and CAC=0, 30% had coronary plaque and 3% had stenosis ≥50%. Among asymptomatic adults, worse glycemic status is associated with higher prevalence and extent of coronary atherosclerosis, high-risk plaque, and stenosis. In diabetes, CAC was more closely associated with CCTA findings and informative in a larger population than the pooled cohort equations.

Coronary artery calcium scoring for cardiovascular risk assessment in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is associated with higher incidence of atherosclerotic cardiovascular disease (ASCVD). Data investigating the role of coronary artery calcium (CAC) scoring in identifying subclinical atherosclerotic disease in IBD patients is scarce. Using data obtained from the CLARIFY registry, a prospective study of no-charge coronary artery calcium (CAC) testing at University Hospitals, we reviewed patients with ulcerative colitis (UC) or Crohn's disease (CD) who underwent CAC scoring from 2014 to 2020. We investigated the concordance between CAC risk and 10-year estimated ASCVD risk by AHA/ACC pooled cohort equation using pre-established thresholds for statin prescription (CAC≥100, 10-year ASCVD risk ≥7.5%). We additionally investigated the association between CAC, preventive therapy initiation and Major Adverse Cardiovascular Events (MACE). A total of 369 patients with IBD were included (174 UC, 195 CD), with median age of 60 years. The median CAC score was 14.9 with no significant difference between UC and CD (P=.76). Overall, 151 (41%) had CAC of 0, 108 (29%) had CAC 1-99, 61 (17%) had CAC 100 to 399, and 49 (13%) had CAC ≥400 with no difference in CAC distribution between CD and UC (P=.17). There was no difference in median CAC between IBD or age/sex-matched controls (P=.34). Approximately half of the patients (52%) with IBD had 10-year estimated ASCVD risk of 7.5% or higher. Among patients with ASCVD risk <7.5% (n=163), 29 (18%) had CAC≥100 and among patients with ASCVD risk ≥7.5% (n=178), 102 (57%) had CAC <100. There was no difference between CAC<100 vs CAC≥100 with respect to CRP, use of immunosuppressive or amino-salicylate therapy, IBD severity or complications. CAC score (AUROC 0.67 [0.56-0.78]), but not PCE ASCVD risk (AUROC 0.60 [0.48-0.73]), was predictive of MACE. The best cut-off for CAC score was 76 (sensitivity=60%, specificity=69%), and was associated with 4-fold increase in MACE (Hazard Ratio 4.0 [2.0-8.1], P < .001). Subclinical atherosclerosis, as evaluated by CAC scoring, is prevalent in patients with IBD, and is associated with cardiovascular events. Further studies are needed to understand underlying biological processes of increased atherosclerotic disease risk among adults with IBD.

An In-Depth Prospective Comprehensive View on Myocardial Infarction (MI) in Young Adults.

Due to major advancements in myocardial infarction (MI) prevention and effective medical treatment, the death rate and incidence of MI have dropped considerably. We know that their risk factors and prognosis may differ; therefore, increasing primary and secondary prevention activities among young people is crucial. Multiple studies have found that MI is the deadliest form of coronary heart disease (CHD). As a result, we made an effort to illuminate MI in young people in our review of the literature. We found that young people, particularly women, are developing MI. Smoking is a key risk factor that should be targeted in an effort to minimize youth MI rates. It is thus important to create superior methods for measuring risk in young people, which may combine both standard and nonconventional risk factors, such as genetic rate scores and coronary artery calcium testing. Henceforth, addressing modifiable risk factors at a younger age has the greatest impact.

Coronary calcium score in the initial evaluation of suspected coronary artery disease

ObjectiveWe evaluated coronary artery calcium (CAC) scoring as an initial diagnostic tool in outpatients and in patients presenting at the emergency department due to suspected coronary artery disease (CAD).Methods10 857...

Insurance Payers Should Cover Selective Coronary Artery Calcium Testing in Intermediate Risk Primary Prevention Patients.

HomeCirculationVol. 146, No. 8Insurance Payers Should Cover Selective Coronary Artery Calcium Testing in Intermediate Risk Primary Prevention Patients No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextInsurance Payers Should Cover Selective Coronary Artery Calcium Testing in Intermediate Risk Primary Prevention Patients Philip Greenland, MD, David J. Maron, MD and Matthew J. Budoff, MD Philip GreenlandPhilip Greenland Correspondence to: Philip Greenland, MD, Department of Preventive Medicine, Feinberg School of Medicine, 680 North Lake Shore Dr, Suite 1400, Chicago, IL 60611. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6327-2439 Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (P.G.). Search for more papers by this author , David J. MaronDavid J. Maron https://orcid.org/0000-0002-4867-8588 Stanford Prevention Research Center, Stanford University, Palo Alto, CA (D.J.M.). Search for more papers by this author and Matthew J. BudoffMatthew J. Budoff https://orcid.org/0000-0002-9616-1946 Lundquist Institute, Torrance, CA (M.J.B.). Search for more papers by this author Originally published22 Aug 2022https://doi.org/10.1161/CIRCULATIONAHA.122.061193Circulation. 2022;146:585–586"Insurance Payers Should Cover Selective Coronary Artery Calcium Testing in Intermediate Risk Primary Prevention Patients." Circulation, 146(8), pp. 585–586FootnotesCirculation is available at www.ahajournals.org/journal/circThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 586.Correspondence to: Philip Greenland, MD, Department of Preventive Medicine, Feinberg School of Medicine, 680 North Lake Shore Dr, Suite 1400, Chicago, IL 60611. Email [email protected]edu

Coronary Artery Calcium Score to Refine the Use of PCSK9i in Asymptomatic Individuals: A Multicohort Study

BackgroundThe value of coronary artery calcium (CAC) in the allocation of PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitors) among individuals without clinically evident atherosclerotic cardiovascular disease (ASCVD) is unknown for indications that do not require confirmed familial hypercholesterolemia. We aimed to assess the ability of CAC to stratify ASCVD risk under 3 non–familial hypercholesterolemia PCSK9i allocation paradigms.Methods and ResultsWe included participants without clinically evident ASCVD from MESA (Multi‐Ethnic Study of Atherosclerosis), CARDIA (Coronary Artery Risk Development in Young Adults) study, DHS (Dallas Heart Study), and HNR (Heinz Nixdorf Recall) study. Three PCSK9i eligibility scenarios were defined: a broad scenario informed only by high low‐density lipoprotein cholesterol levels (N=567), a restrictive one combining higher low‐density lipoprotein cholesterol levels and presence of ≥2 additional risk factors (N=127), and a high‐risk scenario where individuals with subclinical organ damage or high estimated risk would be treated to achieve low‐density lipoprotein cholesterol <55 mg/dL (N=471). The high‐risk scenario had the highest ASCVD event rates (27.8% at 10 years). CAC=0 was observed in 35% participants in the broad scenario, 25% in the restrictive scenario, and 16% in the high‐risk scenario. In all, CAC=0 was associated with the lowest incident ASCVD rates at 5 and 10 years, and CAC burden was independently associated with ASCVD events adjusting for traditional risk factors.ConclusionsCAC may be used to refine the allocation of PCSK9i, potentially leading to a more conservative use if CAC=0. The value of CAC testing is greater in scenarios that use low‐density lipoprotein cholesterol levels and/or traditional risk factors to define PCSK9i eligibility (CAC=0 present in 1 of 3–4 patients), whereas its prevalence is lower when allocation is informed by presence of noncoronary subclinical organ damage.

Artículo traducido] Realización del examen de calcio en los pacientes con psoriasis severa: evaluación del riesgo y potencial de reclasificación en una población de riesgo cardiovascular bajo

BackgroundPatients with severe psoriasis have an increased cardiovascular (CV) risk and prevalence of subclinical coronary artery disease (CAD). Coronary artery calcium (CAC) testing can detect subclinical CAD and improve cardiovascular risk assessment beyond clinical scores. ObjectivesEvaluate the presence and magnitude of subclinical CAD determined by CAC score among the different ESC/EAS CV risk categories, as well as the potential for risk reclassification, in patients with severe psoriasis from a low CV risk population. MethodsUnicentric cross-sectional study in 111 patients with severe chronic plaque psoriasis from a low CV risk population in the Mediterranean region. Patients were classified into four CV risk categories according to the ESC/EAS guideline recommendations and HeartScore/SCORE calibrated charts. Patients underwent coronary computed tomography to determine their CAC scores. Patients in the moderate-risk category with a CAC score of ≥100 were considered to be reclassified as recommended by the 2019 ESC/EAS guidelines. Reclassification was also considered for patients in the low-risk category with a CAC score>0. ResultsPresence of subclinical CAD was detected in 46 (41.4%) patients. These accounted for 86.2% of patients in high/very-high-risk categories and 25.6% of patients in non-high-risk categories. Fourteen (17.1%) of the patients in non-high-risk categories were reclassifiable due to their CAC score. This percentage was higher (25%) when considering the moderate-risk category alone and lower (13.8%) in the low-risk category. Age was the only variable associated with presence of subclinical CAD and reclassification. ConclusionsOver 40% of patients with severe psoriasis from a low-risk region and up to 25% of those in non-high-risk categories have subclinical CAD. CAC appears to be useful for reclassification purposes in CV risk assessment of patients with severe psoriasis. Further research is required to elucidate how CAC could be implemented in everyday practice at outpatient dermatology clinics dedicated to severe psoriasis.

Performance of Coronary Artery Calcium Testing in Patients With Severe Psoriasis: Risk Assessment and Reclassification Potential in a Low Cardiovascular Risk Population

BackgroundPatients with severe psoriasis have an increased cardiovascular (CV) risk and prevalence of subclinical coronary artery disease (CAD). Coronary artery calcium (CAC) testing can detect subclinical CAD and improve cardiovascular risk assessment beyond clinical scores. ObjectivesEvaluate the presence and magnitude of subclinical CAD determined by CAC score among the different ESC/EAS CV risk categories, as well as the potential for risk reclassification, in patients with severe psoriasis from a low CV risk population. MethodsUnicentric cross-sectional study in 111 patients with severe chronic plaque psoriasis from a low CV risk population in the Mediterranean region. Patients were classified into four CV risk categories according to the ESC/EAS guideline recommendations and HeartScore/SCORE calibrated charts. Patients underwent coronary computed tomography to determine their CAC scores. Patients in the moderate-risk category with a CAC score of ≥100 were considered to be reclassified as recommended by the 2019 ESC/EAS guidelines. Reclassification was also considered for patients in the low-risk category with a CAC score>0. ResultsPresence of subclinical CAD was detected in 46 (41.4%) patients. These accounted for 86.2% of patients in high/very-high-risk categories and 25.6% of patients in non-high-risk categories. Fourteen (17.1%) of the patients in non-high-risk categories were reclassifiable due to their CAC score. This percentage was higher (25%) when considering the moderate-risk category alone and lower (13.8%) in the low-risk category. Age was the only variable associated with presence of subclinical CAD and reclassification. ConclusionsOver 40% of patients with severe psoriasis from a low-risk region and up to 25% of those in non-high-risk categories have subclinical CAD. CAC appears to be useful for reclassification purposes in CV risk assessment of patients with severe psoriasis. Further research is required to elucidate how CAC could be implemented in everyday practice at outpatient dermatology clinics dedicated to severe psoriasis.

Effect of No-Charge Coronary Artery Calcium Scoring on Cardiovascular Prevention

Prevention of cardiovascular disease is currently guided by probabilistic risk scores that may misclassify individual risk and commit many middle-aged patients to prolonged pharmacotherapy. The coronary artery calcium (CAC) score, although endorsed for intermediate-risk patients, is not widely adopted because of barriers in reimbursement. The impact of removing cost barrier on cardiovascular outcomes in real-world settings is not known. Within the University Hospitals Health System (Cleveland, Ohio), CAC was offered to patients with at least 1 cardiovascular risk factor at low charge between 2014 and 2017 ($99) and no charge from January 1, 2018 onward. CAC use and access, patient characteristics, reclassification of risk compared with the pooled cohort equations (PCEs) for atherosclerotic vascular disease, statin use, changes in parameters of cardiometabolic health, downstream cardiovascular testing, downstream coronary revascularization, and cardiovascular outcomes were evaluated. A total of 52,151 patients underwent CAC testing over the study period. Median 10-year PCE for atherosclerotic vascular disease, in the entire cohort was 8.3% (4.0% to 15.9%). Among patients with PCE >20%, 21% had CAC <100, whereas 37% of those with PCE <7.5% had CAC ≥100. Among patients who were not on statin before CAC testing, 1-year statin prescription was 24% and was significantly associated with higher CAC scores. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides all decreased significantly 1-year after CAC, and the degree of decrease was strongly linked with CAC scores. One year after CAC, 14% underwent noninvasive ischemic evaluation, 1.4% underwent invasive coronary angiography, and 0.9% underwent revascularization. The majority (74%) of revascularization procedures occurred in patients with CAC >400. In conclusion, reducing or removing the cost burden of CAC leads to significant test uptake by patients, which is followed by reclassification of statin eligibility, increases in the use of preventive medications, and improvement in risk factors, with very low rates of invasive downstream testing.

Self- vs provider-referral differences for coronary artery calcium testing

Study objectivesThe objectives of this study were to identify independent predictors for moderate/accentuated coronary artery calcium (CAC) score and compare patients who self-referred for CAC Computed Tomography (CT) testing to those who were provider-referred. DesignPatients underwent CAC between January to July 2019. The analysis was divided into self-referred patients influenced by a CAC community campaign who identified themselves as having cardiovascular risk factors compared to provider-referred intermediate-risk patients who were asymptomatic. SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used for all analyses. SettingSeven southwest Ohio hospitals from a single network. Participants2124 adult patients who received CAC CT (163 self and 1961 provider-referred). InterventionsCAC CT. Main outcome measuresDemographics, risk factors, lab values, prescriptions, and referral status were used to compare CAC score differences between self- and provider-referred patients. ResultsFor 2124 patients, three predictors for moderate/accentuated CAC score remained significant after multiple logistic regression: CKD (OR 0.24, CI 0.008–0.68, p < 0.05), COPD (OR 0.39, CI 0.19–0.80, p < 0.05), and CAD (OR 0.46, CI 0.22–0.98, p < 0.05). There were four differences between referred groups: history of PVD (OR 0.21, CI 0.05–0.86, p < 0.05), higher triglyceride (OR 1.004, CI 1.00–1.01, p < 0.05), higher LDL levels (OR 0.991, CI 0.98–1.00, p < 0.05), and beta blocker prescription (OR 4.38, CI 1.49–12.85, p < 0.05) in self-referred patients. ConclusionsCAC CT testing is associated with independent risk predictors and can be used to clarify cardiovascular risk in self- and provider-referred patients with statistical similarity. Patients reliably self-refer for CAC CT when risk is present during a community initiative. Such initiatives may have a preventive benefit and lead to earlier pursuit and optimization of anti-lipid therapies.

Impact of coronary artery calcium testing on patient management

BackgroundCoronary artery calcium (CAC) scoring can identify individuals who may benefit from aggressive prevention therapies. However, there is a paucity of contemporary data on the impact of CAC testing on patient management. MethodsRetrospective cohort study of adults who underwent CAC testing at Brigham and Women's Hospital between 2015 and 2019. Information on baseline medications, follow-up medications, lifestyle modification, and downstream cardiovascular testing within one-year post-CAC were obtained from electronic health records. ResultsOf the 839 patients with available baseline and follow-up data, 376 (45%) had a CAC ​= ​0, 289 (34%) had CAC ​= ​1–99, and 174 (21%) had CAC≥100. The mean age at time of CAC testing was 59 ​± ​9.7 years. Patients with higher CAC scores were more likely to be male, have diabetes and hypertension, and have higher low-density lipoprotein cholesterol and lower high-density lipoprotein cholesterol. A non-zero CAC score was associated with initiation of aspirin (41% increase, p ​< ​0.001), anti-hypertensives (9% increase, p ​= ​0.031), and lipid-lowering therapies (114% increase, p ​< ​0.001), whereas CAC ​= ​0 was not. Among individuals with CAC≥100, 75% were started on new or more intense lipid-lowering therapy. Higher calcium scores correlated with increased physician recommendations for diet (p ​= ​0.008) and exercise (p ​= ​0.004). The proportion of cardiovascular downstream testing following CAC was 9.1%, and the majority of patients who underwent additional testing post-CAC had CAC scores ≥100. ConclusionApproximately half of individuals referred for CAC testing had evidence of calcified coronary plaque, and of those who had significant calcifications (CAC≥100), nearly 90% were prescribed lipid-lowering therapies post-CAC. Rates of downstream non-invasive testing were low and such testing was mostly performed in patients who had at least moderate CAC.

Influence of Prediabetes on Coronary Atherosclerotic Plaque Burden Assessed by Coronary Computed Tomography Angiography (CCTA).

IntroductionAccording to CDC there are 88.0 million Americans aged 18 years or older with prediabetes. Cardiovascular disease is the primary cause of morbidity and mortality in diabetes. The relationship between prediabetes and coronary atherosclerosis is not well established. We evaluated the association between prediabetes and coronary atherosclerosis and compared it to non-diabetic population. MethodsIn this retrospective study all patients who underwent CCTA and coronary artery calcium (CAC) testing at our outpatient imaging center for the past 5 years were screened. 253 patients had recorded HbA1c values and were included in the study. 256 slice multi detector CT (GE Revolution, Milwaukee WI) scanner was used for imaging. CAC was scored using non-contrast CT. Total plaque score (TPS) and total stenosis score (TSS) were quantified using coronary CTA. Each of the scores were compared between prediabetic (125) and non-diabetic groups (128). ResultsMean age of the study cohort was 53.2 ± 17.1 years, 66% were males, 114 had hyperlipidemia (45%), 108 had hypertension (43%), 96 were present smokers (38%) and the mean HbA1c was 5.6 ±0.4. In multivariate adjusted regression models, the odds of TPS (OR:2.93; CI: 1.54,5.57) P<0.001, TSS (OR:2.82; CI:1.48,5.38) P<0.002 and CAC score (OR:3.43; CI: 1.74,6.74) p<0.001, were all higher in prediabetic patients. ConclusionOur findings suggest that prediabetics have higher atherosclerotic plaque burden compared to non-diabetics. In prediabetes, increased plaque burden most likely contributes to cardiovascular events. The application of these findings may guide early screening and pharmacological prevention strategies for atherosclerosis in patients with prediabetes.

Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain

ObjectivesThis study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS). BackgroundIt is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting. MethodsWe included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). ResultsOur study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264. ConclusionsIn a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.

Role of Coronary Artery Calcium Testing for Risk Assessment in Primary Prevention of Atherosclerotic Cardiovascular Disease

Current guidelines recommend a few different approaches to the use of coronary artery calcium (CAC) testing as a tool for risk assessment and decision-making regarding drug therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium testing is not recommended for universal screening, particularly in patients at very low or high predicted risk for ASCVD, where its yield and utility for altering clinical decisions are limited. Use of CAC testing appears to be optimal when used in selected patients who are at intermediate or borderline risk of ASCVD as a sequential decision aid after initial quantitative risk assessment and consideration of individual patient risk-enhancing factors (eg, strong family history of premature ASCVD, chronic kidney disease). Although convincing clinical trials have not been completed, observational studies strongly suggest that, in those at intermediate risk, CAC testing can meaningfully reclassify risk and can support improved targeting of drug therapy to patients most likely to benefit. This narrative review summarizes the evidence available about the appropriate role of CAC testing for ASCVD risk assessment. Coronary artery calcium testing should be used selectively in patients who are at intermediate risk of ASCVD, when there is persistent uncertainty after performing standard risk assessment using traditional risk factors in a risk score, and after consideration of additional individual risk-enhancing factors. In these situations, the result of the CAC test can be helpful to clarify whether the patient's true risk is high enough to justify initiation of primary prevention medications, such as statins or aspirin.

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.

The Role of Coronary Artery Calcium Testing for Value-Based Clinical Trials in Primary Prevention.

Review the role of coronary artery calcium (CAC) testing in designing future clinical trials in primary prevention. While there are numerous new agents that have been found to lower cardiovascular event rates in clinical trials, these studies have required a large sample size, in part due to low event rates as well as improved baseline treatments. More precise risk assessment could allow for better identification of individuals who stand to derive the most benefit from various therapies. Coronary CAC testing offers a simple method for identifying high-risk primary prevention cohorts, and thus may allow for improved efficiency of clinical trials, enhanced efficacy of various therapies, and ultimately more favorable cost-effectiveness estimates. The use of CAC testing as part of the inclusion criteria used in clinical trials may result in identifying high-risk individuals who were previously not included in such studies while achieving favorable absolute risk reductions. The advantages afforded by using CAC to enrich clinical trials offer a potential road map for future clinical trials in primary prevention.

Long-term Predictions of Incident Coronary Artery Calcium to 85 Years of Age for Asymptomatic Individuals With and Without Type 2 Diabetes.

To examine the utility of repeated computed tomography (CT) coronary artery calcium (CAC) testing, we assessed risks of detectable CAC and its cardiovascular consequences in individuals with and without type 2 diabetes ages 45-85 years. We included 5,836 individuals (618 with type 2 diabetes, 2,972 without baseline CAC) from the Multi-Ethnic Study of Atherosclerosis. With logistic and Cox regression we evaluated the impact of type 2 diabetes, diabetes treatment duration, and other predictors on prevalent and incident CAC. We used time-dependent Cox modeling of follow-up data (median 15.9 years) for two repeat CT exams and cardiovascular events to assess the association of CAC at follow-up CT with cardiovascular events. For 45 year olds with type 2 diabetes, the likelihood of CAC at baseline was 23% vs. 17% for those without. Median age at incident CAC was 52.2 vs. 62.3 years for those with and without diabetes, respectively. Each 5 years of diabetes treatment increased the odds and hazard rate of CAC by 19% (95% CI 8-33) and 22% (95% CI 6-41). Male sex, White ethnicity/race, hypertension, hypercholesterolemia, obesity, and low serum creatinine also increased CAC. CAC at follow-up CT independently increased coronary heart disease rates. We estimated cumulative CAC incidence to age 85 years. Patients with type 2 diabetes develop CAC at a younger age than those without diabetes. Because incident CAC is associated with increased coronary heart disease risk, the value of periodic CAC-based risk assessment in type 2 diabetes should be evaluated.