High Calcium Score Research Articles

Myocardial perfusion imaging in stable symptomatic patients with extensive coronary atherosclerosis

High coronary artery calcium (CAC) scores are associated with a high likelihood of ischaemia and obstructive coronary disease. Myocardial perfusion imaging (MPI) is a key investigation to determine the need for revascularization. However, the value of MPI in presence of extensive CAC has so far only been demonstrated in asymptomatic patients, whereas its value in symptomatic patients remains largely unclear. Therefore, we studied the impact of MPI in symptomatic patients with a CAC score ≥ 1,000. We included 282 patients (mean age 69 ± 9 years, 63% men) without a history of coronary disease with suspected stable angina referred for MPI and with a CAC score ≥ 1,000. On follow-up at 18 months invasive angiography, coronary revascularization, nonfatal myocardial infarction and death were recorded. MPI was normal in 54 %, equivocal in 10 % and abnormal in 37 % (fixed defect 9 % and ischaemia 28 %) of patients. More abnormal MPI findings were observed in men, smokers and those with even higher CAC scores. During follow-up, 1 patient (with nonischaemic MPI) died from a cardiac cause, 1 patient (with ischaemic MPI) suffered a myocardial infarction and 92 patients (33 %) underwent revascularization. Ischaemia on MPI was a strong predictor of coronary revascularization (odds ratio 13.1; 95 % CI 7.1-24.3; p < 0.001). Ischaemia on MPI is observed in approximately 30 % of patients with a CAC score ≥ 1,000, and is a strong predictor of coronary revascularization. However, nonischaemic MPI does not exclude revascularization, and patients with persisting complaints should be considered for invasive angiography.

Stress myocardial perfusion computed tomography at 320 detector-row to detect hemodynamically significant coronary stenoses in the presence of a high coronary calcium score

Objectives: We sought to assess the diagnostic performance of visual and quantitative analysis of stress perfusion CT (CTP) imaging with 320-slice CT, when added to coronary computed tomographic angiography (CCTA), against invasively determined fractional flow reserve (FFR) in the presence of a high coronary calcium score. Background: Cardiac CT examination integrating CCTA and stress CTP allows for comprehensive assessment of coronary arterial stenosis and myocardial ischemia. However, further clinical validation is required in high-risk populations. Methods: Thirty-three patients with high calcium score stratified by higher than 400 Agatston units underwent comprehensive CT examination starting stress CTP followed by rest CCTA and angiography. FFR was measured in all main coronary arteries with a luminal narrowing greater than 50%. FFR<0.80 was considered hemodynamically significant. Two observers visually assessed presence or absence of perfusion defect in each major coronary arterial territory. The transmural perfusion ratio (TPR) was calculated using 16-segment model. Results: A total of 48 coronary vessels had flow limiting stenoses. The sensitivity and specificity of CCTA and visual CTP analysis alone to detect flow limiting CAD was 91% and 62%, respectively, and 77%, 73%, respectively. With use of quantitative analysis of CTP employing TPR, 5 lesions were correctly reclassified as hemodynamically significant, resulting in sensitivity of 87% and specificity of 75%. Combined assessment was better predictor of flow limiting CAD, with a sensitivity of 81% and specificity of 92%, with an AUC of 0.87, compared with 0.77 for CCTA alone and 0.81 for CTP alone. ![Figure][1] Figure 1 Conclusions: Stress myocardial CTP over CCTA had moderate sensitivity and high specificity for predicting flow limiting CAD. [1]: pending:yes

Progression of coronary artery calcification after kidney transplantation

Calcification of coronary vessels progresses rapidly in hemodialysis (HD) patients and comprises a strong predictor of cardiovascular events. The aim of this prospective study was to evaluate the coronary artery calcification (CAC) in patients with end stage renal disease undergoing regular HD and to determine the effect of renal transplantation (RT) in the progression of CAC, using the Agatston technique for calcium scoring. The study included 20 patients with end-stage renal disease undergoing a regular HD treatment (16 males, 4 females) 54.1 ± 9.5 years old who had just received a renal transplant and 16 more HD patients (11 males, 5 females) 54.4 ± 13.8 years old as control group. The baseline evaluation showed a very high prevalence of CAC in both groups, which was positively correlated with age (p < 0.001) and CRP (p = 0.03). The second (follow-up) evaluation showed a significant slower progression of calcification after RT. In both groups, high calcium score values in the follow-up evaluation had a strong positive correlation with baseline calcium score (p < 0.001).

Can nontriggered thoracic CT be used for coronary artery calcium scoring? A phantom study

Coronary artery calcium score, traditionally based on electrocardiography (ECG)-triggered computed tomography (CT), predicts cardiovascular risk. However, nontriggered CT is extensively utilized. The study-purpose is to evaluate the in vitro agreement in coronary calcium score between nontriggered thoracic CT and ECG-triggered cardiac CT. Three artificial coronary arteries containing calcifications of different densities (high, medium, and low), and sizes (large, medium, and small), were studied in a moving cardiac phantom. Two 64-detector CT systems were used. The phantom moved at 0-90 mm∕s in nontriggered low-dose CT as index test, and at 0-30 mm∕s in ECG-triggered CT as reference. Differences in calcium scores between nontriggered and ECG-triggered CT were analyzed by t-test and 95% confidence interval. The sensitivity to detect calcification was calculated as the percentage of positive calcium scores. Overall, calcium scores in nontriggered CT were not significantly different to those in ECG-triggered CT (p>0.05). Calcium scores in nontriggered CT were within the 95% confidence interval of calcium scores in ECG-triggered CT, except predominantly at higher velocities (≥50 mm∕s) for the high-density and large-size calcifications. The sensitivity for a nonzero calcium score was 100% for large calcifications, but 46%±11% for small calcifications in nontriggered CT. When performing multiple measurements, good agreement in positive calcium scores is found between nontriggered thoracic and ECG-triggered cardiac CT. Agreement decreases with increasing coronary velocity. From this phantom study, it can be concluded that a high calcium score can be detected by nontriggered CT, and thus, that nontriggered CT likely can identify individuals at high risk of cardiovascular disease. On the other hand, a zero calcium score in nontriggered CT does not reliably exclude coronary calcification.

CT Coronary Angiography Is Feasible for the Assessment of Coronary Artery Disease in Chronic Dialysis Patients, Despite High Average Calcium Scores

PurposeSignificant obstructive coronary artery disease (CAD) is common in asymptomatic dialysis patients. Identifying these high risk patients is warranted and may improve the prognosis of this vulnerable patient group. Routine catheterization of incident dialysis patients has been proposed, but is considered too invasive. CT-angiography may therefore be more appropriate. However, extensive coronary calcification, often present in this patient group, might hamper adequate lumen evaluation. The objective of this study was to assess the feasibility of CT-angiography in this patient group.MethodsFor this analysis all patients currently participating in the ICD2 trial (ISRCTN20479861), with no history of PCI or CABG were included. The major epicardial vessels were evaluated on a segment basis (segment 1–3, 5–8, 11 and 13) by a team consisting of an interventional and an imaging specialist. Segments were scored as not significant, significant and not interpretable.ResultsA total of 70 dialysis patients, with a mean age of 66±8 yrs and predominantly male (70%) were included. The median calcium score was 623 [79, 1619].Over 90% of the analyzed segments were considered interpretable. The incidence of significant CAD on CT was 43% and was associated with cardiovascular events during follow-up. The incidence of cardiovascular events after 2-years follow-up: 36% vs. 0% in patients with no significant CAD (p<0.01).ConclusionDespite the high calcium scores CT-angiography is feasible for the evaluation of the extent of CAD in dialysis patients. Moreover the presence of significant CAD on CT was associated with events during follow-up.

Accuracy and Clinical Outcomes of Computed Tomography Coronary Angiography in the Presence of a High Coronary Calcium Score

A high coronary calcium burden may adversely affect image quality of CT coronary angiography (CTCA). The ability to rule out clinically significant disease in this setting is uncertain. We examined CTCA findings in patients with a calcium score of >600. Utilising a search of death notices, structured patient interview and medical records, downstream investigations, cardiovascular events, revascularisation and mortality were recorded. Sixty patients with a calcium score >600 had CTCA performed on the same day. Coronary disease findings were: mild 28%, moderate 33%, severe 32% and non-diagnostic 7%. During a median 1.75-year follow-up, 31 (53%) of patients underwent further assessment for coronary disease, eight patients (13%) underwent revascularisation and there were two non-cardiovascular and one cardiovascular deaths. No patient with mild or moderate disease at CTCA had subsequently demonstrated ischaemia, was deemed to require PCI or suffered cardiac mortality. The negative predictive value of CTCA for subsequent PCI and all-cause mortality was 97% (100% for cardiac mortality only). The positive predictive value of CTCA for revascularisation or CV death was 42%. In patients with an elevated coronary calcium score, a negative CTCA implies an excellent short-term outcome and appears to exclude clinically significant coronary disease.

High Calcium Scores in Patients (PTS) with a Low Framingham Risk of Cardiovascular (CVS) Disease: Re-Interpreting CVS Risk Assessment; Should We Focus on the Patient or the Population?

High Calcium Scores in Patients (PTS) with a Low Framingham Risk of Cardiovascular (CVS) Disease: Re-Interpreting CVS Risk Assessment; Should We Focus on the Patient or the Population?

A systematic review and economic evaluation of new-generation computed tomography scanners for imaging in coronary artery disease and congenital heart disease: Somatom Definition Flash, Aquilion ONE, Brilliance iCT and Discovery CT750 HD

Computed tomography (CT) is important in diagnosing and managing many conditions, including coronary artery disease (CAD) and congenital heart disease. Current CT scanners can very accurately diagnose CAD requiring revascularisation in most patients. However, imaging technologies have developed rapidly and new-generation computed tomography (NGCCT) scanners may benefit patients who are difficult to image (e.g. obese patients, patients with high or irregular heart beats and patients who have high levels of coronary calcium or a previous stent or bypass graft). To assess the clinical effectiveness and cost-effectiveness of NGCCT for diagnosing clinically significant CAD in patients who are difficult to image using 64-slice computed tomography and treatment planning in complex congenital heart disease. Bibliographic databases were searched from 2000 to February/March 2011, including MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database and Science Citation Index (SCI). Trial registers and conference proceedings were searched. Systematic review methods followed published guidance. Risk of bias was assessed using QUADAS-2. Results were stratified by patient group. Summary sensitivity and specificity were calculated using a bivariate summary receiver operating characteristic, or random effects model. Heterogeneity was assessed using the chi-squared statistic and I(2)-statistic. Cost-effectiveness of NGCCT was modelled separately for suspected and known CAD, evaluating invasive coronary angiography (ICA) only, ICA after positive NGCCT (NGCCT-ICA), and NGCCT only. The cost-effectiveness of NGCCT, compared with 64-slice CT, in reducing imaging-associated radiation in congenital heart disease was assessed. Twenty-four studies reported accuracy of NGCCT for diagnosing CAD in difficult-to-image patients. No clinical effectiveness studies of NGCCT in congenital heart disease were identified. The pooled per-patient estimates of sensitivity were 97.7% [95% confidence interval (CI) 88.0% to 99.9%], 97.7% (95% CI 93.2% to 99.3%) and 96.0% (95% CI 88.8% to 99.2%) for patients with arrhythmias, high heart rates and previous stent, respectively. The corresponding estimates of specificity were 81.7% (95% CI 71.6% to 89.4%), 86.3% (95% CI 80.2% to 90.7%) and 81.6% (95% CI 74.7% to 87.3%), respectively. In patients with high coronary calcium scores, previous bypass grafts or obesity, only per-segment or per-artery data were available. Sensitivity estimates remained high (> 90% in all but one study). In patients with suspected CAD, the NGCCT-only strategy appeared most cost-effective; the incremental cost-effectiveness ratio (ICER) of NGCCT-ICA compared with NGCCT only was £71,000. In patients with known CAD, the most cost-effective strategy was NGCCT-ICA (highest cost saving, dominates ICA only). The ICER of NGCCT only compared with NGCCT-ICA was £726,230. For radiation exposure only, the ICER for NGCCT compared with 64-slice CT in congenital heart disease ranged from £521,000 for the youngest patients to £90,000 for adults. Available data were limited, particularly for obese patients and patients with previous bypass grafts. All studies of the accuracy of NGCCT assume that the reference standard (ICA) is 100% sensitive and specific; however, there is some evidence that ICA may sometimes underestimate the extent and severity of stenosis. Patients with more than one criterion that could contribute to difficulty in imaging were often excluded from studies; the effect on test accuracy of multiple difficult to image criteria remains uncertain. NGCCT may be sufficiently accurate to diagnose clinically significant CAD in some or all difficult-to-image patient groups. Economic analyses suggest that NGCCT is likely to be considered cost-effective for difficult-to-image patients with CAD, at current levels of willingness to pay in the NHS. For patients with suspected CAD, NGCCT only would be most favourable; for patients with known CAD, NGCCT-ICA would be most favourable. No studies assessing the effects of NGCCT on therapeutic decision making, or subsequent patient outcomes, were identified. The ideal study to address these questions would be a large multi-centre RCT. However, one possible alternative might be to establish a multicentre tracker study. High-quality test accuracy studies, particularly in obese patients, patients with high coronary calcium, and those with previous bypass grafts are needed to confirm the findings of our systematic review. These studies should include patients with multiple difficult to image criteria. The National Institute for Health Research Health Technology Assessment programme. This project was funded by the HTA programme, on behalf of NICE, as project number 10/107/01.

High coronary artery calcium score affects clinical outcome despite normal stress myocardial perfusion imaging and normal left ventricular ejection fraction

Normal myocardial perfusion imaging (MPI) indicates a low risk for cardiac death and new ischaemic events. However, the impact of normal MPI combined with a high coronary artery calcium score (CACS) is not clear. The aims of this study were to evaluate the risk of severely elevated CACS and to identify other risk factors in patients with normal MPI. The study included 318 consecutive patients who underwent a Tc-sestamibi MPI protocol along with either the ergometer bicycle test or the pharmacological stress test. Acquisition of CACS was performed immediately before MPI. Patient history and events were retrieved from hospital files. The median follow-up time was 989 days. End points were myocardial infarction, need for revascularization of coronary arteries and/or death. CACS was less than 400 in 256 patients (81%) and at least 400 in 62 patients with normal MPI. Cox regression analysis showed that CACS was a predictor of cardiovascular events or death [relative risk (RR) 3.4, P=0.008]. Inability to perform the ergometer stress test (RR 5.6, P=0.02) was also included in the model. CACS (RR 4.2, P=0.01) and diabetes (RR 3.7, P=0.03) were the strongest predictors of cardiac events without death. CACS is the single most important predictor of cardiac events and/or death in patients with normal MPI. If possible, CACS could be included when performing MPI to identify patients with an increased risk for cardiac events and/or death.

Systematic Review of the Accuracy of Dual-Source Cardiac CT for Detection of Arterial Stenosis in Difficult to Image Patient Groups

To assess the diagnostic performance of dual-source cardiac (DSC) computed tomography (CT) newer-generation CT instruments for identifying anatomically significant coronary artery disease (CAD) in patients who are difficult to image by using 64-section CT. A literature search comprised bibliographic databases (January 1, 2000, to March 22, 2011, with a pragmatic update on September 6, 2012), trial registries, and conference proceedings. Only studies using invasive coronary angiography as reference standard were included. Risk of bias was assessed (QUADAS-2). Results were stratified according to patient group on the basis of clinical characteristics. Summary estimates of sensitivity and specificity of DSC CT for detecting 50% or greater arterial stenosis were calculated by using a bivariate summary receiver operating characteristic or random-effects model. Twenty-five studies reported accuracy of DSC CT for diagnosing CAD in difficult to image patients; in 22 studies, one of two CT units of the same manufacturer (Somatom Definition or Somatom Definition Flash) was used, and in the remaining three, a different CT unit of another manufacturer (Aquilion One) was used. The pooled, per-patient estimates of sensitivity were 97.7% (95% confidence interval [CI]: 88.0%, 99.9%) and 97.7% (95% CI: 93.2%, 99.3%) for patients with arrhythmias and high heart rates, respectively. The corresponding pooled estimates of specificity were 81.7% (95% CI: 71.6%, 89.4%) and 86.3% (95% CI: 80.2%, 90.7%), respectively. All data were acquired by using Somatom Definition. In two studies with Somatom and one study with Aquilion One, sensitivity estimates of 90% or greater were reported in patients with previous stent implantations; specificities were 81.7% and 89.5% for Somatom and 81.0% for Aquilion One. In patients with high coronary calcium scores, previous bypass grafts, or obesity, only per-segment or per-artery data were available. Sensitivity estimates remained high (>90% in all but one study), and specificities ranged from 79.1% to 100%. All data were acquired by using Somatom Definition. DSC CT may be sufficiently accurate to diagnose clinically significant CAD in some or all difficult to image patients. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121136/-/DC1.

Relation between coronary plaque calcium deposits as described by computed tomography coronary angiography and acute results of stent deployment as assessed by intravascular ultrasound

IntroductionThe findings from intravascular ultrasound studies on the impact of calcium deposits on the results of stent implantation are conflicting.AimTo evaluate whether calcium deposits as assessed by (CTCA) influence results of stent deployment.Material and methodsThe study population comprised 60 patients (43 male; age 64.2 ±8.6 years) who underwent CTCA before stent implantation. Lesion calcium score, total calcium length, and maximal area and maximal thickness of calcium deposits within the lesion segment were assessed. Plaques were divided into those with calcium score ≥ median (group 1), calcium score < median (group 2), and without calcium (group 3). Intravascular ultrasound (IVUS) was performed after attainment of optimal angiographic results of the stent procedure. Focal and diffuse stent expansion was defined as either minimum stent area (MSA) or mean stent area over the length of the stent divided by reference lumen area.ResultsThe proximal reference segments of lesions with higher calcium score contained a larger plaque burden (47 ±12% vs. 41 ±9% vs. 34 ±18%, p = 0.02) – respectively for groups 1, 2, and 3. Positive correlation was observed between lesion calcium score and frequency of post-dilation (R = 0.28, p = 0.03). There was no difference in focal stent expansion (71 ±14% vs. 65 ±15% vs.71 ±15%, p = 0.3) or diffuse stent expansion (92 ±30% vs. 85 ±30% vs. 93 ±38%, p = 0.7) comparing groups 1, 2, and 3. Lesion calcium score, total length of calcium, and maximum area and thickness of calcium deposits did not correlate with focal or diffuse stent expansion.ConclusionsLesions with a higher CTCA calcium score had larger reference plaque burden after stent implantation and more likely required post-dilation, but final stent expansion as assessed by IVUS was not affected by the amount of CTCA calcium provided an angiographically optimal result was achieved.

High Calcium Scores in Patients (PTS) with a Low Framingham Risk of Cardiovascular (CVS) Disease. Re-Interpreting CVS Risk Assessment: Should We Focus on the Patient or the Population?

High Calcium Scores in Patients (PTS) with a Low Framingham Risk of Cardiovascular (CVS) Disease. Re-Interpreting CVS Risk Assessment: Should We Focus on the Patient or the Population?

Risk factors of chronic Kidney disease influencing cardiac calcification

We sought to determine the influence of risk factors of chronic kidney disease (CKD) on cardiac calcification. We studied the correlation between coronary artery calcium score (CACS) and the type and duration of dialysis as well as the presence of diabetes mellitus and hypertension. The relation between calcium score and mortality was also analyzed. Patients with CKD attending the outpatient department or admitted in our hospital were included. They were subjected to high-resolution computerized tomography of the thorax to determine their CACS. Serum levels of intact parathyroid hormone (iPTH), highly sensitive C-reactive protein (hCRP), homocysteine, calcium, phosphorus, and calcium × phosphorus product were measured. Out of the 50 patients studied, 39 were hypertensive (78%), 32 were diabetic (64.4%), 20 were on hemodialysis, and 13 were on continuous ambulatory peritoneal dialysis. The mean CACS was 388.6. Twenty-nine patients had high iPTH levels and 92.9% of them had calcium score >400 (P = 0.013). Twenty-eight patients had high hCRP and 85.7% of these patients had calcium score >400 (P = 0.048). Patients on dialysis for more than two years had higher calcium score >400 (P = 0.035). 43% of diabetics had calcium score >400 (P = 0.008). All the six patients who died had calcium score >400 (P = 0). There was statistically no significant association noted between hypertension, high calcium x phosphorus product, and high homocysteine levels, and high calcium score. Our study suggests that higher values of iPTH, hCRP, and longer duration on dialysis are associated with accelerated cardiac calcification. Calcification scores >400 are associated with increased mortality.

Neutrophil to lymphocyte ratio and cardiovascular diseases: a review

The role of inflammatory markers in cardiovascular diseases has been studied extensively and a consistent relationship between various inflammatory markers and cardiovascular diseases has been established in the past. Neutrophil to lymphocyte ratio (NLR) is a new addition to the long list of these inflammatory markers. NLR, which is calculated from complete blood count with differential, is an inexpensive, easy to obtain, widely available marker of inflammation, which can aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. It has been associated with arterial stiffness and high coronary calcium score, which are themselves significant markers of cardiovascular disease. NLR is reported as an independent predictor of outcome in stable coronary artery disease, as well as a predictor of short- and long-term mortality in patients with acute coronary syndromes. It is linked with increased risk of ventricular arrhythmias during percutaneous coronary intervention (PCI) and higher long-term mortality in patients undergoing PCI irrespective of indications of PCI. In patients admitted with advanced heart failure, high NLR was reported with higher inpatient mortality. Recently, NLR has been reported as a prognostic marker for outcome from coronary artery bypass grafting and postcoronary artery bypass grafting atrial fibrillation.

Subclinical coronary atherosclerosis in young adults: prevalence, characteristics, predictors with coronary computed tomography angiography

The purpose of this study was to assess the characteristics and predictors of subclinical coronary atherosclerosis in young adults. The study also evaluated predictors of cardiac events. We retrospectively enrolled 914 self-referred asymptomatic subjects under the age of 45 (552 men, 362 women) who had undergone both coronary CT angiography (CCTA) and coronary artery calcium scoring. Two radiologists analyzed plaque composition and degree of stenosis. For all subjects, we evaluated clinical risk factors and investigated cardiac events. Subclinical coronary atherosclerosis was found in 86 subjects (9.4%). Among them, 64 subjects (74.4%) had a single coronary artery plaque. On analysis of individual segments, the most common type of plaque was non-calcified plaque (NCP) (58%), which was found in 63 subjects (6.9%). Significant coronary artery stenosis was found in 9 subjects (0.1%). Predictors of subclinical coronary atherosclerosis were age, male gender, hypertension, and diabetes mellitus. Male gender, diabetes mellitus, and amount of smoking were independent predictors of NCP. High low density lipoprotein cholesterol and calcium scores were also significant predictors of stenosis. Myocardial infarction developed in 1 subject, unstable angina in 2, stable angina in 1, and death in 1 (2.45 cardiac events per 1,000 person-years of follow-up). Multivariate analysis revealed hazard ratios of 2.2 for subclinical coronary atherosclerosis, 49.17 for NCP, and 105.58 for significant stenosis. The prevalence of subclinical coronary atherosclerosis in asymptomatic young adults is not negligible. CCTA has the potential to enhance risk stratification and prediction for coronary artery disease in asymptomatic young adults.

Letter in response to Andrea K.Y. Lee et al. “Normalcy rate of computed tomographic coronary angiography”

With interest we read the recently published letter by Andrea K.Y. Lee et al., entitled “Normalcy rate of computed tomographic coronary angiography” [1]. The authors assessed the normalcy rate (NR) of computed tomographic coronary angiography (CTCA) in a clinical population of patients with a very low pretest probability (≤4%) for coronary artery disease (CAD). A total of 601 patients (mean pretest probability 2.7%) were analyzed for the presence and severity of CAD. Using thresholds of ≥50% and ≥70% coronary artery diameter stenoses, the NR of CTCA were 94% and 97%, respectively.

Extremely high coronary artery calcium score is associated with a high cancer incidence

Calcium score, obtained by computed tomographic coronary angiography, can estimate the severity of coronary atherosclerosis [1–3]. Although the severity of atherosclerosis may not be directly related to the stenosis of coronary arteries [4], calcium score had been proved to improve the classification of coronary heart disease (CHD) risks [5–8]. CHD risks can be evaluated by classifying the calcium score to 0, 1–10, 11–100, 101–400, and larger than 400 [9,10]. However, calcium score can be much larger than 400, and has been reported to be more than 5000 [11].

Assessment of coronary artery calcium scoring

Calcium accumulation in the coronary arteries is a known indicator of atherosclerosis. The purpose of this study was to demonstrate the effect of patients' demographic characteristics on calcium scoring and the topographic accumulation of calcium in the coronary arteries. Two-hundred ninety-nine patients were included in the study (192 male, 107 female; mean age 59.08±10.7; range 19 to 84 years). All patients with total calcium scores of 1 Hounsfield unit or more underwent 16-slice multi-detector computed tomography with calcium scoring evaluation. Their coronary trees were divided into 14 different segments, and the number of lesions in each segment was calculated separately. When the coronary arteries were examined for calcium accumulation by segment, the proximal segment of the LAD (left anterior descending coronary artery) had the most calcium accumulation. Total calcium scores were higher in patients with high total and LDL cholesterol values than in normolipidemic patients. Total calcium scores were higher for patients with hypertension than for patients without hypertension. Calcium scores of smokers and non-smokers were not significantly different. Diabetic patients had higher calcium scores than patients without diabetes. No significant difference was identified between patients with and without a positive family history of coronary artery disease. Total calcium scores were higher for older patients and for patients with hyperlipidemia. Segmental analysis of calcium scoring demonstrates that calcium accumulation is mostly seen in the proximal LAD. Coronary artery calcification is increased by hypertension, age and hyperlipidemia.

A Novel Technology for Measuring Cumulative Cardiac Biomarker Exposure over Time: What Happened When We Weren't Looking?

Cardiac troponin testing is front and center for the diagnosis of acute myocardial infarction (MI) in patients with signs and symptoms suggestive of an acute coronary syndrome, and in the absence of an ST-segment elevation on their electrocardiogram. For at least 15 years, the troponin concentration on presentation or the peak value during hospitalization has been recognized to carry both short- and long-term prognostic information. More recently, longitudinal follow-up of biomarkers after an MI has led to the recognition that patients with persistent increases in cardiac troponin or natriuretic peptide concentrations also have a poor prognosis compared with post-MI patients who have a decrease in concentrations (1, 2). With the recent evolution to “high-sensitivity” cardiac troponin assays, which can achieve a 10-fold increase in low-end sensitivity compared with their contemporary counterparts, detectable troponin concentrations can now be measured in 25%–67% of the general population, depending on the patient's age (3, 4). Even these low-level increases are not benign in these seemingly asymptomatic individuals, because such increases are associated with an increased risk of adverse cardiovascular events, including MI. Although cardiac imaging can provide some insight into the cardiac pathology underlying a persistent biomarker increase after an MI or in the general population, imaging still provides limited insight into a longitudinal process, given the cross-sectional nature of an imaging study. For example, in a patient with a high coronary calcium score according to computed tomography and an increased left ventricular mass by echocardiography, it is difficult to determine whether a detectable cardiac troponin concentration is due to a clinically unrecognized MI or to a persistent increase caused by myocardial pathology. Examples of 2 possible post-MI patterns for patients identified with a chronic troponin increase are shown in Fig. 1. Over an extended period of time, the patient with …

A Systematic Review of the Predictive Value of a Coronary Computed Tomography Angiography as Compared With Coronary Calcium Scoring in Alternative Noninvasive Technique in Detecting Coronary Artery Disease and Evaluating Acute Coronary Syndrome in an Acute Care Setting

Approximately 6 million patients present to the emergency department each year for evaluation of chest pain, and 70% of chest pain presentations are noncardiac in origin. This systematic review article compares noninvasive tests (coronary computed tomography angiography and coronary calcium scoring) to determine the predictive value to detect coronary artery disease and evaluate acute coronary syndrome associated with major cardiovascular events. There was a direct correlation with major cardiovascular events to higher calcium scores indicating that coronary artery calcium scores are strong predictors of the prognosis of coronary artery disease rather than angiographic findings. Further studies are needed.