Severe Coronary Artery Calcification Research Articles

Coronary calcification on invasive angiography and the Agatston score—a single-center experience

Aim: The pattern and severity of coronary artery calcification (CAC) can influence prognosis and outcome in percutaneous coronary intervention. An objective assessment of CAC during invasive angiography may provide additional prognostic information. This study aimed to assess the correlation between the angiographic Birmingham calcium score (BCS) and the Agatston coronary calcium score (CCS) performed as part of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). Methods: In this retrospective observational study, patients undergoing SPECT-MPI and invasive coronary angiography as part of their routine management were included. BCS was calculated by reviewing angiography images in retrospect by an observer blinded to the SPECT-MPI calcium score. Spearman’s correlation was used to analyze the correlation between BCS and SPECT-MPI. Receiver operating characteristic curve was used to detect cut-off for BCS that would detect clinically significant CAC [> 400 Agatston units (AU)]. Kaplan-Meier was used to report on outcomes at 5 years follow-up. Results: In this cohort of 151 patients, there was a positive correlation between BCS and CCS [Spearman correlation coefficient (r) = 0.558, P < 0.001]. Cumulative BCS of 1 was able to identify clinically significant CAC [area under the curve 0.788, 95% confidence interval (CI) 0.714–0.863]. Cumulative BCS ≥ 3 was associated with major adverse outcomes at 5 years follow-up (log rank P = 0.013). Conclusion: BCS correlates well with established higher CCS. Application of BCS during invasive coronary angiography will aid risk stratification, management, and follow-up with no extra patient involvement, radiation, or costs.

Clinical impact of cardiovascular calcifications on stroke incidence in primary prevention: analysis in NADESICO study.

The utility of assessment of cardiovascular calcifications for predicting stroke incidence remains unclear. This study assessed the relationship between cardiovascular calcifications including coronary artery calcification (CAC), aortic valve (AVC), and aortic root (ARC) assessed by coronary computed tomography (CT) and stroke incidence in patients with suspected CAD. In this multicenter prospective cohort study, 1187 patients suspected of CAD who underwent coronary CT were enrolled. Cardiovascular events including stroke were documented. Hazard ratio (HR) and confidence interval (CI) were assessed by Cox proportional hazard model adjusted for the Framingham risk score. C statistics for stroke incidence were also examined by models including cardiovascular calcifications. A total of 980 patients (mean age, 65 ± 7years; females, 45.8%) were assessed by the CAC, AVC, and ARC Agatston scores. During a median follow-up of 4.0years, 19 patients developed stroke. Cox proportional hazard model showed severe CAC (Agatston score ≥ 90th percentile [580.0 value]) and presence of AVC and ARC were associated with stroke incidence (HR; 10.33 [95% CI; 2.08-51.26], 3.08 [1.19-7.98], and 2.75 [1.03-7.30], respectively). C statistic in the model with CAC and AVC severity for predicting stroke incidence was 0.841 (95% CI; 0.761-0.920), which was superior to the model with CAC alone (0.762 [95% CI; 0.665-0.859], P < 0.01). CAC, AVC, and ARC were associated with stroke incidence in patients suspected of CAD. Assessment of both CAC and AVC may be useful for prediction of stroke incidence.

Myosteatosis is associated with coronary artery calcification in patients with type 2 diabetes.

Myosteatosis, rather than low muscle mass, is the primary etiologic factor of sarcopenia in patients with type 2 diabetes mellitus (T2DM). Myosteatosis may lead to a series of metabolic dysfunctions, such as insulin resistance, systematic inflammation, and oxidative stress, and all these dysfunctions are closely associated with the acceleration of T2DM and atherosclerosis. To investigate the association between myosteatosis and coronary artery calcification (CAC) in patients with T2DM. Patients with T2DM, who had not experienced major cardiovascular events and had undergone both abdominal and thoracic computed tomography (CT) scans, were included. The mean skeletal muscle attenuation was assessed using abdominal CT images at the L3 level. The CAC score was determined from thoracic CT images using the Agatston scoring method. Myosteatosis was diagnosed according to Martin's criteria. Severe CAC (SCAC) was defined when the CAC score exceeded 300. Logistic regression and decision tree analyses were performed. A total of 652 patients with T2DM were enrolled. Among them, 167 (25.6%) patients had SCAC. Logistic regression analysis demonstrated that myosteatosis, age, duration of diabetes, cigarette smoking, and alcohol consumption were independent risk factors of SCAC. Myosteatosis was significantly associated with an increased risk of SCAC (OR = 2.381, P = 0.003). The association between myosteatosis and SCAC was significant in the younger patients (OR = 2.672, 95%CI: 1.477-4.834, P = 0.002), but not the older patients (OR = 1.456, 95%CI: 0.863-2.455, P = 0.188), and was more prominent in the population with lower risks of atherosclerosis. The decision tree analyses prioritized older age as the primary variable for SCAC. In older patients, cigarette smoking was the main contributing factor for SCAC, while in younger patients, it was myosteatosis. Myosteatosis is a novel risk factor for atherosclerosis in patients with T2DM, especially in the population with younger ages and fewer traditional risk factors.

Coronary Artery Calcification on Low-Dose Lung Cancer Screening CT in South Korea: Visual and Artificial Intelligence-Based Assessment and Association With Cardiovascular Events.

Background: Coronary artery calcification (CAC) on lung cancer screening low-dose chest CT (LDCT) is a cardiovascular risk marker. South Korea was the first Asian country to initiate a national LDCT lung cancer screening program, although CAC-related outcomes are poorly explored. Objective: To evaluate CAC prevalence and severity using visual analysis and artificial intelligence (AI) methods and to characterize CAC's association with major adverse cardiovascular events (MACEs) in patients undergoing LDCT in Korea's national lung cancer screening program. Methods: This retrospective study included 1002 patients (mean age, 62.4±5.4 years; 994 men, 8 women) who underwent LDCT at two Korean medical centers between April 2017 and May 2023 as part of Korea's national lung cancer screening program. Two radiologists independently assessed CAC presence and severity using visual analysis, consulting a third radiologist to resolve differences. Two AI software applications were also used to assess CAC presence and severity. MACE occurrences were identified by EMR review. Results: Interreader agreement for CAC presence and severity, expressed as kappa, were 0.793 and 0.671, respectively. CAC prevalence was 53.4% by consensus visual assessment, 56.6% by AI software I, and 60.1% by AI software II. CAC severity was mild, moderate, and severe by consensus visual analysis in 28.0%, 10.3% and 15.1%; by AI software I in 39.9%, 14.0%, and 6.2%; and by AI software II in 34.9%, 14.3%, and 7.3%. MACE occurred in 36 of 625 (5.6%) patients with follow-up after LDCT (median, 1108 days). MACE incidence in patients with no, mild, moderate, and severe CAC, for consensus visual analysis was 1.1%, 5.0%, 2.9%, and 8.6% (p<.001); for AI software I was 1.3%, 3.0%, 7.9%, and 11.3% (p<.001); and for AI software II was 1.2%, 5.0%, 7.7%, and 9.6% (p<.001) Conclusion: For Korea's national lung cancer screening program, MACE occurrence increased significantly with increasing CAC severity, whether assessed by visual analysis or AI software. The study is limited by the large sex imbalance for Korea's national lung cancer screening program. Clinical Impact: The findings provide reference data for healthcare practitioners engaged in developing and overseeing national lung cancer screening programs, highlighting the importance of routine CAC evaluation.

Analysis of the correlation between pericoronary adipose tissue mean attenuation and plaque characteristics and stenosis in coronary CT angiography.

Coronary artery disease (CAD) is a predominant cardiovascular disorder, particularly in the aging population. The pathophysiology of atherosclerosis involves lipid deposition and inflammation of the arterial walls. With coronary computed tomography angiography offering insights into coronary anatomy and pathology, parameters such as pericoronary adipose tissue mean attenuation (PCATMA) have gained significance in the understanding of cardiac diseases. A retrospective study encompassing 130 patients with CAD was conducted to analyze 269 observation points. Coronary CT Angiography was employed, with specific attention paid to the measurement of PCATMA and a qualitative and quantitative assessment of plaques. Statistical analyses were performed using Statistical Package for the Social Sciences software (version 27.0), independent samples t test, one-way ANOVA, and multivariate logistic regression analysis. There was a notable correlation between PCATMA expression and severity of coronary artery calcification and stenosis. Patients with higher coronary artery calcification scores and more pronounced stenosis had elevated PCATMA values. Variances in PCATMA based on plaque type and degree of stenosis were significant (P < .05). Multivariate logistic regression revealed that plaque presence, type, and degree of stenosis were independent determinants of PCATMA expression. PCATMA expression is closely associated with CAD progression. As plaque calcification and arterial stenosis increase, there is a concomitant increase in PCATMA expression, potentially serving as a pivotal prognostic indicator.

The Associations Between Abdominal Obesity and Coronary Artery Calcification in Chronic Kidney Disease Population.

Cardiovascular disease (CVD) is the primary cause of mortality in chronic kidney disease (CKD) patients, with metabolic disorders exacerbating this risk. Compared with body mass index, waist circumference (WC) has been proposed as a more effective indicator of abnormal visceral fat. However, the associations among CKD, abnormal WC, and CVD remain understudied. A cross-sectional study in Taiwan (July 2006 to May 2016) involved 10,342 participants undergoing self-paid health checkups at a single medical center. Physical examinations and blood samples were taken to assess metabolic parameters, and renal function was evaluated using the Chronic Kidney Disease Epidemiology Collaboration formula. Coronary artery calcification (CAC) scores were determined through coronary 256-slice multidetector computed tomography angiography, with a CAC score of >0 Agatston unit (AU) and ≥ 400 AU denoting positive CAC and severe CAC, respectively. Sex-based comparisons were conducted between individuals with CKD and those without CKD. In the CKD group, both sexes exhibited significantly elevated levels for systolic blood pressure, serum fasting blood glucose (FBG), and hemoglobin A1c (HbA1c) as well as reduced serum high-density lipoprotein cholesterol. Examination of the associations of abnormal WC revealed that for both sexes, individuals with abdominal obesity (AO) were significantly older and had higher systolic/diastolic blood pressure, serum FBG, HbA1c, and lipid profiles compared with those without AO. Multiple logistic regression analysis revealed that CKD patients exhibited a more pronounced association with severe CAC scores compared with AO patients (odds ratios [ORs]: 2.7 and 1.4, respectively). Furthermore, the combined effects of AO and CKD (AO[+]/CKD[+]) resulted in increased risks of positive CAC (OR: 2.4, 95% confidence interval [CI]: 1.6-3.5) and severe CAC (OR: 4.4, 95% CI: 1.4-14.2). Abdominal obesity significantly raised the odds of CAC and was associated to a 4.4-fold increased risk of severe CAC in CKD patients.

Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium>1,000.

Although a coronary artery calcium (CAC) of≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined. Among persons with a CAC of≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates. The authors studied 2,246 asymptomatic patients with a CAC of≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by≥2 major ASCVD events or 1 major event and≥2 high-risk conditions (1.4 per 100 person-years). The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC≥300). Diabetes (HR: 2.04 [95%CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95%CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95%CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95%CI: 0.8-1.9]), severe LM CAC (1.3 [95%CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95%CI: 3.4-10.8]). Among asymptomatic patients with a CAC of≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.

Artificial Intelligence in Coronary Artery Calcium Scoring Detection and Quantification.

Coronary artery calcium (CAC) is a marker of coronary atherosclerosis, and the presence and severity of CAC have been shown to be powerful predictors of future cardiovascular events. Due to its value in risk discrimination and reclassification beyond traditional risk factors, CAC has been supported by recent guidelines, particularly for the purposes of informing shared decision-making regarding the use of preventive therapies. In addition to dedicated ECG-gated CAC scans, the presence and severity of CAC can also be accurately estimated on non-contrast chest computed tomography scans performed for other clinical indications. However, the presence of such "incidental" CAC is rarely reported. Advances in artificial intelligence have now enabled automatic CAC scoring for both cardiac and non-cardiac CT scans. Various AI approaches, from rule-based models to machine learning algorithms and deep learning, have been applied to automate CAC scoring. Convolutional neural networks, a deep learning technique, have had the most successful approach, with high agreement with manual scoring demonstrated in multiple studies. Such automated CAC measurements may enable wider and more accurate detection of CAC from non-gated CT studies, thus improving the efficiency of healthcare systems to identify and treat previously undiagnosed coronary artery disease.

Chest Computed Tomography for Lymphoma Staging: A Wasted Opportunity for Cardiovascular Risk Stratification?

Patients with a lymphoma diagnosis undergo non-gated chest computed tomography (CT) scans as part of cancer diagnosis or staging. Although coronary artery calcification (CAC) is traditionally evaluated on dedicated cardiac CT, CAC can also be detected on standard chest CT. This exploratory study aimed to determine the prognostic value of CAC detected on non-gated chest CT and to report its use on clinical practice. Consecutive patients with a lymphoma diagnosis who performed non-contrasted non-gated chest CT for cancer diagnosis or staging were included and retrospectively evaluated. Coronary artery calcification was evaluated by quantitative (Agatston score) and qualitative (visual) assessment. Fifty-seven patients were included in this study (mean age 61±15 years; 58% male). Coronary artery calcification was identified in 22 patients (39%), most of them with multi-vessel involvement. Coronary artery calcification was qualitatively classified as mild, moderate and severe in 11%, 19% and 9% patients, respectively. This study suggested that moderate or severe CAC was an independent predictor of all-cause mortality (odds ratio 3, 95% confidence interval 2-11; p=0.04) after adjusting for cardiovascular risk factors and lymphoma staging. Regarding quantitative evaluation, a higher CAC score was also associated with higher mortality. While significant CAC was identified in 22 patients, it was only reported in four patients. The preliminary findings of this hypothesis-generating study support the investigation of CAC identified by chest CT for diagnosis/staging of cancer as a risk modifier in the global risk assessment of patients with lymphoma. The unrecognition and underreporting of this finding may represent a wasted opportunity to detect subclinical coronary atherosclerosis in these patients and may help in guiding preventive cardiology care.

Systematic Review of the Efficacy of Orbital Atherectomy in Improving the Outcome of Percutaneous Corornary Intervention in People With Diabetes.

The optimal approach to deal with severe coronary artery calcification (CAC) in people with diabetes remains ill-defined. People with diabetes have a significant risk of developing severe vessel calcification and coronary artery disease (CAD). CADis the leading cause of death in people with diabetes. Individuals with diabetes mainly present with severe multivessel stenosis, diffuse coronary calcification, and severe atherosclerosis, which are poor prognostic factors of revascularization procedures. Studies have shown that the revascularization of arteries in people with diabetes often results in worse outcomes than in people without diabetes. Coronary artery bypass grafting (CABG) has been recommended as the standard of care for people with DM and complex anatomic diseases, including left main CAD. However, percutaneous coronary intervention (PCI)is more acceptable to patients in clinical practice because of decreased trauma and rapid recovery. Severe CAC has traditionally been challenging for PCI and a frequent indication for surgical revascularization. This study aims to determine the effectiveness of orbital atherectomy (OA) in improving PCIoutcomes in patients with diabetes and identify possible adverse effects that preclude its use. The study is reported according to PRISMA and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search of EMBASE, Scopus, Web of Science, Cochrane Library, CINAHL, and MEDLINE was conducted for studies that utilized OA before PCI in people with diabetes. A reference list of the eligible articles was also screened. A narrative synthesis was done by representing the data on the effect direction plot, followed by vote counting. Eighteen studies were included in the analysis. Success rate/successful stent delivery was >90%, while freedom from angiographic complication and major adverse cardiovascular and cerebrovascular events (MACCE) were both >80% on the effect direction plot for people with diabetes and those without diabetes. People with diabetes had low event rates similar to those without diabetes. OA appears to be a viable treatment approach for people with diabetes. However, RCTs with a longer duration of follow-up are required to establish the appropriate treatment strategy for severe CAC in people with diabetes.

Abstract C121: Follow-up of moderate and severe coronary artery calcifications identified on lung cancer screening CT scans: An opportunity to improve cardiac health outcomes in Black men and women

Abstract Background: The USPSTF currently recommends lung cancer screening (LCS) by low-dose CT (LDCT) in those 50 to 80 years of age with 20+ pack-years of smoking who are currently smoking or quit smoking within the last 15 years. LCS LDCT often detects non-cancer related incidental findings, most commonly coronary artery calcifications (CAC). CAC is a measure of subclinical coronary atherosclerosis, is higher in those with tobacco use, and may require additional clinical assessment after LCS. In the National Lung Screening Trial, reductions in all-cause mortality were stronger among Black than White participants undergoing LDCT. It was hypothesized that this may have been due to follow-up and treatment of incidental findings such as CAC during the trial. Methods: In this on-going observational study, we are evaluating clinical follow-up of moderate or severe CAC within 12 months of LCS among individuals undergoing baseline LCS at two Michigan health systems, one urban and one rural. We report here our initial findings for individuals with a baseline LCS LDCT at Henry Ford Health in 2018. Pearson Chi Square and McNemar’s tests were used to determine differences between race and sex groups and in change in statin use and cardiology visits (yes/no) pre- to post-screening. Results: Of 1,630 individuals (18% Black) with a baseline LDCT in 2018, moderate or severe CAC was documented in 154 (9.4%). Moderate or severe CAC prevalence was significantly higher among Black versus Non-Black ( 17.7 % vs 7.1%; p= &amp;lt;0.001) individuals and men versus women ( 11.7% vs 7.1%; p=0.002 ). Pre- to post-LCS increases in statin use (68.2% vs. 76.0%; p=0.02) and cardiology visits (25.9% vs. 50.7%; p&amp;lt;0.01) were observed, overall. Statin use did not differ by race, sex, or race-sex group in the pre- or post- periods. Cardiology visits were less common among Blacks (18.2% vs. 28.9%; p=0.14) and women ( 18.2% vs. 28.9%; p= 0.14) in the pre-LCS period with Black women (8.3%) being the least likely to have a cardiology visit before LCS. Post-LCS, the cardiology gap between Black and Non-Black individuals (43.6% vs. 55.6%: p=0.16) narrowed and was eliminated between women and men (53.6 % vs. 50%; p=0.67). This was due in part to a substantial uptick of cardiology visits post-LCS in Black females. However, Black men, were significantly less likely than Non-Black men (32.3 % vs 56.7% ; p=0.024 ) and Black women (32.2% vs. 62.5%; p=0.024) to have a cardiology visit post-LCS . Conclusions: Our study is on-going; however, preliminary results suggest that in addition to reducing lung cancer mortality, LCS provides an opportunity for CAC detection and its related management. LCS, if implemented equitably with comprehensive follow-up of incidental findings, may help to close gaps in cardiac care for Black individuals and women. Further investigation is needed to assess whether appropriate follow-up of CAC decreases cardiovascular risks for those undergoing screening. Citation Format: Christine Neslund-Dudas, Katie R. Zarins, Punith Shetty, Andrea E. Cassidy-Bushrow, Nada Al-Antary, Katie A. Latack, Vritti Gupta, Michael Simoff, Riley Draper, Samuel Wilcox, Kendra Worden, Kathy LaRaia, Kelly Hirko. Follow-up of moderate and severe coronary artery calcifications identified on lung cancer screening CT scans: An opportunity to improve cardiac health outcomes in Black men and women [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C121.

Coronary artery calcium assessment on routine non-gated chest CT as a gatekeeper for additional imaging in patients with stable chest pain

Abstract Aims In Coronary Artery Disease (CAD), currently applied risk assessment methods often overestimate patients’ risk of obstructive CAD. To enhance and patient-tailor risk estimation, assessment of Coronary Artery Calcium (CAC) can be applied. In ∼10% of patients presenting with stable chest pain a non-gated chest computed tomography (CT) has been previously performed, suitable for CAC assessment. This study is the first to investigate the clinical value of CAC assessment on non-gated chest CT for risk assessment of obstructive CAD. Purpose This study aims to point out the clinical utility of visual CAC assessment for enhancing risk assessment and avoid unnecessary additional imaging in patients presenting with stable chest pain. Methods For this study, all patients referred for coronary CT angiography (CCTA), in whom a prior non-gated chest CT was performed, were included. To assess the extent of patients’ CAC, an ordinal score was applied. CAD was assessed on CCTA and obstructive CAD was defined as stenosis of ≥70%. Patients were stratified in to groups according to CAC severity, pre-test probability and number of risk factors. Percentages of patients with obstructive CAD were compared between the groups. Results A total of 181 patients of 30-88 years old were included. The percentage of obstructive CAD was significantly different between de CAC groups (p&amp;lt;0.01). The absence of CAC ruled out obstructive CAD with 100% certainty, irrespective of sex, pre-test probability, type of complaint and number of risk factors. Additionally, a mild CAC score ruled out obstructive CAD in patients with low – intermediate PTP or non-anginal complaints, with 100% certainty. Conclusion CAC assessment on non-gated chest CT can safely rule out obstructive CAD in patients presenting with stable chest pain and can therefore function as a radiation-free and cost-free gatekeeper for additional imaging.CCTA results for CAC severityDecisiontree patients with chest pain

Registre REFORCE

Severe coronary artery calcification, too often underestimated, increases the complexity of percutaneous coronary interventions. Atherectomy is one of preferred approach for the preparation of calcified lesions before stent placement. Orbital atherectomy is a new method that has proven to be safe and effective in the preparation of calcium plaques (ORBIT I and ORBIT II studies). The recent introduction in France allows to perform a prospective registry named REFORCE. Its main objective is to include 300 patients in order to evaluate security and safety of the device in France during routine use.

Dynamic Perfusion Computed Tomography for the Assessment of Concomitant Coronary Artery Disease in Patients with a History of Percutaneous Transluminal Angioplasty for Chronic Limb-Threatening Ischemia-A Pilot Study.

Chronic limb-threatening ischemia (CLTI) is associated with high rates of long-term cardiovascular mortality. Exercise stress testing to detect obstructive coronary artery disease (CAD) can be difficult in this subset of patients due to inability to undergo exercise testing, presence of balanced ischemia and severe coronary artery calcification (CAC). To test the feasibility of regadenoson stress dynamic perfusion computed tomography (DPCT) in CLTI patients. Between 2018 and 2023, coronary computed tomography angiography (CTA) and, in the case of a calcium score higher than 400, DPCT, were performed in 25 CLTI patients with a history of endovascular revascularization. Of the 25 patients, 19 had a calcium score higher than 400, requiring DPCT image acquisition. Obstructive CAD could be ruled out in 10 of the 25 patients. Of the 15 CTA/DPCT+ patients, 13 proceeded to coronary angiography (CAG). Revascularization was necessary in all 13 patients. In these 13 patients, vessel-based sensitivity and specificity of coronary CTA/DPCT as compared to invasive evaluation was 75%, respectively. At follow-up (27 ± 21 months) there was no statistically significant difference in all-cause mortality between CTA/DPCT- positive and -negative patients (p = 0.065). Despite a high prevalence of severe CAC, coronary CTA complemented by DPCT may be a feasible method to detect obstructive and functionally significant CAD in CLTI patients.

Coronary Artery Calcium Identified on Non-Gated Chest CT Scans: A Wasted Opportunity for Preventive Cardiological Care

Coronary artery calcium (CAC) evaluated on dedicated cardiac computed tomography (CT) is an independent predictor of cardiovascular events. This study aimed to evaluate the correlation between CAC detected on non-gated standard chest CT and coronary lesions on coronary angiography (CAG) and determine its impact on prognosis. Consecutive patients who underwent CAG due to acute coronary syndrome and had prior non-contrasted non-gated chest CT were included and retrospectively evaluated. Coronary artery calcium was evaluated by quantitative (Agatston score) and qualitative (visual assessment) assessment. A total of 114 patients were included in this study. The mean time difference between chest CT and CAG was 23 months. Coronary artery calcium was visually classified as mild, moderate, and severe in 31%, 33%, and 16% of patients, respectively. Moderate or severe CAC was an independent predictor of significant lesions on CAG (OR 22; 95% CI 8-61; p<0.001) and all-cause mortality (OR 4; 95% CI 2-9; p=0.001). Quantitative CAC evaluation accurately predicted significant lesions on CAG (AUC 0.81; p<0.001). While significant CAC was identified in 80% of chest CTs, formal reporting was 25%. Coronary artery calcium evaluation with chest CT was feasible and strongly associated with severity of coronary disease on CAG and mortality. Although the identification of CAC on chest CT represents a unique opportunity for cardiovascular risk stratification for preventive care, CAC underreporting is frequent.

Identifying Coronary Artery Calcification Using Chest X-ray Radiographs and Machine Learning: The Role of the Radiomics Score.

To evaluate the ability of radiomics score (RS)-based machine learning to identify moderate to severe coronary artery calcium (CAC) on chest x-ray radiographs (CXR). We included 559 patients who underwent a CAC scan with CXR obtained within 6 months and divided them into training (n = 391) and validation (n = 168) cohorts. We extracted radiomic features from annotated cardiac contours in the CXR images and developed an RS through feature selection with the least absolute shrinkage and selection operator regression in the training cohort. We evaluated the incremental value of the RS in predicting CAC scores when combined with basic clinical factor in the validation cohort. To predict a CAC score ≥100, we built an RS-based machine learning model using random forest; the input variables were age, sex, body mass index, and RS. The RS was the most prominent factor for the CAC score ≥100 predictions (odds ratio = 2.33; 95% confidence interval: 1.62-3.44; P < 0.001) compared with basic clinical factor. The machine learning model was tested in the validation cohort and showed an area under the receiver operating characteristic curve of 0.808 (95% confidence interval: 0.75-0.87) for a CAC score ≥100 predictions. The use of an RS-based machine learning model may have the potential as an imaging marker to screen patients with moderate to severe CAC scores before diagnostic imaging tests, and it may improve the pretest probability of detecting coronary artery disease in clinical practice.

Evaluation of Clinical Applicability of Coronary Artery Calcium Assessment on Non–Gated Chest Computed Tomography, Compared With the Classic Agatston Score on Cardiac Computed Tomography

Given current pretest probability (PTP) estimations tend to overestimate patients' risk for obstructive coronary artery disease, evaluation of patients' coronary artery calcium (CAC) is more precise. The value of CAC assessment with the Agatston score on cardiac computed tomography (CT) for risk estimation has been well indicated in patients with stable chest pain. CAC can be equally well assessed on routine non-gated chest CT, which is often available. This study aims to determine the clinical applicability of CAC assessment on non-gated CT in patients with stable chest pain compared with the classic Agatston score on gated CT. Consecutive patients referred for evaluation of the Agatston score, who had a previously performed non-gated chest CT for evaluation of noncardiac diseases, were included. CAC on non-gated CT was ordinally scored. Subsequently, patients were stratified according to CAC severity and PTP. The agreement and correlation between the classic Agatston score and CAC on non-gated CT were evaluated. The discriminative power for risk reclassification of both CAC assessment methods was assessed. Invasive coronary angiography was used as the gold standard, when available. A total of 140 patients aged between 30 and 88years were included. The agreement between ordinally scored CAC and the Agatston score was excellent (κ=0.82) and the correlation strong (r=0.94). Most patients (80%) with an intermediate PTP had no or mild CAC on non-gated CT. They were reclassified at low risk with 100% accuracy compared with invasive coronary angiography. Similarly, 86% of patients had an Agatston score <300. These patients were reclassified with 98% accuracy. In patients with high PTP, the accuracy remained substantial and comparable, 94% and 89%, respectively. In conclusion, we believe this is the first study to assess the clinical applicability of CAC on non-gated CT in patients with stable chest pain, compared with the classic Agatston score. The agreement between methods was excellent and the correlation strong. Furthermore, CAC assessment on non-gated CT could reclassify patients' risk for obstructive coronary artery disease as accurately as could the classic Agatston score.

An Opportunity to Seize From Low Hanging Fruits: Capitalising on Incidentally Reported Coronary Artery Calcification.

We investigated the prevalence of incidental coronary artery calcifications (CAC) from non-electrocardiogram (ECG)-gated computed tomography (CT) chest (both contrast and non-contrast) for inpatients. We also assessed for downstream investigation and statin prescription from the inpatient teams. Incidental CAC are frequent findings on non-ECG-gated CTchest. It is associated with adverse prognosis in multiple patient cohorts. All non-ECG-gated CT chest done as inpatients from a single centre referred from 1 January 2022 to 31 December 2022 with reported incidental CAC were reviewed for inclusion. Patients who had history of known coronary artery disease, history of coronary stent or bypass, and presence of cardiac devices were excluded. Total of 123 patients were included, making the prevalence 6.2% (123/1,980). The median age is 76 years (interquartile range 69-85) and predominantly male at 54.5%. The majority of CT chest done were contrasted scans (91.1%). Only 26.8% of CAC were reported on its severity with visual quantification, with 7.3% each reported for both moderate and severe CAC. Only 2.4% of CAC were reported in the conclusion of the CT report. Most of these patients were asymptomatic (34.1%). A total of 20.3% of patients had further tests done. Inpatient hospital mortality was 8.1%. About 23.6% and 34.1% of patients were on aspirin and statin therapy respectively at baseline. There was only 1 patient (1.2%) who was prescribed with new statin therapy on discharge. Incidental CAC is prevalent in inpatient settings and remains under-recognised by ordering clinicians, with low prescription rate of statin therapy. Practice-changing measures to standardise reporting of incidental CAC is needed to identify patients with subclinical coronary disease and initiate preventive interventions.

Association of serum thyroid hormone and coronary artery calcification in patients who underwent invasive coronary angiography: an observational study.

Thyroid hormones (TH) are known to have a range of effects on the cardiovascular system. However, there is still controversy regarding the relationship between thyroid function and coronary artery calcification (CAC). The purpose of this paper is to investigate the relationship between TH and CAC, especially severe CAC, in patients who underwent invasive coronary angiography (ICA). This may provide further insights into the potential role of TH in the development and progression of cardiovascular disease. This observational study included 4221 patients who underwent ICA after completing CTA in a single center. We collected demographic, clinical, and laboratory data from electronic medical records and measured CAC scores via non-contrast cardiac CT. The study found that there is a negative correlation between the CAC score and FT3 level, even after adjusting for potential confounding factors, but there was no correlation between the CAC score and FT4 or TSH. When categorized into quartiles, the highest quartile of FT3 was associated with a decrease (β = -104.37, 95%CI: -172.54, -36.21) in calcification score compared to the lowest quartile. This correlation was more significant in the subgroup of individuals with diabetes or hypertension. The study found a negative correlation between FT3 and CAC in patients who underwent ICA. The correlation was consistent with other studies and may suggest that low levels of FT3 are associated with severe CAC. The study may provide new evidence for future research on CAC and potential therapeutic approaches.

Investigating the impact of non-gated thoracic CT prior to CTCA to reduce layered testing

To determine the proportion of computed tomography (CT) coronary angiography (CTCA) referrals with coronary artery calcification (CAC) evident on previous non-cardiac CT imaging and how this impacted the diagnostic yield for CTCA, the requirement for additional diagnostic testing, and the associated costs to confirm or refute obstructive coronary artery disease (CAD). A retrospective review of CTCA examinations was undertaken between 01/05/2018 and 31/05/2020 in which the examinations were cross referenced for previous non-gated thoracic CT at Royal United Hospitals Bath. Major epicardial vessel CAC on baseline CT was re-evaluated by published semi-quantitative methods, giving a per-patient CAC score (mild=1-3, moderate=4-6, severe >6). Subsequent incomplete CTCA diagnostic yield, further testing, and cost implications were examined. Of the 2140 CTCA examinations identified, 13% (280/2140) had a preceding non-gated thoracic CT (53% female, age 63±11 years). The incomplete diagnostic rate increased with CAC grade, mild 32%, (RR 12; 95% CI 4-40), moderate 64% (RR 25; 95% CI 8-80), severe 75%, (RR 29; 95% CI 9-94). Additional diagnostic testing occurred in 4% for the mild CAC category, and 14% and 42% for moderate and severe, respectively. When severe CAC was identified on a non-gated thoracic CT a cost saving of £171/patient (dobutamine stress echo [DSE]) and £61/patient (myocardial perfusion scintigraphy [MPS]) was established with a direct to functional testing pathway. In patients referred for CTCA where severe CAC was identified on a preceding non-gated thoracic CT a direct to functional testing altered management in 42% of cases and was cost-effective.