Zero Calcium Score Research Articles

ASSESSMENT OF ATHEROMATOUS PLAQUE BY MULTISLICE COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY IN PATIENT WITH ZERO CALCIUM SCORE

Background: Zero calcium score (CS) is associated with low risk for mortality but not low risk for acute coronary disease developments. Soft plaque is vulnerable to fissuring and rupture. Objective: To evaluate the frequency of coronary atheromatous plaque in patients with zero CS and the associated risk factors. Patients and methods: This was a cross-sectional, retrospective study with 235 consecutive individuals with zero CS at Islam Cardiac Center from August 2019 to August 2020. A significance level of 5% was adopted. Results: The frequency of atheromatous plaque in coronary arteries in 235 patients with zero CS was 26.81% (63 individuals). In the subgroup of atheromatous plaque with zero CS, mean age was 58±28 years, 40 (63.5%) were females, 29 (46.03%) hypertensive, 33 (52.38%) diabetics, 31 (49.2%) dyslipidemias, 12(19.05% had family history of premature coronary artery diseases (CAD), 20 (31.75%) smokers and body mass index (BMI) was 27.64±1.5. Fifteen patients (23.8%) had obstructive plaques (> 50%). Conclusions: The frequency of atheromatous plaques with zero CS was high. So, absence of calcification does not exclude the presence of plaques, one fourth of them were obstructive, especially with aged individuals.

Factors Associated with Non-calcified Plaques in Patients with Coronary Artery Calcium Score of Zero

Background: The coronary artery calcium score is used for risk stratification in asymptomatic patients. Although coronary arterydisease can occur in the absence of coronary artery calcifications, no conditions associated with the presence of soft non-calcifiedplaques have been described in this scenario, beyond the presence of symptoms.Objectives: The aim of this study was to determine the associations between non-calcified plaques and independent variables inpatients with coronary artery calcium score of zero.Methods: Consecutive patients with coronary artery score of zero Agatston units who also underwent computed tomography coronaryangiography were included in the study. Univariate logistic regression analysis was used to find associations. (15) Sensitivity,specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LH+) and negative likelihoodratio (LH-) were calculated.Results: Among a total of 93 patients, 10% (n = 9) presented non-calcified plaque. A positive exercise stress test was associated withplaques of any degree of severity (OR 6.5; 95% CI, 1.3-33, p = 0.02). This association persisted for non-severe plaques when the positiveexercise stress test was combined with a negative myocardial perfusion SPECT or stress echocardiography for ischemia (OR,12.4; 95% CI 1.5-101, p = 0.02). Sensitivity and specificity of ST-segment depression for non-calcified plaque of any degree of severitywas 44.4% and 86%, respectively, with NPV of 94%, PPV of 25%, LR+ of 3.11 and LR– of 0.65.Conclusions: ST-segment depression could be associated with non-calcified plaques in patients without coronary artery calcifications,even with normal exercise stress myocardial perfusion or wall motion (non-obstructive disease).

Presence And Severity Of Coronary Atherosclerosis In Patients With Zero Calcium Score On Computed Tomography Coronary Angiography: Relying On Calcium Scoring Alone May Miss Clinically Important Coronary Artery Disease.

Introduction: Coronary artery calcification is known as a specific indicator of coronary atherosclerotic disease. However, relying on calcium scoring alone may miss non-calcified plaques with clinical importance in young high risk individuals. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. The aim of our study was to identify the presence and severity of coronary plaques in computed tomography coronary angiography (CTCA) in patients with a zero calcium score. Our objective was to find the frequency of presence and severity of coronary plaques on computed tomography coronary angiography (CTCA) in patients with zero calcium score.

Non-diabetic Patients With Atypical Chest Pain And Coronary Artery Calcium (CAC) Score Of Zero Are Low Risk For Cardiovascular Events At Two Years From Index Presentation

Introduction: Various studies have shown that patients with a Coronary Artery Calcium (CAC) score of zero have low risk of cardiovascular events or all-cause mortality in the medium and long term. Our aim was to identify a subgroup of patients presenting with stable chest pain in Rapid Access Chest Pain Clinic (RACPC) where CAC score alone can be useful in screening prognostically significant coronary artery disease.

294 Assessment of the Diagnostic Utility of Non-Invasive Cardiac Imaging Modalities in Accurately Excluding Obstructive Coronary Artery Disease in Low to Intermediate Risk Patients. A Calcium Score of Zero is Predictive of a Negative Myocardial Perfusion Study and Thus can be Utilized in the Absence of an MPS for Exclusion of Obstructive Coronary Artery Disease

Myocardial perfusion scan (MPS) is an established non-invasive diagnostic tool for assessing reversible ischaemia in low-to- intermediate-risk chest pain patients. The diagnostic utility of Coronary Artery Calcium Score {CACS} in isolation is less established in this cohort at excluding obstructive coronary artery disease. In comparison to MPS; CACS is less costly; more time efficient and utilizes smaller doses of ionizing radiation. In this tertiary single-centred retrospective analysis we assessed the utility of a CACS of 0 in the prediction of a negative MPS; and ultimately the exclusion of obstructive coronary artery disease. 137 consecutive patients of whom underwent simultaneous CACs and MPS with low to intermediate risk chest pain were included in the study. The criteria for adjunctive CACs assessment included patients aged between 45- 75years; with no prior history of ischaemic heart disease. 137 patients underwent paired MPS and CACs; 37 of the 137 patients {27%} had a CACS of zero; all of whom had a paired negative MPS. 100 patients {73%} had a CACs of >1; with 9 positive MPS results showing demonstrable reversible perfusion defects. The mean age of patients was 62 years; with 53% Male and 47% Female. Further stratification incorporating cardiac risk factors included diabetes mellitus, smoking history, hypertension and hypercholesteraemia with 80% having greater than one risk factor. CACS of 0 predicts a negative MPS {p=0.113; Fisher`s exact test}. Coronary artery calcium score of zero is suggestive of a negative myocardial perfusion study; although not statistically significant. Further studies are recommended with the aim of applying coronary artery calcium scoring as a diagnostic non-invasive screening tool in patients with low to intermediate risk chest pain.

287 Aortitis and Aortic Valvulitis from Autoimmune Non-Necrotising Vasculitis

A 45-year-old female presented with Acute pulmonary oedema associated with Severe Aortic regurgitation (AR) . Past medical history included long term immunosuppression with Hydroxychloroquine and Prednisolone for the management of Discoid Lupus with no previous systemic involvement. Trans-oesophageal Echocardiogram demonstrated thickened, fibrotic, tented aortic valve leaflets without central coaptation causing severe AR . There were no lesions typical of Libman-Sacks endocarditis and no appreciable masses or vegetations. Computed tomography coronary angiogram showed thickening around the aortic root with stenotic lesions in the coronary arteries and a zero-calcium score. Coronary angiogram confirmed these stenotic lesions. Fluorodeoxyglucose - Positron emission tomography showed increased uptake within the aortic root, ascending aorta, and proximal head and neck vessels .The findings were suggestive of vasculitis, however, a complete vasculitis screen was non-contributory. Mechanical Aortic Valve Replacement and Coronary Artery Bypass Grafting to the Right Coronary Artery and Left Anterior Descending Coronary Artery was performed. Histopathology of the aortic root/valve revealed non-necrotising aortitis (NNA), most likely representative of autoimmune associated aortitis. NNA is associated with autoimmune disease in approximately 50% of the cases with a slight female predominance and a typical age of presentation between 60-90 years. Differentials include Takayasu Aortitis, IgG4-related Aortitis, Syphilitic Aortitis, Systemic Lupus Erythematosus, and Isolated Idiopathic Aortitis. In this case, biopsy showed non-specific chronic aortitis with negative spirochete immunohistochemistry, scant IgG4 plasma cells, and no giant cells, with considerable overlap between various aetiologies. The history of immunosuppression treatment may have contributed to the modified histological appearance of aortitis.

A Coronary Artery Calcium Score of Zero in Patients Who Have Undergone Coronary Computed Tomography Angiography Is Associated With Freedom From Major Adverse Cardiovascular Events.

BackgroundThe coronary artery calcification score (CACS) is a good marker of future cardiovascular risk. We determined the association between the CACS and the prognosis in patients who have undergone coronary computed tomography angiography (CCTA).MethodsWe performed a prospective cohort study and enrolled 502 consecutive patients who underwent CCTA for screening of coronary artery disease (CAD) at Fukuoka University Hospital (FU-CCTA Registry) and either were clinically suspected of having CAD or had at least one cardiovascular risk factor with a follow-up of up to 5 years. The patients were divided into CACS = 0 and CACS > 0 groups. Using CCTA, ≥ 50% coronary stenosis was diagnosed as CAD, and the number of significantly stenosed coronary vessels (VD), Gensini score and CACS were quantified. The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization).Results%CAD, the number of VD and the Gensini score in the CACS = 0 group were significantly lower than those in the CACS > 0 group. %MACE in the CACS = 0 group was also significantly lower than that in the CACS > 0 group. Kaplan-Meier curves indicated that the CACS = 0 group showed significantly greater freedom from MACE than the CACS > 0 group (P = 0.008). Finally, only CACS = 0 was independently associated with MACE (odd ratio: 0.41, 95% confidence interval: 0.17 - 0.97, P = 0.041).ConclusionsA CACS of 0 in patients who underwent CCTA was associated with a good prognosis.

148 Pericardial Decompression Syndrome - a Case Report of Transient Ventricular Failure Post-pericardiocentesis

Pericardial decompression syndrome (PDS) is a rare syndrome characterised by cardiac dysfunction following pericardiocentesis for large pericardial effusions with suspected tamponade [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar]. It is a significant cause of morbidity in patients with metastatic malignancies [[2]Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar]. A 36-year-old male with metastatic lung adenocarcinoma presented with dyspnoea, tachycardia, hypotension, and right heart failure. Electrocardiogram showed electrical alternans and chest x-ray revealed cardiac enlargement. A transthoracic echocardiogram (TTE) demonstrated a large global pericardial effusion with features of tamponade. Pericardiocentesis immediately removed 1.2L of haemoserous fluid. Eleven hours later, the patient developed pulmonary oedema requiring diuretics and non-invasive ventilation. TTE revealed biventricular dilatation with severe global systolic dysfunction, and raised pulmonary pressures. A small residual pericardial effusion remained. CT coronary angiogram revealed calcium score of zero. He was discharged on bisoprolol, ramipril, and ivabradine. Progress TTE 6 weeks post-pericardiocentesis revealed resolution of systolic function. Three possible mechanisms include pre/afterload mismatch [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar], unmasking of pre-existing LV dysfunction [[3]Wolfe M.W. Edelman E.R. Transient systolic dysfunction after relief of cardiac tamponade.Annals of Internal Medicine. 1993; 119: 42-44Crossref PubMed Scopus (42) Google Scholar], and myocardial stunning from compression of epicardial vessels [[4]Braverman A.C. Sundaresan S. Cardiac tamponade and severe ventricular dysfunction.Annals of Internal Medicine. 1994; 120: 442Crossref PubMed Scopus (20) Google Scholar]. Literature reviews [2Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar, 5Ayoub C. Chang M. Kritharides L. A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?.Cardiovascular Ultrasound. 2015; 13: 1-12PubMed Google Scholar] note that PDS occurred after drainage of 450-2100ml, onset within seconds to weeks, a third of cases were fatal, and two thirds of systolic dysfunction normalised. Intercostal catheters are routinely clamped to prevent re-expansion pulmonary oedema, however no such guidelines exist for pericardiocentesis. Here we suggest limiting immediate drainage to 200ml in order to reduce the likelihood of PDS. Further research on limiting the rate and volume of drainage may clarify how to prevent PDS.

Calcium score as a screening method for cardiovascular disease diagnosis

Coronary artery calcification (CAC) is characteristic of coronary atherosclerosis, which is often detected by chest computed tomography. The standardized method for assessing CAC is the calcium score (CS) using the Agatston scoring system. A semi-quantitative ECG-synchronized assessment of coronary calcium score is considered a strong prognostic factor for coronary events in asymptomatic patients. Zero CS can serve as the strongest unfavorable risk factor for cardiovascular events in 10-15 years. According to international guidelines, CS should be used in patients of intermediate and low risks with a family history of cardiovascular diseases, as well as in patients with diabetes older than 40 years. The aim of this review was to summarize current data on the clinical significance of CS taking into account the results of international multicenter studies, current international guidelines and further prospects for its wider use in cardiology practice.

Predictors of a Coronary Artery Calcium Score of Zero in Patients with Familial Hypercholesterolaemia

Predictors of a Coronary Artery Calcium Score of Zero in Patients with Familial Hypercholesterolaemia

Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective.

Stable chest pain is a common clinical presentation that often requires further investigation using noninvasive or invasive testing, resulting in a resource-consuming problem worldwide. At onset of 2016, the National Institute for Health and Care Excellence (NICE) published an update on its guideline on chest pain. Three key changes to the 2010 version were provided by the new NICE guideline. First, the new guideline recommends that the previously proposed pretest probability risk score should no longer be used. Second, they also recommend that a calcium score of zero should no longer be used to rule out coronary artery disease (CAD) in patients with low pretest probability. Third, the new guideline recommends that all patients with new onset chest pain should be investigated with a coronary computed tomographic angiography (CTA) as a first-line investigation. However, in real world the impact of implementation of CTA for the evaluation of new onset chest pain remains to be evaluated, especially regarding its cost effectiveness. The aim of the present report was to discuss the results of the studies supporting new NICE guideline and its comparison with European and US guidelines.

Abstract 17402: Increased Epicardial Adipose Tissue Volume is Associated With Left Ventricular Diastolic Function in Patients With Zero Coronary Artery Calcium Score

Background: Recent publications suggested that epicardial adipose tissue (EAT) contributes to the pathogenesis of coronary atherosclerosis. Although some studies showed the association between EAT accumulation and left ventricular (LV) diastolic dysfunction, these associations are not fully understood. Methods: We evaluated 153 patients without coronary artery disease who underwent coronary computed tomography (CT) angiography and Doppler echocardiography. We evaluated 153 patients (mean age of 60 years and 54% men) with zero coronary artery calcium score in coronary CT. Visceral adipose tissue (VAT) area was simultaneously measured by abdominal scans, and EAT volume was also calculated. These measurements were corrected by body surface area; VAT area index (VATAI), and EAT volume index (EATVI). The early diastolic mitral annular velocity at the septal (septal E’) and lateral (lateral E’) were measured using tissue Doppler echocardiography. Results: The mean values of BMI, VATAI, EATVI, and LVMI were 23.7 ± 3.8 kg/m 2 , 52.6 ± 26.4 cm 2 /m 2 , 71.3 ± 29.8 cm 3 /m 2 , and 83.3 ± 17.7 g/m 2 , respectively. The mean septal E’ and lateral E’ velocities were 7.2 ± 2.2 cm/s and 9.8 ± 2.9 cm/s, respectively. Each E’ velocity was negatively correlated with EATVI (septal, R = 0.276, p < 0.001; lateral, R = 0.342, p < 0.001) and VATAI (septal, R = 0.241, p = 0.03; lateral, R = 0.255, p = 0.002; Figure). In contrast, each E’ velocity was not correlated with LVMI (septal, R = 0.161, p = 0.03; lateral, R = 0.118, p = 0.14) and BMI (septal, R = 0.182, p = 0.03; lateral, R = 0.152, p = 0.06). To determine each E’ velocity, we performed stepwise multiple regression analyses where all clinical parameters were entered. Diastolic blood pressure (p = 0.014), statin use (p = 0.011), LVMI (p = 0.003), and EATVI (p = 0.004) were independently correlated with septal E’ velocity, and statin use (p = 0.024), LVMI (p = 0.011), and EATVI (p < 0.001) were independently correlated with lateral E’ velocity. Conclusion: An increase in EATVI was associated with the decrease of early diastolic mitral annular velocity along each side of the left ventricle in patients with coronary calcium score of zero. These findings indicate that EAT accumulation may cause LV diastolic dysfunction in the early phase of coronary artery disease.

SUBTOTAL LEFT MAIN DISEASE IN PATIENT WITH ZERO CALCIUM SCORE: IS IT POSSIBLE?

SUBTOTAL LEFT MAIN DISEASE IN PATIENT WITH ZERO CALCIUM SCORE: IS IT POSSIBLE?

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography.

BackgroundIn view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature.ObjectiveTo evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA).MethodsThis is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted.ResultsThe frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable.ConclusionsThe frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain.

BackgroundThe accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD).ObjectiveTo test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations.MethodsPatients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography.ResultsIn 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability < 50%, zero calcium score had a negative predictive value of 95% (95%CI = 83%-99%), with a number needed to test of 2.1 for obtaining one additional discharge.ConclusionZero calcium score substantially reduces the pretest probability of obstructive CAD in patients admitted to the CCU with acute chest pain. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Role of Coronary Artery Calcium Score of Zero and Other Negative Risk Markers for Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis (MESA).

Limited attention has been paid to negative cardiovascular disease (CVD) risk markers despite their potential to improve medical decision making. We compared 13 negative risk markers using diagnostic likelihood ratios (DLRs), which model the change in risk for an individual after the result of an additional test. We examined 6814 participants from the Multi-Ethnic Study of Atherosclerosis. Coronary artery calcium score of 0, carotid intima-media thickness <25th percentile, absence of carotid plaque, brachial flow-mediated dilation >5% change, ankle-brachial index >0.9 and <1.3, high-sensitivity C-reactive protein <2 mg/L, homocysteine <10 µmol/L, N-terminal pro-brain natriuretic peptide <100 pg/mL, no microalbuminuria, no family history of coronary heart disease (any/premature), absence of metabolic syndrome, and healthy lifestyle were compared for all and hard coronary heart disease and all CVD events over the 10-year follow-up. Models were adjusted for traditional CVD risk factors. Among all negative risk markers, coronary artery calcium score of 0 was the strongest, with an adjusted mean DLR of 0.41 (SD, 0.12) for all coronary heart disease and 0.54 (SD, 0.12) for CVD, followed by carotid intima-media thickness <25th percentile (DLR, 0.65 [SD, 0.04] and 0.75 [SD, 0.04], respectively). High-sensitivity C-reactive protein <2 mg/L and normal ankle-brachial index had DLRs >0.80. Among clinical features, absence of any family history of coronary heart disease was the strongest (DLRs, 0.76 [SD, 0.07] and 0.81 [SD, 0.06], respectively). Net reclassification improvement analyses yielded similar findings, with coronary artery calcium score of 0 resulting in the largest, most accurate downward risk reclassification. Negative results of atherosclerosis-imaging tests, particularly coronary artery calcium score of 0, resulted in the greatest downward shift in estimated CVD risk. These results may help guide discussions on the identification of individuals less likely to receive net benefit from lifelong preventive pharmacotherapy.

Abnormal Myocardial Perfusion Scintigraphy in Patient with Zero Calcium Score: Is it Possible?

Abnormal Myocardial Perfusion Scintigraphy in Patient with Zero Calcium Score: Is it Possible?

Heart beats: not to be beaten.

Heart beats: not to be beaten.

151 Prevalence of Coronary Artery Disease and Major Adverse Cardiovascular Events in Patients with A Zero Calcium Score: A Prospective Cardiac CT Study

IntroductionCardiac computed tomography (CT), consisting of coronary artery calcium (CAC) scoring and CT angiography (CTa), is recommended by NICE for the exclusion of coronary artery disease (CAD) in intermediate-risk symptomatic...