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Coronary Artery Calcification : W hat It Means and How to Use It

A major teaching hospital of Harvard Medical School. Coronary Artery Calcification : W hat It Means and How to Use It. Melvin E. Clouse, M.D. Coronary Artery Calcification:. Wosika& Sosman-JAMA, 1934; 102:591-593 Snellan & Nauta-Fortschr Rontgenstahlen, 1937; 56:277-286

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Coronary Artery Calcification : W hat It Means and How to Use It

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  1. A major teaching hospital of Harvard Medical School Coronary Artery Calcification:What It Means and How to Use It Melvin E. Clouse, M.D.

  2. Coronary Artery Calcification: • Wosika& Sosman-JAMA, 1934; 102:591-593 • Snellan & Nauta-Fortschr Rontgenstahlen, 1937; 56:277-286 • Habbe & Wright-Detection Coronary Atherosclerosis. AJR, 1950; 63: 50-62 • Blankenhorn & Stern-AJR, 1959; 81: 772-777 • Electron Beam Computed Tomography: Imatron (David King) • Agatston & Janowitz-Quantification of CoronaryArtery Calcium Using Ultrafast Computed Tomography. JACC 1990; 15: 827-32. • Software Development Scoring/Reconstruction

  3. A major teaching hospital of Harvard Medical School Do We Need A New Test? Is there a problem? Will it be effective? Evaluate Current Trends Evaluate New Test Time line for acceptance

  4. CORONARYARTERYDISEASE Magnitude of the Problem • 1.5 Million MIs per year and over 500,000 deaths per year. • 40% of all deaths are in the US to CV disease. In 150,000 – 250,000 Americans the only symptom of CVD is a fatal heart attack Conclusion:Desperate need for further early warning system

  5. P.T.

  6. 204 M<55, F <65 with MIs • 60 % had LDL <131 mg/dl • 41 % had LDL <100 mg/dl • 38 % had LDL >130 mg/dl • Only 25% would have qualified for Statins using NCEP AATP III guidelines Akosah et al, JACC 2003

  7. Examples of Coronary Artery Scans NO CALCIFICATION “zero score” MODERATE CALCIFICATION SIGNIFICANT CALCIFICATION “high score”

  8. Rx Recommendations/Ca++ Score SCORE 0 Risk Factor Modification on Lo fat diet, Weight Reduction, No Smoking Serum LDL 100 mgm/dl For Elevated LDL -- STATIN Drugs Re-exam 3 years MODERATE SCORE – 25-50th %tile Risk Factor Modification – As Above LDL  100 mgm/dl Re-exam 1 year HI SCORE -- 75-90%tile Treadmill MIBI -- Same as above with Statins/LDL  100 mgm/dl

  9. EBCT & NCEP In Asymptomatic Women • without SX NCEP Hi Risk • NCEP Lo Risk • EBCT+, EBCT- • 42% EBCT+ (score 73% tile) 58% EBCT- • NCEP Hi Risk- 53.5% EBCT+: 37.7% EBCT - • NCEP Lo Risk -46.5% EBCT+: 62.3% EBCT - • Lo Risk NECP (47% EBCT +) would not receive Rx • Hi Risk NECP (37% EBCT -) would receive Rx • Hecht and Superko JACC 37:1506-1515 ( 1)

  10. Using Ca++ as Reference Rx 58.6% Correctly Identified <55 yrs. 65% correct >55 yrs. 52.2% correct Hecht #2

  11. NCEP ATP II • Dietary Intervention • LDL-C >130 mg/dL > 2 Risk Factors • Drug Rx • LDL-C >160 mg/dL • HDL-C < 35 mg/dL (also risk factor) • JAMA 269;3015-23, 1993

  12. Total Cholesterol Education Program ATP II ATP III Total Cholesterol 100-200 100-199 LDL 62-130 62-99 HDL 35-77 40-77 Triglycerides 30-200 30-149 Lp(a) 30-140 <30

  13. Framingham Heart StudyScore and Risk Prediction Multivariable Statistical Model Age Total Hypertension Cholesterol Sex HDL Smoking LDL Diabetes Triglycerides Estimates coronary event risk in asymptomatic populations.

  14. ATP III Framingham Risk Scoring Step 1: Age Step 4: Systolic Blood Pressure Step 6: Adding Up the Points Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2 ³160 2 3 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 3: HDL-Cholesterol HDL-C (mg/dL) Points ³60 -1 50-59 0 40-49 1 <40 2 Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Assessing CHD Risk in Men Step 7: CHD Risk Point Total 10-Year Risk Point Total 10-Year Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 2% ³17 ³30% 6 2% 7 3% 8 4% 9 5% 10 6% Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1 ³280 11 8 5 3 1 Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

  15. Non-Invasive Testing Coronary Ca++ Risk-NCEP ATP III Population Recommend Low 35% Lifestyle HCE<10% Intermediate 40% Noninvasive test Ca++,diet, statin HCE<20% High 25% Intensive CHD, HTN, Diabetes intervention (statins) FHS-Risk HCE/10yr >20%

  16. Risk Assesment of Asymptomatic Patients Coronary Ca++ studies must be able to predict the risk of future coronary events.

  17. CAC/Predictor HCEPhysician/self referral Arad et al 1996 Circulation 1173 pts Arad et al 2000 JACC 1172 pts Raggi & Callister 2000 Circulation 172/632 pts Raggi & Callister 2001 AHJ 676/10,122 pts Kondos 2003 Circulation 5635 pts Shaw & Raggi 2003 Radiology 10,377pts Wong et al 2000 AJC 926 pts

  18. Predictive Value EBCT Coronary Arteries 19 mo follow-up 1173 pts. Mean age 53 +/- 11 yrs. 18 subjects had 26 cv events Ca++ thresholds Score Sen % Spec % 100 89 77 160 89 82 600 50 95 Odds ratio range 20-34.4 (P<0.0009-0.00001) ARAD Circulation 1996

  19. CAC Predictor HCEProspective Studies Gerci, et al 2003 SFHS 5585 pts South Bay Heart Watch: Secci, et al 1997 Circulation 326 (462/461) Detrano, et al 1999 Circulation 1196 pts/2-3yr* Park, et al 2002 Circulation 967 pts / 6yrs Greenland 2004 JAMA 1312 pts /7yrs (risk factor nor CAC event predictor, CAC no sig. incremental value,use not justified)

  20. CAC/FRS Non heterogeneous multi ethnic population 1029, 65+/- 7.8 years CAC score >300 associated with higher risk coronary event than FRS alone. Sig. Use when FRS is in 10-19% range for HCE in 10 years Greenland et al. JAMA 2004;291:210-15

  21. Predicting Coronary Death or Nonfatal Myocardial Infarction for Framingham Risk Scores (FRS) The receiver operating characteristics curves illustrate FRS alone or plus coronary artery calcium score (CACS). Area under the curves are 0.63 for FRS alone, 0.68 for FRS plus CACS. P<.001 for the comparison between the 2 areas. Greenland et al, JAMA 2004; 291:210-215

  22. 13-19 20-29 30-39 40-49 >50 91% 85% 85% 75% 71% 66% 60% Prevalence of Coronary Atherosclerosis (%) 37% 21% 17% Tuzcu et al. Circulation 2001; 103:2705-2710

  23. Atherosclerosis/CVD • Long term, indolent, preventable disease • Accounts for 40 % of all deaths • >2nd thru 7th leading causes of adult death combined • 84.7 % who die are older than 65 years • 80% CHD mortality in individuals < 65 years of age occurs during 1st attack • 57% men and 64% women who die suddenly had no previous symptoms (150,000) • Cost – 386.4 billion (greater than 1/3 of our $1 trillion dollar health care economy)

  24. CAC Summary • Follow CAC over time (RFM) • Stable/Progression/Regression • Combine with FRS/NCEP ATP III • Before statin treatment • Cost benefit analysis algorithm initial exam for cardiac work up • Chest pain patients-screen EW pts. Rumberger et al, JACC 1999;33:453-62 Raggi et al, Am J Cardiol 2000;85:283-28 Hect & Superko, JACC 2001;37:1 506-1 511 Laudon et al, J Emergency Med 1999 Waters et al, Clin Investigation 1993

  25. HOMELANDSECURITY

  26. CAC Summary • Scanning technology validated • Reproducible, variability – EBCT/MDCT • Independent predictive value CAC for HCE • Only non-invasive method to demonstrate total plaque burden • Plaque burden: most important predictor of • hard coronary events / mortality • Only non-invasive test to detect early CAD • Quantify disease • Institute measures to stop progression • Monitor disease progress

  27. Development of Coronary Artery Plaque EBT “positive” for coronary calcium Consistent with the “diffuse” nature of coronary artery disease, plaque development can be seen in various stages in multiple areas of the coronary artery system.

  28. Atherosclerosis Timeline Foam Cells Fatty Streak Intermediate Lesion Fibrous Plaque Complicated Lesion/Rupture Atheroma Endothelial Dysfunction From first decade From third decade From fourth decade Thrombosis, hematoma Smooth muscle and collagen Growth mainly by lipid accumulation Stary HC, et al. Circulation. 1995;92:1355-74. Artery wall often gets larger with increasing plaque-Glagov NEJM 1987

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