https://doi.org/10.4081/monaldi.2023.2720
Coronary artery calcium score: we know where we are but not where we may be
Submitted: July 18, 2023
Accepted: August 16, 2023
Published: September 6, 2023
Accepted: August 16, 2023
Abstract Views: 871
PDF: 254
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Cardiac computed tomography angiography (CCTA) has emerged as a cost-effective and time-saving technique for excluding coronary artery disease. One valuable tool obtained by CCTA is the coronary artery calcium (CAC) score. The use of CAC scoring has shown promise in the risk assessment and stratification of cardiovascular disease. CAC scores can be complemented by plaque analysis to assess vulnerable plaque characteristics and further refine risk assessment. This paper aims to provide a comprehensive understanding of the value of the CAC as a prognostic tool and its implications for patient risk assessment, treatment strategies, and outcomes. CAC scoring has demonstrated superior ability in stratifying patients, especially asymptomatic individuals, compared to traditional risk factors and scoring systems. The main evidence suggests that individuals with a CAC score of 0 have a good long-term prognosis, while an elevated CAC score is associated with increased cardiovascular risk. Finally, the clinical power of CAC scoring and the development of new models for risk stratification could be enhanced by machine learning algorithms.
Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010;121:948-54. Erratum in: Circulation 2010;121:e259.
Detrano R, Guerci AD, Carr JJ. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008;358:1336-45.
Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. G Ital Cardiol (Rome) 2022;23:e1-e75. [Article in Italian].
Authors/Task Force Members, ESC Committee for Practice Guidelines (CPG), ESC National Cardiac Societies. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Atherosclerosis 2019;290:140-205. Corrigendum in: Atherosclerosis 2020;294:80-2. Erratum in: Atherosclerosis 2020;292:160-2.
Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15:827-32.
Budoff MJ, Achenbach S, Blumenthal RS, et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006;114:1761-91.
Criqui MH, Denenberg JO, Ix JH, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular events. JAMA 2014;311:271-8. Erratum in: JAMA 2015;313:1374.
Rumberger JA, Kaufman L. A rosetta stone for coronary calcium risk stratification: agatston, volume, and mass scores in 11,490 individuals. AJR Am J Roentgenol 2003;181:743-8.
Cury RC, Leipsic J, Abbara S, et al. CAD-RADS™ 2.0 - 2022 coronary artery disease-reporting and data system: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2022;16:536-57.
Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004;291:210-5. Erratum in: JAMA 2004;291:563.
Rodriguez-Granillo GA, Carrascosa P, Bruining N, et al. Defining the non-vulnerable and vulnerable patients with computed tomography coronary angiography: evaluation of atherosclerotic plaque burden and composition. Eur Heart J Cardiovasc Imaging 2016;17:481-91.
Pergola V, Cabrelle G, Mattesi G, et al. Added value of CCTA-derived features to predict MACEs in stable patients undergoing coronary computed tomography. Diagnostics (Basel) 2022;12:1446.
Pergola V, Previtero M, Cecere A, et al. Clinical value and time course of pericoronary fat inflammation in patients with angiographically nonobstructive coronaries: a preliminary report. J Clin Med 2021;10:1786.
Baritussio A, Vacirca F, Ocagli H, et al. Assessment of coronary inflammation by pericoronary fat attenuation index in clinically suspected myocarditis with infarct-like presentation. J Clin Med 2021;10:4200.
Writing Committee Members, Gulati M, Levy PD, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. J Am Coll Cardiol 2021;78:e187-285.
Knuuti J, Wijns W, Saraste A et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407-77. Erratum in: Eur Heart J 2020;41:407-77.
Pergola V, Cabrelle G, Previtero M, et al. Impact of the "atherosclerotic pabulum" on in-hospital mortality for SARS-CoV-2 infection. Is calcium score able to identify at-risk patients?. Clin Cardiol 2022;45:629-40.
Budoff MJ, Diamond GA, Raggi P, et al. Continuous probabilistic prediction of angiographically significant coronary artery disease using electron beam tomography. Circulation 2002;105:1791-6.
Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging 2009;2:675-88. Erratum in: JACC Cardiovasc Imaging 2010;3:1089.
Winther S, Schmidt SE, Mayrhofer T, et al. Incorporating coronary calcification into pre-test assessment of the likelihood of coronary artery disease. J Am Coll Cardiol 2020;76:2421-32.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e164.
Blaha MJ, Budoff MJ, De Filippis AP, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet 2011;378:684-92.
Valenti V, Hartaigh BÓ, Heo R, et al. A 15-year warranty period for asymptomatic individuals without coronary artery calcium: a prospective follow-up of 9,715 individuals. JACC Cardiovasc Imaging 2015;8:900-9.
Mittal TK, Pottle A, Nicol E, et al. Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score. Eur Heart J Cardiovasc Imaging 2017;18:922-9.
Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:3227-37. Erratum in: Eur Heart J 2022;43:4468.
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation 2019;140:e563-95. Erratum in: Circulation 2019;74:e647-8. Erratum in: Circulation 2020;141:e59. Erratum in: Circulation 2020;141:e773.
Wilson PW, D'Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-47.
Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations. JAMA 2014;311:1406-15.
Budoff MJ, McClelland RL, Nasir K, et al. Cardiovascular events with absent or minimal coronary calcification: the multi-ethnic study of atherosclerosis (MESA). Am Heart J 2009;158:554-61.
Hoff JA, Chomka EV, Krainik AJ, et al. Age and gender distributions of coronary artery calcium detected by electron beam tomography in 35,246 adults. Am J Cardiol 2001;87:1335-9.
Vliegenthart R, Oudkerk M, Hofman A, et al. Coronary calcification improves cardiovascular risk prediction in the elderly. Circulation 2005;112:572-7.
LaMonte MJ, FitzGerald SJ, Church TS, et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol 2005;162:421-9.
Kronmal RA, McClelland RL, Detrano R, et al. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the multi-ethnic study of atherosclerosis (MESA). Circulation 2007;115:2722-30.
Wetscherek MTA, McNaughton E, Majcher V, et al. Incidental coronary artery calcification on non-gated CT thorax correlates with risk of cardiovascular events and death. Eur Radiol 2023;33:4723-33.
Rijlaarsdam-Hermsen D, Lo-Kioeng-Shioe MS, Kuijpers D, et al. Prognostic value of the coronary artery calcium score in suspected coronary artery disease: a study of 644 symptomatic patients. Neth Heart J 2020;28:44-50.
Yeboah J, Young R, McClelland RL, et al. Utility of nontraditional risk markers in atherosclerotic cardiovascular disease risk assessment. J Am Coll Cardiol 2016;67:139-47.
Folsom AR, Kronmal RA, Detrano RC, et al. Coronary artery calcification compared with carotid intima-media thickness in the prediction of cardiovascular disease incidence: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med 2008;168:1333-9. Erratum in: Arch Intern Med 2008;168:1782.
Yeboah J, McClelland RL, Polonsky TS, et al. Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA 2012;308:788-95.
Verghese D, Manubolu S, Budoff MJ. Contemporary use of coronary artery calcium for the allocation of aspirin in light of the 2022 USPSTF guideline recommendations. Am J Prev Cardiol 2022;12:100427.
Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014;63:2935-59. Erratum in: J Am Coll Cardiol 2014;63:3026.
US Preventive Services Task Force, Curry SJ, Krist AH, et al. Risk assessment for cardiovascular disease with nontraditional risk factors: US preventive services task force recommendation statement. JAMA 2018;320:272-80.
Hecht HS, Cronin P, Blaha MJ, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr 2017;11:74-84.
Sundström J, Sullivan L, D'Agostino RB, et al. Plasma homocysteine, hypertension incidence, and blood pressure tracking: the Framingham heart study. Hypertension 2003;42:1100-5.
Piepoli MF, Hoes AW, Agewall, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315-81.
Anderson TJ, Grégoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2016;32:1263-82.
McClelland RL, Jorgensen NW, Budoff M, et al. 10-year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (multi-ethnic study of atherosclerosis) with validation in the HNR (Heinz Nixdorf recall) Study and the DHS (Dallas Heart study). J Am Coll Cardiol 2015;66:1643-53.
Blaha MJ, Cainzos-Achirica M, Greenland P, et al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the multi-ethnic study of atherosclerosis (MESA). Circulation 2016;133:849-58.
Yu J, Qian L, Sun W, et al. Automated total and vessel-specific coronary artery calcium (CAC) quantification on chest CT: direct comparison with CAC scoring on non-contrast cardiac CT. BMC Med Imaging 2022;22:177.
Ota K, Nakanishi R, Hashimoto H, et al. Association between coronary artery calcium score on non-contrast chest computed tomography and all-cause mortality among patients with congestive heart failure. Heart Vessels 2022;37:262-72.
Yang G, Chen Y, Ning X et al. Automatic coronary calcium scoring using noncontrast and contrast CT images. Med Phys 2016;43:2174.
Lee D, Joo HJ, Jung HW, Lim DS. Investigating potential mediator between statin and coronary artery calcification. PLoS One 2018;13:e0203702.
Puri R, Nicholls SJ, Shao M, et al. Impact of statins on serial coronary calcification during atheroma progression and regression. J Am Coll Cardiol 2015;65:1273-82.
Park HB, Arsanjani R, Sung JM, et al. Impact of statins based on high-risk plaque features on coronary plaque progression in mild stenosis lesions: results from the PARADIGM study. Eur Heart J Cardiovasc Imaging 2023;24:1536-43.
Budoff MJ, Shaw LJ, Liu ST, et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007;49:1860-70.
Zreik M, Lessmann N, van Hamersvelt RW, et al. Deep learning analysis of the myocardium in coronary CT angiography for identification of patients with functionally significant coronary artery stenosis. Med Image Anal 2018;44:72-85.
Mu D, Bai J, Chen W, et al. Calcium scoring at coronary CT angiography using deep learning. Radiology 2022;302:309-16.
Wang W, Wang H, Chen Q, et al. Coronary artery calcium score quantification using a deep-learning algorithm. Clin Radiol 2020;75:237.e11-237.e16.
Han D, Kolli KK, Gransar H, et al. Machine learning based risk prediction model for asymptomatic individuals who underwent coronary artery calcium score: comparison with traditional risk prediction approaches. J Cardiovasc Comput Tomogr 2020;14:168-76.
Ren Y, Li Y, Pan W, et al. Predictive value of CAC score combined with clinical features for obstructive coronary heart disease on coronary computed tomography angiography: a machine learning method. BMC Cardiovasc Disord 2022;22:569.
Lubbers M, Dedic A, Coenen A, et al. Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial. Eur Heart J 2016;37:1232-43.
How to Cite
Mattesi, Giulia, Maria Teresa Savo, Morena De Amicis, Filippo Amato, Elena Cozza, Simone Corradin, Stefano Da Pozzo, Marco Previtero, Riccardo Bariani, Giorgio De Conti, Ilaria Rigato, Valeria Pergola, and Raffaella Motta. 2023. “Coronary Artery Calcium Score: We Know Where We Are But Not Where We May Be”. Monaldi Archives for Chest Disease 94 (1). https://doi.org/10.4081/monaldi.2023.2720.
Copyright (c) 2023 The Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
