Coronary artery calcium score: current status

Neves, Priscilla Ornellas; Andrade, Joalbo; Monção, Henry

doi:10.1590/0100-3984.2015.0235

Priscilla Ornellas Neves Mailing address: Dr. Priscilla Ornellas Neves. Hospital Santa Luzia – Centro de Diagnóstico por Imagem. SHLS 716, conjunto E, Asa Sul. Brasília, DF, Brazil. E-mail: prineves@yahoo.com

Full Member of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), MD, Radiologist at the Hospital Santa Luzia, Brasília, DF, Brazil

Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, Brazil

Joalbo Andrade

MD, PhD, Radiologist at the Hospital Santa Luzia, Brasília, DF, Brazil

Henry Monção

Full Member of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), MD, Radiologist at the Hospital Santa Luzia, Brasília, DF, Brazil

Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, Brazil

Mailing address: Dr. Priscilla Ornellas Neves. Hospital Santa Luzia – Centro de Diagnóstico por Imagem. SHLS 716, conjunto E, Asa Sul. Brasília, DF, Brazil. E-mail: prineves@yahoo.com

Figures (3)
Tables (4)

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Figure 1
Tool for calculating the CAC score in percentiles, according to the distribution by age, gender, and ethnicity, as per the MESA.

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Figure 2
CAC score in a 51-year-old White female. A: Calcified plaque in the anterior descending artery. CAC score = 36 (Agatston method), consistent with discrete coronary calcification, indicating low cardiovascular risk. B: However, if the CAC score adjusted for age, gender, and ethnicity is used, according to the MESA, the score should be considered as being accentuated, indicating marked cardiovascular risk, because it is above the 90th percentile for this group.

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Figure 3
CAC score in a 65-year-old white male. A: Calcified plaques in the anterior descending artery, in addition to others (not shown) in the other coronary arteries. CAC score = 285 (Agatston method), consistent with moderate coronary calcification, indicating moderate cardiovascular risk. B: However, if the CAC score adjusted for age, gender, and ethnicity is used, according to the MESA, the calcium score should be considered discrete, indicating a low cardiovascular risk because it is below the 75th percentile for this group. C: If this same CAC score (Agatston 285) had been found in a woman of the same age and ethnicity, her adjusted score would be considered pronounced, indicating marked cardiovascular risk (above the 90th percentile).

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Table 1
Comparison of the CAC score and Framingham risk score, alone and in combination, as predictors of major cardiovascular events, based on the area under the curve.

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Table 2
Recommendation for the use of the CAC score in asymptomatic patients.

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Table 3
Degree of coronary artery calcification by absolute CAC scores and CAC scores adjusted for gender, age and ethnicity, with clinical interpretations

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Table 4
CAC score. Prognosis and recommended treatment strategies.^* * The estimated number needed to produce damage from aspirin use (one episode of major bleeding over the five year period) is 442 patients(28). Therefore, when the anticipated benefit exceeds the risk (e.g., when the FRS is ≥ 10% in patients with a calcium score of 1-100), the use of aspirin should be considered. CAC score (Agatston method). FRS, Framingham risk score.

	Sample	Follow-up	Area under the (ROC) curve^* * Area under the (ROC) curve > 0.7: satisfactory performance. CACS, coronary artery calcium score; FRS, Framingham risk score; M, males; F, females.
Study	Number of patients / age	Years (mean)	CACS	FRS	CACS + FRS
Raggi et al.⁽²⁰20 Raggi P, Shaw LJ, Berman DS, et al. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol. 2004;43:1663-9.⁾	10377	5	-	0.68 (M) / 0.67 (F)	0.72 (M) / 0.75 (F)
Greenland et al.⁽¹²12 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.⁾	1312 / > 45 years	7	-	0.63	0.68
Arad et al.⁽¹¹11 Arad Y, Goodman KJ, Roth M, et al. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46:158-65.⁾	4613 / 50-70 years	4.3	0.79	0.69	-
Becker et al.⁽¹³13 Becker A, Leber A, Becker C, et al. Predictive value of coronary calcifications for future cardiac events in asymptomatic individuals. Am Heart J. 2008;155:154-60.⁾	1726 / 57.7 ± 13.3 years	3.3	0.81	0.63	-

		Low risk	Low risk + family
Authority guidelines	Low risk	+ DM	history^* * First-degree male relative < 55 years of age or first-degree female relative < 65 years of age. of early CAD	Intermediate risk	High risk
2010 ACCF/SCCT/ACR⁽²¹21 Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56:1864-94.⁾	Inappropriate	-	Appropriate	Appropriate	Uncertain
2014 ACR⁽²²22 Earls JP, Woodard PK, Abbara S, et al. ACR appropriateness criteria asymptomatic patient at risk for coronary artery disease. J Am Coll Radiol. 2014;11:12-9.⁾	Typically inappropriate	-	Can be appropriate	Appropriate	Typically inappropriate
2010 ACCF/AHA⁽²³23 Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;56:e50-103.⁾	IIb	-	-	IIa	-
2012 ESC⁽²⁴24 Perk J, De Backer G, Gohlke H, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33:1635-701.⁾	-	-	-	IIa	-
2014 II Diretriz da SBC/CBR⁽¹⁸18 Sara L, Szarf G, Tachibana A, et al. II Diretriz de Ressonância Magnética e Tomografia Computadorizada Cardiovascular da Sociedade Brasileira de Cardiologia e do Colégio Brasileiro de Radiologia. Arq Bras Cardiol. 2014;103(6 supl 3):1-86.⁾	III	IIa	IIa	I	III
2013 ACC/AHA⁽²⁵25 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. Circulation. 2014;129(25 Suppl 2):S49-73.⁾	IIb: If, after risk assessment, the treatment based on the decision is uncertain, evaluation with the CAC score can be
	considered in order to define the most appropriate therapeutic strategy^† † After discussing with the patient, when the decision to initiate statin therapy is difficult to make in selected individuals who are not in one of the four groups benefiting from the use of statin, defined as described: atherosclerotic cardiovascular disease (ACD); primary elevation of low-density lipoprotein cholesterol (LDL C) ≥ 190 mg/dL; 40-75 years of age with diabetes and an LDL-C of 70- 189 mg/dL; and 40-75 years of age without ACD or diabetes, with an LDL-C of 70-189 mg/dL and a ≥ 7.5% estimated 10-year risk of ACD.

Degree of coronary	Absolute CAC score	CAC score adjusted for gender,
artery calcification	(Agatston method)	age and ethnicity - percentile	Clinical interpretation
Absent	0	0	Very low risk of future coronary events
Discrete	1-100	≤ 75	Low risk of future coronary events; low probability of myocardial ischemia
Moderate	101-400	76-90	Increased risk of future coronary events (aggravating factor); consider reclas-
			sifying the individual as high risk
Accentuated	> 400	> 90	Increased probability of myocardial ischemia

		CAC score = 0	CAC score 1-100	CAC score > 100
Population (% patients)⁽²⁸28 Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:453-60.⁾		56%	26%	18%
Annual frequency of events⁽²⁹29 Blaha MJ, Budoff MJ, Defilippis AP, et al. Associations between Creactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet. 2011;378:684-92.⁾		0.1%	0.5%	1.9%
Annual frequency of cardiovascular events⁽²⁸28 Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:453-60.⁾		0.4%	0.8%	2.4%
Number needed to treat (to prevent one cardiovascular event over a five year period)
Treatment with aspirin - Number needed to treat⁽²⁸28 Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:453-60.⁾	FRS < 10%	2036	571^* * The estimated number needed to produce damage from aspirin use (one episode of major bleeding over the five year period) is 442 patients(28). Therefore, when the anticipated benefit exceeds the risk (e.g., when the FRS is ≥ 10% in patients with a calcium score of 1-100), the use of aspirin should be considered. CAC score (Agatston method). FRS, Framingham risk score.	173
	FRS < 10%	808	146^* * The estimated number needed to produce damage from aspirin use (one episode of major bleeding over the five year period) is 442 patients(28). Therefore, when the anticipated benefit exceeds the risk (e.g., when the FRS is ≥ 10% in patients with a calcium score of 1-100), the use of aspirin should be considered. CAC score (Agatston method). FRS, Framingham risk score.	92
Treatment with statins - Number needed to treat⁽³⁰30 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.⁾	FRS ≥ 10%	549	94	24
Treatment recommendations
	CAC score = 0	CAC score 1-100		CAC score > 100
Recommended	None	Tailored use of statins + aspirin		Statins + aspirin
Recommendation for all patients	Life style change + monitoring of cardiovascular risk factors

[1] Mailing address: Dr. Priscilla Ornellas Neves. Hospital Santa Luzia – Centro de Diagnóstico por Imagem. SHLS 716, conjunto E, Asa Sul. Brasília, DF, Brazil. E-mail: prineves@yahoo.com

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Coronary artery calcium score: current status

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