Cardiac CTCalcium scoring 2008

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naren on Mar 03, 2010 Says :

simply amazing presentation...

jane on Jul 27, 2009 Says :

great presentation Doc.Thanks a lot for sharing it. angiography is a lot easier subject now for me.this presentation is a lot more helpful and understandable than the lectures. thanks again

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Slide 1 :

Coronary Artery Calcium: Does it Play a role in the age of CT Angiography Matthew Budoff, MD, FACC, FAHA Associate Professor of Medicine Director, Cardiac CT Harbor-UCLA Medical Center, Torrance, CA Name of company: GE - speakers bureau (SB)

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20% 80% Total Coronary Artery Plaque and EBCT Coronary Calcium 80% Plaque Detectable by IVUS, Pathology Lipid Rich Fibrotic Calcified 20% 80%

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Recommended Uses OF Coronary Artery Calcium Use a calcium score to screen patients with moderate (intermediate) Framingham risk Positive CAC scans indicate incremental risk Alters therapeutic goal (LDL, BP, etc) Identify patients who do not need further cardiac evaluation (scores of zero) Track Progression of Atherosclerosis non-invasively Improve Compliance (Adherence)

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Relative Risk DM Smoke HTN <10 10-100 101-400 401-1000 >1000 EBT Coronary Calcium Score All Cause Mortality [NDR] n = 10,377 asymptomatic men and women f/u = 5.0+3.5 yrs. Shaw, Raggi et al Radiology 2003 EBT found to be independent and incremental to risk factors All Cause Mortality in Patients Without Known CAD

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Prediction of Cardiac Events in Asymptomatic Patients by EBT The St. Francis Heart Study, JACC 2005 SFHS 3 Baseline EBT Calcium Score Annual Event Rate (%)

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Outcome Data – St Francis Randomized Trial A double-blind, placebo-controlled randomized clinical trial of atorvastatin 20 mg daily with anti-oxidants versus matching placebos in 1,005 asymptomatic men and women age 50 to 70 years with coronary calcium scores at or above the 80th percentile for age and gender. Mean duration of treatment was 4.3 years. Treatment reduced low-density lipoprotein cholesterol by 39.1% to 43.4% (p < 0.0001), while reducing clinical endpoints by 30% (6.9% vs. 9.9%). Event rates were more significantly reduced in participants with baseline calcium score >400 (8.7% vs. 15.0%, p=0.046 [42% reduction]). Arad Y et al. Treatment of Asymptomatic Adults with Elevated Coronary Calcium Scores with Atorvastatin, Vitamin C, and Vitamin E: The St. Francis Heart Study Randomized Clinical Trial. J Am Coll Cardiol 2005: 46: 166-172.

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All Cause Mortality and CAC Scores: Long Term Prognosis in 25, 253 patients Budoff, et al. JACC 2007; 49: 1860-70 10.4

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Time to Follow-up (Years) Cumulative Survival 0 Vessel (n=19,302) 1 Vessel (n=2,563) 2 Vessel (n=1,432) 3 Vessel (n=848) 3 Vessel + LM (n=195) ?2=182, p<0.0001 for the variable and for each category subset. 0.00 2.00 4.00 6.00 8.00 10.00 12.00 0.80 0.85 0.90 0.95 1.00 Budoff, et al. JACC 2007; 49: 1860-70 Cumulative Survival by the Coronary Calcium Extent in the Number of Vascular Territories

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0.0 2.0 4.0 6.0 8.0 10.0 12.0 0.70 0.75 0.80 0.85 0.90 0.95 1.00 Time to Follow-up (Years) Cumulative Survival 0 Vessel (n=24,340) 1 Vessel (n=596) 2 Vessel (n=143) 3 Vessel (n=28) Left Main (n=146) ?2=251, p<0.0001 Cumulative Survival in Patients with No Significant Calcium Score but with CAC Scores in the Range of 11-100 Budoff, et al. JACC 2007; 49: 1860-70

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0.00 2.00 4.00 6.00 8.00 10.00 12.00 Time to Follow-up (Years) 0.75 0.80 0.85 0.90 0.95 1.00 0.00 1.00 2.00 3.00 4.00 5.00 Time to Follow-up (Years) 0.75 0.80 0.85 0.90 0.95 1.00 Near- and Long-Term Survival from 2 Cohorts – over 35,000 patients n=10,377 n=25,257 99.4% 97.8% 95.2% 90.4% 81.8% 99.4% 97.8% 94.5% 93.0% 76.9% ?2=1503, p<0.0001, interaction p1,000 81.8% 76.9% 4.9% Budoff et al, JACC 2007 ?2=1503, p<0.0001, interaction p

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Cooper Clinic Study - 10,782 Patients: 3.5 year follow-up Adjusted age, history of diabetes, hypertension, elevated cholesterol, over weight Ref Nonfatal MI & CHD Death 2.7 (0.8-9.3) 6.0 (2.1-17) 9.7 (3.6-26) 21.1 (7.8-57)

Slide 12 :

Taylor et al – PACC Study – JACC 2005 2000 patients, mean age 43 Coronary calcium was associated with an 11.8-fold increased risk for incident coronary heart disease (CHD) (p 0.002) in a Cox model controlling for the Framingham risk score. In young, asymptomatic men, the presence of coronary artery calcification provides substantial, cost-effective, independent prognostic value in predicting incident CHD that is incremental to measured coronary risk factors.

Slide 13 :

Anand EHJ 2006 – 510 Diabetics

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CAC vs. Stress Echo – Ramakrishna JACC 2006 The occurrence of death/MI was significantly different in patients with a CACS 100 versus a CACS 100 but not in patients with normal exercise WMSI versus abnormal exercise WMSI (p 0.17).

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MESA Study – 6,814 Patients: 3.5 year follow-up Fully adjusted – Detrano et al– ACC Abstract - JACC March 07 Ref Nonfatal MI & CHD Death 4.47 (2.45,8.13) 10.26 (5.62,18.71) 14.13 (7.91,25.22)

Slide 16 :

Calcium Versus PROCAM/Framingham 10% 54% 36% 8% 58% 34% 2% 10% 88% Myocardial Infarction (%) Becker AHJ 2007

Slide 17 :

“measurement of coronary calcium is an option for advanced risk assessment. High coronary calcium scores (e.g., >75th percentile for age and sex) denotes advanced atherosclerosis and provides rationale for intensified LDL-lowering therapy.” NCEP ATP-III : Noninvasive Testing - 2001

Slide 18 :

European Guidelines European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (2003) which state that “Coronary calcium scanning is thus especially suited for patients at medium risk”, and use CAC to qualify conventional risk analysis. Updated in 2007 – not yet released

Slide 19 :

AHA – Circulation 2005 This recommendation to measure atherosclerosis burden, in clinically selected intermediate–CAD risk patients (eg, those with a 10% to 20% Framingham 10-year risk estimate) to refine clinical risk prediction and to select patients for altered targets for lipid-lowering therapies.

Slide 20 :

New Guidelines From AHA

Slide 21 :

AHA 2006 Cardiac CT improves risk prediction, especially in individuals determined to be at intermediate risk according to the NCEP ATP III criteria and for whom decisions concerning prevention strategies may be altered based on the test results.

Slide 22 :

Calcium is Very Sensitive for obstruction Zero Scores have a 95-99% negative predictive power Budoff et al (1851 patients) - 95% Haberl et al (1764 patients) - 99% Rumberger et al (213 patients) – 97% Knez et al (2111 patients) – 99% Negative predictive value declines to 84% in younger cohorts

Slide 23 :

ASNC/ACC Appropriateness 2006

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Naghavi et al. AJC 2006

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5 USES OF CAC Use a calcium score to screen patients with moderate (intermediate) Framingham risk Positive CAC scans indicate incremental risk Alters therapeutic goal (LDL, BP, etc) Identify patients who do not need further cardiac evaluation (scores of zero) Consider serial imaging as ongoing management tool (progression) Improve compliance Non-invasive Angiography

Slide 26 :

RAGGI - ATVB

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Attenuating Progression Attenuates RISK Raggi, Callister, Shaw ATVB 2004

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Slide 30 :

Odds ratio of maintaining statin therapy with various levels of baseline CAC (3.6 yr f/u) – Kalia et al. 2006 2.4 5.1 1.1 4.2 1.9 9.1 9.3 3.0 28.9

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Slide 32 :

Limit Top and bottom slices more accurately – reduce Radiation Use of Scout is not as accurate as CAC

Slide 33 :

CAC Prior to CTA Zero Scores have a 96-99% negative predictive power High Scores are non-diagnostic with CTA Heuschmid AJR 2005 Sens Specificity 59% 87% All patients 93% 94% CAC <1000 Limit Top and bottom slices more accurately – reduce Radiation Test run for breath hold and following instructions

Slide 34 :

? CALCIUM OR PLAQUE RUPTURE

Slide 35 :

CAC pre-CTA? Reduces radiation (limits start and endpoints) Zero score negative predictive power of 97% Helps with plaque rupture vs. calcium High scores are more likely to be non-diagnostic or less accurate Adds prognostic information to the scan Quantitates plaque burden better than CTA

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