Can total cardiac calcium predict the coronary calcium score?

doi:10.1016/j.ijcard.2009.06.057

International Journal of Cardiology

Volume 146, Issue 2, 21 January 2011, Pages 202-206

https://doi.org/10.1016/j.ijcard.2009.06.057 Get rights and content

Abstract

Background

Mitral annular calcification (MAC) shares the same risk factors as atherosclerosis and is associated with coronary artery disease as well as cardiovascular events. However, sensitivity and positive predictive value are low. We hypothesized that a global echocardiographic calcium score would better predict coronary atherosclerotic burden, as assessed by coronary artery calcium score (CAC), than MAC alone.

Methods

An echocardiographic score was devised to measure global cardiac calcification in a semi-quantitative manner; this included calcification in the aortic valve and root, the mitral valve and annulus, and the sub-mitral apparatus. This score, and a simplified version, were compared with a similar calcification score by CT scan, as well as the CAC.

Results

There was a good correlation between the two global calcification scores; the echocardiographic score also correlated with CAC. Using CAC >400 as a measure of severe coronary atherosclerosis, an echocardiographic score ≥5 had a positive predictive value of 60%. Importantly, the simplified score performed equally well (≥3 had a positive predictive value of 62%).

Conclusions

Global cardiac calcification, assessed by CT scan or echocardiography, correlates with the extent of coronary calcium. A semi-quantitative calcium score can be easily applied during routine echocardiographic interpretation and can alert the reader to the possibility of severe coronary atherosclerosis.

Section snippets

Determination of CAC score by CT scan

Patients who had clinically indicated cardiac CT scans performed from December 2005 to March 2008 were identified. Most of these patients had equivocal stress tests and thus were at intermediate risk for coronary disease. Echocardiography databases were searched to identify those patients who also had an echocardiogram within 12 months of the CT scan. CT scans that were difficult to interpret due to extensive artifact (e.g. those with pacemaker leads, sternal wires, prosthetic valves, etc.) were

Statistical analyses

Continuous variables are presented as mean ± standard deviation and number and percentages for categorical variables. CAC score was not normally distributed (bimodal distribution), therefore we conducted our analyses using non-parametric tests. Furthermore, due to the non-linear relationship between the variables analyzed we used Spearman's correlation coefficient (rho) between coronary calcium scores measured by CT and echocardiography. To identify the best cutoff for the echocardiographic

Results

The mean age of the subjects was 56 ± 13 years. Sixty-one percent (25/41) were men. The mean CAC in the sample was 947 (±2586). The mean echocardiographic calcium score was 3.4 (± 2.5).

There was a positive correlation between age and the various CT measures (rho = 0.49/0.65/0.63 for non-coronary/coronary/total calcium). There was also a positive correlation between age and the echocardiographic scores (rho = 0.47/0.44 for total score/simplified score).

Discussion

Calcification of cardiac structures is common in the age groups typically treated by internists and cardiologists. MAC has been well studied and found to be associated with calcification of the aorta and the aortic valve [2], [14]. When severe, MAC also predicts chronic kidney disease [15] and it can occasionally cause mitral stenosis [16]. It shares many risk factors with atherosclerosis [4], [5]. Other types of extra-coronary cardiovascular calcification (e.g. aortic valve and aorta) also

Limitations

This was a retrospective study involving a small number of patients. All subjects were referred for cardiac CT on clinical grounds, a possible source of bias. Thus the findings cannot be considered definitive. The echocardiographic score should be tested in different populations and clinical situations. However, we were able to show the utility of the new echocardiographic score in assessing noncoronary cardiac calcification using CT scanning as a gold standard.

An echocardiographic calcium

Conclusions

A semi-quantitative calcium score was devised to assess overall (non-coronary) cardiac calcification. This score proved easy to apply to clinically indicated echocardiograms of varying technical quality. When compared with CT as a gold standard, the new score performed reasonably well. Importantly the echo score, when dichotomized at a value of 5 or greater, can serve as a marker of severe coronary disease. From a practical standpoint the simplified version (dichotomized at a value of 3 or

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [22].

References (22)

S. Kohsaka et al.
Impact of mitral annular calcification on cardiovascular events in a multiethnic community: the Northern Manhattan Study
J Am Coll Cardiol Img
(2008)
E. Barasch et al.
Clinical significance of calcification of the fibrous skeleton of the heart and aortosclerosis in community dwelling elderly. The Cardiovascular Health Study (CHS)
Am Heart J
(2006)
W.C. Roberts
The senile cardiac calcification syndrome
Am J Cardiol
(1986)
Y. Adler et al.
Mitral annulus calcification—a window to diffuse atherosclerosis of the vascular system
Atherosclerosis
(2001)
Y. Adler et al.
Usefulness of helical computed tomography in detection of mitral annular calcification as a marker of coronary artery disease
Int J Cardiol
(2005)
R. Detrano et al.
Prognostic value of coronary calcification and angiographic stenoses in patients undergoing coronary angiography
J Am Coll Cardiol
(1996)
Y. Arad 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)
M.J. Budoff et al.
Coronary calcium predicts events better with absolute calcium scores than age–sex–race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis)
J Am Coll Cardiol
(2009)
A.S. Agatston et al.
Quantification of coronary artery calcium using ultrafast computed tomography
J Am Coll Cardiol
(1990)
A. Jesri et al.
Severe mitral annular calcification predicts chronic kidney disease
Int J Cardiol
(2008)

S.M. Muddassir et al.

Mitral annular calcification as a cause of mitral valve gradients

Int J Cardiol

(2007)

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The direct correlation between Echocardiographic non-coronary calcium score (ECS) and lesion severity on invasive coronary angiography (ICA) is not reported. The aim of the present study was to find the correlation between ECS and Gensini score.
One hundred seventy patients aged ≥18 years posted for clinically indicated ICA were included. All the patients underwent standard transthoracic echocardiography. ECS and Gensisni scores were calculated. The primary outcome measure was to find a correlation of ECS with Gensini score, whereas the secondary outcome measure was to correlate ECS with traditional risk factors for coronary artery disease. The Chi-square/Fisher exact test was used to compare qualitative variables. Spearman’s correlation analysis was used for assessing the correlation between ECS score and the Gensini score. Receiver-operating characteristic curve analysis was performed to detect the cut-off value of the ECS score.
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The correlation of total ECS with Gensini score was positive and statistically significant.
Usefulness of the Echocardiographic Calcium Score to Refine Risk of Major Adverse Cardiovascular Events Beyond the Traditional Framingham Risk Score
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Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs <3) in the low-risk group (p = 0.03), while GCCS <3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at <7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.
Calcium detection, its quantification, and grayscale morphology-based risk stratification using machine learning in multimodality big data coronary and carotid scans: A review
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Atherosclerosis is the leading cause of cardiovascular disease (CVD) and stroke. Typically, atherosclerotic calcium is found during the mature stage of the atherosclerosis disease. It is therefore often a challenge to identify and quantify the calcium. This is due to the presence of multiple components of plaque buildup in the arterial walls. The American College of Cardiology/American Heart Association guidelines point to the importance of calcium in the coronary and carotid arteries and further recommend its quantification for the prevention of heart disease. It is therefore essential to stratify the CVD risk of the patient into low- and high-risk bins.
Calcium formation in the artery walls is multifocal in nature with sizes at the micrometer level. Thus, its detection requires high-resolution imaging. Clinical experience has shown that even though optical coherence tomography offers better resolution, intravascular ultrasound still remains an important imaging modality for coronary wall imaging. For a computer-based analysis system to be complete, it must be scientifically and clinically validated. This study presents a state-of-the-art review (condensation of 152 publications after examining 200 articles) covering the methods for calcium detection and its quantification for coronary and carotid arteries, the pros and cons of these methods, and the risk stratification strategies. The review also presents different kinds of statistical models and gold standard solutions for the evaluation of software systems useful for calcium detection and quantification. Finally, the review concludes with a possible vision for designing the next-generation system for better clinical outcomes.
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Thoracic aortic calcification (TAC) is associated with adverse cardiovascular outcomes, and for the cardiovascular imager, is predominantly encountered in 4 settings: 1) incidentally, for example, during a coronary artery calcium scan; 2) as part of dedicated screening; 3) in the evaluation of an embolic event; or 4) in procedural planning. This review focuses on TAC in these contexts. Within atherosclerosis, TAC is common, variable in extent, and begins in the intima with a patchy distribution. In metabolic disorders, aortitis, and radiation-associated cardiovascular disease, calcification preferentially involves the media and is often more concentric. As an incidental finding, atherosclerotic TAC provides limited incremental discriminative value, and current data do not support screening. After an embolic event, the demonstration of thoracic atheroma provides diagnostic clarity, but has limited treatment implications. Before any procedure, the plan often changes if the most severe form of TAC, a porcelain aorta, is discovered.
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Increasing evidence exists regarding calcium detected in aortic cusps and/or mitral annulus (AOC_MAC) at transthoracic echocardiogram as a predictor of cardiovascular (CV) events and mortality.
To verify whether AOC_MAC has a prognostic role in the setting of primary prevention independently of the presence of atrial fibrillation (AF).
All subjects consecutively referred from January 2011 to October 2014 to the Cardiovascular Centre for CV risk assessment in primary prevention were selected. AOC_MAC was assessed by transthoracic echocardiography. Primary study endpoint was a composite of CV hospitalizations/all-cause death.
The 1389 study patients were 70 years old, 43% males, 24% had diabetes mellitus, 75% arterial hypertension, 56% dyslipidaemia. Of all, 997 (72%) were in sinus rhythm (SR), 392 (28%) in AF. Patients with AF were older and more frequently males, with larger atria than SR subjects. During a median follow-up of 32 months, 165 patients (12%) were hospitalized for CV cause, 68 (5%) died. The primary endpoint occurred more frequently in patients with than without AOC_MAC (18% vs 11%, p < 0.001). AF patients showed higher event-rate compared with patients in SR (20% vs 10%, respectively; p < 0.01). AOC_MAC emerged as an independent prognosticator of primary endpoint in SR patients (HR 1.74 [1.07–2.82], p = 0.02), together with increasing age and left ventricular hypertrophy, while AOC_MAC had no prognostic relevance in AF patients.
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Can total cardiac calcium predict the coronary calcium score?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Determination of CAC score by CT scan

Statistical analyses

Results

Discussion

Limitations

Conclusions

Acknowledgement

J Am Coll Cardiol Img

Am Heart J

Am J Cardiol

Atherosclerosis

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

Int J Cardiol