Transcript Electron Beam Computed Tomography

Coronary Calcium Scoring for Risk
Stratification and Guidelines
Matthew Budoff, MD, FACC, FAHA
Professor of Medicine
Director, Cardiac CT
Harbor-UCLA Medical Center, Torrance, CA
Name of company: GE - grant
NEW GUIDELINES
Recommendations for Calcium Scoring
Methods
I IIa IIb III
I IIa IIb III
I IIa IIb III
Measurement of CAC is reasonable for cardiovascular
risk assessment in asymptomatic adults at
intermediate risk (10% to 20% 10-year risk.
Measurement of CAC may be reasonable for
cardiovascular risk assessment persons at low to
intermediate risk (6% to 10% 10-year risk).
In asymptomatic adults with diabetes, 40 years of age
and older, measurement of CAC is reasonable for
cardiovascular risk assessment.

Computed tomography for coronary calcium
should be considered for cardiovascular
risk assessment in asymptomatic adults at
moderate risk. IIa
Yeboah JAMA 2012 - MESA
CAC and CTA
Hou JACC 2012
BIOMARKERS Wang NEJM 2006
10 biomarkers in 3209 participants attending a routine examination of the Framingham Heart Study: the levels of
C-reactive protein, B-type natriuretic peptide, N-terminal pro–atrial natriuretic peptide, aldosterone, renin,
fibrinogen, D-dimer, plasminogen-activator inhibitor type 1, and homocysteine; and the urinary albumin-tocreatinine ratio.
NEJM CRP/Fibrinogen Oct 2012

Net Reclassification
with CRP 1.5%
BLAHA Lancet 2011
MESA – BLAHA Lancet 2011
Shemesh - Ungated Studies
8782 patients, 6 year f/u
Reclassification of ATP III Risk
Categories Using CAC
CAC Score
51.5%
28.8%
19.7%
14.1 %
high risk
23.1 %
Intermediate
62.9 %
risk
0
low risk
10
20
% 10-year risk
ATPIII Score Risk Assessment
Scheme according to Wilson PWF et al
JACC 41:1889 – 1906, 2003 with HNR data
Rotterdam Heart – JACC 2010
Addition of CRP did not improve C Statistic or Reclassification
Rotterdam – Annals 2012
CAC and CHF – Rotterdam JACC
2012
1897 Patients
 6.8 year follow up
 CAC scores were
associated with heart
failure (p 0.001), with
a hazard ratio of 4.1
 Net reclassification
index 34.0%).

EISNER Randomized Controlled Trial
2137 middle-aged + risk factors without CVD
45-79y without CAD/CVD followed 4 years
No Scan
Scan
• Clinical evaluation
• Clinical evaluation
• Questionnaire
• Questionnaire
• Risk factor consultation
• Risk factor consultation
• CAC scan
• Scan consultation
Rozanski. Berman. Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research. JACC 2011;57:1622.
Does CAC scanning improve
outcomes?
• Favorable change
in RF, Rx with increasing CAC
• CACS may effectively triage care – evaluation,
intensification of therapy – without increasing cost
Parameters
CACS = 0
CACS>400
P
Change in LDL-12 mg/dL
-29 mg/dL
<0.001
C
Change in SBP
-4 mm Hg
-9 mm Hg
<0.001
Exercise
32%
47%
0.03
New Lipid Rx
19%
65%
<0.001
New BP Rx
20%
46%
<0.001
New ASA Rx
5%
21%
<0.001
Lipid Adherence
80%
88%
0.04
Rozanski. Berman. EISNER. JACC 2011;57:1622. CACS 0 = 631. CACS>400 = 109.
EISNER Study – Costs Compared to
No Scan Group
P<0.005 for both measures
Rozanski JACC 2011
NICE GUIDELINES
NICE GUIDELINES
NICE ALGORITHM
“Imaging has at least 3 virtues”
It individualizes risk assessment beyond use of
age, which is a less reliable surrogate for
atherosclerosis burden
It provides an integrated assessment of the
lifetime exposure to risk factors
It identifies individuals who are susceptible to developing
atherosclerosis beyond
established risk factors
Grundy. Circulation 2008;117:569-573
“Imaging has at least 3 virtues”
Once subclinical atherosclerosis is
detected, intensity of drug therapy
could be adjusted for plaque burden
Grundy. Circulation 2008;117:569-573