Transcript Fever, Leukocytosis, and Dysuria in a 57 year old

Coronary Artery Calcium Scoring
James Rider, MD FACC
Cardiology Associates of Bellin Health
Epidemiology
• Coronary disease is the leading cause of death in the U.S
• 450,000 deaths yearly from coronary disease
• There are 1.2 million new heart attacks yearly in the U.S.
• Accounts for 36% of all deaths and exceeds death rates
from all cancers and accidental deaths combined
• Most people have no symptoms prior to a heart attack
Who is at Risk?
• Most people who suffer a heart attack do not fall
into a “high risk” category
• The traditional tools we have to identify who is
at risk depend on statistical analysis of large
pools of historical data.
Quiz
• Which of the following is the best predictor of a
future heart attack:
–
–
–
–
–
–
A) High blood pressure
B) Diabetes
C) Age
D) High coronary calcium score
E) Smoking
F) High cholesterol
Quiz
• Which of the following is the best predictor of a
future heart attack:
–
–
–
–
–
–
A) High blood pressure
B) Diabetes
C) Age
D) High coronary calcium score
E) Smoking
F) High cholesterol
Case Example
•
•
•
•
•
•
•
•
48 year old female executive
Avid distance runner
Total cholesterol 192
Good cholesterol 41
Bad cholesterol 124
Blood pressure 122/71
Smoked for 1 year while in college
Father died of heart attack at age 54
Case Example
• What is her risk of a heart attack?
• Should she be treated for her cholesterol?
Case Example
Case Example
Framingham Score
Goals in Primary Prevention of
Cardiovascular Disease
• Better identify those at risk for cardiovascular events by
directly detecting plaque build-up early
• Aggressive treatment of risk factors (cholesterol
medication, aspirin, BP control, exercise, diabetes
treatment, and quitting smoking)
• By intensifying treatment strategies in those at the
highest levels of risk this will improve efficacy, safety,
and cost-effectiveness of these treatments
Is There a Better Tool
for Identifying People Who are at Risk?
•
•
•
•
Routine exercise stress testing
C-reactive protein
Carotid Intimal Medial Thickness
Coronary Calcium Scoring
Coronary Calcium
• Coronary calcification is found when the arteries harden
from plaque build-up
• First identified in the 1950’s from plain x-rays
• Early generation CT scanners were able to detect calcium
but scanner speeds too slow for reliable measurement of
calcium in the beating heart
• Faster CT speeds improved in the 1980’s to allow
measurement of coronary calcium
Coronary Artery Calcium Scoring (CACS)
• Recent generation CT scanners can image the beating
heart in 6-10 seconds, latest generation in ¼ of a second
• No IV or dye needed
• Entire scanning process takes 5-10 minutes
• Protocol designed to minimize radiation exposure
• Typical radiation is equivalent to about 2 chest x-rays
(about 8-10 times less than a standard CT)
Coronary Artery Calcium Scoring (CACS)
Coronary Artery Calcium Scoring (CACS)
Coronary Artery Calcium Scoring (CACS)
•
•
•
•
•
Normal score = 0
Minimal disease = 1-10
Mild disease 11-100
Moderate disease 101-400
Severe disease >400
Criticism for Calcium Scoring
• Calcium scoring was criticized in the 1990’s for
poor correlation between the amount of calcium
and the presence of blockages
• This is a fundamental misunderstanding
• Coronary calcification = coronary disease
• Up to 75% of all heart attacks occur at the site of
non-critical blockages (50% blockage or less)
and are due to ruptured plaque and clot
formation
Positive Remodeling
Early
Late
How a Heart Attack Occurs
Prognostic Significance
Shaw et al. Radiology 2003
Case Example
• 48 year old executive with a Framingham score of 1%
chance of a heart attack in the next 10 years based on
statistical models
• Coronary calcium score 1206
• Based on calcium score her risk is estimated at 20-30%
over the next 10 years
• Now identified as a high risk individual and will be
treated as a coronary risk equivalent
Case Example
CACS in Green Bay
• Calcium score historically costs $350-400
• Now much more affordable
– Bellin Health $50
– Prevea Health $49.95
– Aurora BayCare $100
• Images of the chest are read by the radiologists
• Available through a self-referral process based
on criteria or through your primary care provider
Who Should Have the Test
• Recommended by American Heart Association for people at
intermediate risk (Framingham score 10-20%)
• Can be considered in people who are at low risk (score <10%)
but controversial
• Criteria for self-referral at Bellin:
– Male over age 30 with at least one risk factor
– Female over age 40 with at least one risk factor
• Controversial in patients at high risk (known diabetes or history
of blockages in the arteries of the neck or legs) – these patients
should be treated aggressively regardless of calcium score. Might
help some of these patients become more motivated to treat risk
factors aggressively
• Controversial in older patients over age 70
Who Should Not Have the Test
• History of angioplasty or coronary stents
• History of coronary bypass surgery
• Very low risk individual
– Young patients with no risk factors
• Patients who have already had a calcium score
What to Do With Test Results
• Review results with your primary care provider
• Remember the limitations of the test
– Does not detect plaque that has not yet hardened
• Review your risk factors with your provider and
with the calcium score results create an
individualized plan to treat your risk factors
Take Home Message
• Coronary calcium scoring is a powerful tool
for helping people identify if they are at risk
for a heart attack.
• Test is now widely available and affordable.
• This test may detect early plaque that does
not require treatment with stents or surgery
but does requires aggressive treatment of
risk factors.