Endocrinol Metab.  2017 Mar;32(1):47-57. 10.3803/EnM.2017.32.1.47.

The Implication of Coronary Artery Calcium Testing for Cardiovascular Disease Prevention and Diabetes

• Blankstein R
• Gupta A
• Rana JS
• Nasir K

• KMID: 2413286
• DOI: http://doi.org/10.3803/EnM.2017.32.1.47

Abstract

Over the last two decades coronary artery calcium (CAC) scanning has emerged as a quick, safe, and inexpensive method to detect the presence of coronary atherosclerosis. Data from multiple studies has shown that compared to individuals who do not have any coronary calcifications, those with severe calcifications (i.e., CAC score >300) have a 10-fold increase in their risk of coronary heart disease events and cardiovascular disease. Conversely, those that have a CAC of 0 have a very low event rate (~0.1%/year), with data that now extends to 15 years in some studies. Thus, the most notable implication of identifying CAC in individuals who do not have known cardiovascular disease is that it allows targeting of more aggressive therapies to those who have the highest risk of having future events. Such identification of risk is especially important for individuals who are not on any therapies for coronary heart disease, or when intensification of treatment is being considered but has an uncertain role. This review will highlight some of the recent data on CAC testing, while focusing on the implications of those findings on patient management. The evolving role of CAC in patients with diabetes will also be highlighted.

Keyword

Atherosclerosis; Coronary artery disease; Diabetes; Prevention and control

MeSH Terms

Atherosclerosis
Calcium*
Cardiovascular Diseases*
Coronary Artery Disease
Coronary Disease
Coronary Vessels*
Humans
Methods
Calcium

Figure

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  Fig. 1 Conceptual frameworks of how the presence or absence of coronary artery calcium (CAC) may influence patient management.

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  Fig. 2 Unadjusted Kaplan-Meier cumulative-event curves for coronary events among participants with coronary artery calcium scores of 0, 1 to 100, 101 to 300, and more than 300. The figure shows the rates for any coronary event. The differences among all curves are statistically significant (P<0.001). Adapted from Detrano et al. [1], with permission from Massachusetts Medical Society.

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  Fig. 3 Relationship between pretest and posttest cardiovascular disease (CVD) risk after the knowledge of the negative result of each risk marker. The regression lines display the relationship between the pretest predicted 10-year atherosclerotic CVD risk (x axis) and the posttest risk (y axis) after the knowledge of the negative result of each risk marker. A broken back line is displayed as reference (risk shift with no additional testing). Results were obtained by plotting the pretest and posttest risk on the basis of the diagnostic likelihood ratio of each Multi-Ethnic Study of Atherosclerosis (MESA) participant and then applying a linear fit. Adapted from Blaha et al. [10], with permission from Wolters Kluwer Health, Inc. CAC, coronary artery calcium; BNP, brain natriuretic peptide; CIMT, carotid intima-media thickness; CHD, coronary heart disease; ABI, ankle brachial index; hs-CRP, high-sensitivity C-reactive protein.

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  Fig. 4 Cumulative incidence of coronary heart disease events among Multi-Ethnic Study of Atherosclerosis (MESA) participants with low low-density lipoprotein cholesterol (<130 mg/dL) stratified by the presence or absence of diabetes, hypertension as well as the presence or absence of coronary artery calcium (CAC). (A) No diabetes, (B) diabetes, (C) no hypertension, and (D) hypertension. Adapted from Blankstein et al. [3].

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  Fig. 5 (A) Coronary artery calcium (CAC) distribution across statin eligibility groups according to the American College of Cardiology/American Heart Association (ACC/AHA) cholesterol management guidelines. (B) Impact of the absence of CAC in reclassifying risk below the threshold for statin consideration suggested by ACC/AHA cholesterol management guidelines across the spectrum of estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk score (nondiabetic patients with low-density lipoprotein cholesterol of 70 to 189 mg/dL). Adapted from Nasir et al. [13].

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  Fig. 6 (A, B) Coronary and cardiovascular event rate for subjects with and without statin indication according to European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology (AHA/ACC) guidelines, stratified by coronary artery calcification (CAC) group, showing a distinct increase in event rates for both coronary and cardiovascular events with increasing CAC score, irrespective of statin indication according to ESC and AHA/ACC guidelines. Adapted from Mahabadi et al. [14], with permission from Elsevier.

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  Fig. 7 Estimated risk/benefit of aspirin in primary prevention by coronary artery calcium (CAC) score in Multi-Ethnic Study of Atherosclerosis (MESA) participants. Coronary heart disease (CHD) risk was calculated using the Framingham Risk Score. The red line represents the estimated 5-year number needed to harm based on a 0.23% increase in major bleeding over 5 years. The 5-year number needed to treat estimations is based on an 18% relative reduction in coronary heart disease events. Adapted from Miedema et al. [16], with permission from Wolters Kluwer Health, Inc.

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  Fig. 8 Annualized unadjusted cardiovascular disease (CVD) event rates in Multi-Ethnic Study of Atherosclerosis (MESA) stratified by coronary artery calcification (CAC) and the presence of diabetes mellitus (DM), metabolic syndrome (MetS), or neither. Adapted from Malik et al. [45], with permission from American Diabetes Association.

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