Skip to main content
SpringerLink
Log in

Variation in atherosclerotic plaque composition according to increasing coronary artery calcium scores on computed tomography angiography

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Increasing coronary artery calcium scores (CACS) are independently associated with cardiac events. Recent advents in coronary computed tomography angiography (CCTA) have allowed us to better characterize individual plaque. Currently, it is unknown if higher CACS are likely to be associated with more calcified or mixed and heterogeneous plaque burden on CCTA. The study population consisted of 1,043 South Korean asymptomatic subjects (49 ± 10 years, 62% men) who underwent CCTA (64-slice MDCT). Plaques were classified on contrast-enhanced CCTA as non-calcified, mixed, and calcified on a per-segment basis according to the modified American Heart Association classification. The majority of the study participants had no coronary calcification (n = 866, 83%), whereas CACS> 0 was observed in 177 participants (17%). Only 40 (5%) participants in absence of CACS had exclusively non-calcified plaque, whereas 10 (1.2%) had significant coronary artery disease. With increasing CACS, study participants were more likely to have exclusively mixed or combination atherosclerotic plaques (P = 0.001). Among individuals with CACS 1–10, the prevalence of at least two coronary segments with mixed plaques was 4%, increasing up to 18 and 41% with CACS of 11–100 and >100. The respective prevalence of ≥2 coronary segments (calcified plaques) with increasing CACS were 6%, 16 and 26% (P = 0.01) and of non-calcified plaques were 6%, 6 and 11% (P = 0.71). In multivariable adjusted analyses, those with CACS >100 were 7.17 times (95% CI: 1.36–37.68) more likely to have ≥2 coronary segments with calcified plaque comparing with CACS 1–10. On the other hand the respective risk was higher for presence of ≥2 segments with mixed plaques (odds ratio: 15.81, 95% CI: 3.14–79.58). Absence of CAC is associated with a negligible presence of any atherosclerotic disease as detected by CCTA in asymptomatic population. A higher CACS is more likely to be associated with heterogeneous coronary plaque (combination of calcified, non-calcified, and mixed plaques), and appears to be more strongly associated with a higher burden of mixed plaque.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

CACS:

Coronary artery calcium scores

CTA:

Coronary CT angiography

References

  1. Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima JA, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE (2006) Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American heart association committee on cardiovascular imaging and intervention, council on cardiovascular radiology and intervention, and committee on cardiac imaging, council on clinical cardiology. Circulation 114:1761–1791

    Article  PubMed  Google Scholar 

  2. Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, Lauer MS, Post WS, Raggi P, Redberg RF, Rodgers GP, Shaw LJ, Taylor AJ, Weintraub WS (2007) ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the society of atherosclerosis imaging and prevention and the society of cardiovascular computed tomography. J Am Coll Cardiol 49:378–402

    Article  PubMed  Google Scholar 

  3. Sangiorgi G, Rumberger JA, Severson A, Edwards WD, Gregoire J, Fitzpatrick LA, Schwartz RS (1998) Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology. J Am Coll Cardiol 31:126–133

    Article  CAS  PubMed  Google Scholar 

  4. Rumberger JA, Simons DB, Fitzpatrick LA, Sheedy PF, Schwartz RS (1995) Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area. A histopathologic correlative study. Circulation 92:2157–2162

    CAS  PubMed  Google Scholar 

  5. Johnson RC, Leopold JA, Loscalzo J (2006) Vascular calcification: pathobiological mechanisms and clinical implications. Circ Res 99:1044–1059

    Article  CAS  PubMed  Google Scholar 

  6. Leber AW, Knez A, von Ziegler F, Becker A, Nikolaou K, Paul S, Wintersperger B, Reiser M, Becker CR, Steinbeck G, Boekstegers P (2005) Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol 46:147–154

    Article  PubMed  Google Scholar 

  7. Lin F, Shaw LJ, Berman DS, Callister TQ, Weinsaft JW, Wong FJ, Szulc M, Tandon V, Okin PM, Devereux RB, Min JK (2008) Multidetector computed tomography coronary artery plaque predictors of stress-induced myocardial ischemia by SPECT. Atherosclerosis 197:700–709

    Article  CAS  PubMed  Google Scholar 

  8. Pundziute G, Schuijf JD, Jukema JW, Boersma E, de Roos A, van der Wall EE, Bax JJ (2007) Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol 49:62–70

    Article  PubMed  Google Scholar 

  9. Pundziute G, Schuijf JD, Jukema JW, Decramer I, Sarno G, Vanhoenacker PK, Reiber JH, Schalij MJ, Wijns W, Baz JJ (2008) Head-to-head comparison of coronary plaque evaluation between multislice computed tomography and intravascular ultrasound radiofrequency data analysis. J Am Coll Cardiol Int 1:176–182

    Google Scholar 

  10. Haberl R, Becker A, Leber A, Knez A, Becker C, Lang C, Bruning R, Reiser M, Steinbeck G (2001) Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients. J Am Coll Cardiol 37:451–457

    Article  CAS  PubMed  Google Scholar 

  11. Budoff MJ, Diamond GA, Raggi P, Arad Y, Guerci AD, Callister TQ, Berman D (2002) Continuous probabilistic prediction of angiographically significant coronary artery disease using electron beam tomography. Circulation 105:1791–1796

    Article  PubMed  Google Scholar 

  12. Choi EK, Choi S, Rivera JJ, Nasir K, Chang SA, Chun EJ, Kim HK, Choi DJ, Blumenthal RS, Chang HJ (2008) Coronary CT angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol 52:357–365

    Article  PubMed  Google Scholar 

  13. Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Griffith LS, McGoon DC, Murphy ML, Roe BB (1975) A reporting system on patients evaluated for coronary artery disease, report of the Ad hoc committee for grading of coronary artery disease, council on cardiovascular surgery, American Heart Association. Circulation 51:5–40

    CAS  PubMed  Google Scholar 

  14. Leber AW, Becker A, Knez A, von Ziegler F, Sirol M, Nikolaou K, Ohnesorge B, Fayad ZA, Becker CR, Reiser M, Steinbeck G, Boekstegers P (2006) Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: a comparative study using intravascular ultrasound. J Am Coll Cardiol 47:672–677

    Article  PubMed  Google Scholar 

  15. Cheruvu PK, Finn AV, Gardner C, Caplan J, Goldstein J, Stone GW, Virmani R, Muller JE (2007) Frequency and distribution of thin-cap fibroatheroma and ruptured plaques in human coronary arteries: a pathologic study. J Am Coll Cardiol 50:940–949

    Article  PubMed  Google Scholar 

  16. Farb A, Burke AP, Tang AL, Liang TY, Mannan P, Smialek J, Virmani R (1996) Coronary plaque erosion without rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. Circulation 93:1354–1363

    CAS  PubMed  Google Scholar 

  17. Huang H, Virmani R, Younis H, Burke AP, Kamm RD, Lee RT (2001) The impact of calcification on the biomechanical stability of atherosclerotic plaques. Circulation 103:1051–1056

    CAS  PubMed  Google Scholar 

  18. Shanahan CM (2007) Inflammation ushers in calcification: a cycle of damage and protection? Circulation 116:2782–2785

    Article  PubMed  Google Scholar 

  19. Nadra I, Mason JC, Philippidis P, Florey O, Smythe CD, McCarthy GM, Landis RC, Haskard DO (2005) Proinflammatory activation of macrophages by basic calcium phosphate crystals via protein kinase C and MAP kinase pathways: a vicious cycle of inflammation and arterial calcification? Circ Res 96:1248–1256

    Article  CAS  PubMed  Google Scholar 

  20. Nakamura M, Nishikawa H, Mukai S, Setsuda M, Nakajima K, Tamada H, Suzuki H, Ohnishi T, Kakuta Y, Nakano T, Yeung AC (2001) Impact of coronary artery remodeling on clinical presentation of coronary artery disease: an intravascular ultrasound study. J Am Coll Cardiol 37:63–69

    Article  CAS  PubMed  Google Scholar 

  21. Beckman JA, Ganz J, Creager MA, Ganz P, Kinlay S (2001) Relationship of clinical presentation and calcification of culprit coronary artery stenoses. Arterioscler Thromb Vasc Biol 21:1618–1622

    Article  CAS  PubMed  Google Scholar 

  22. Weiss RM (2001) Another calcium paradox? Arterioscler Thromb Vasc Biol 21:1561–1562

    CAS  PubMed  Google Scholar 

  23. Gottlieb I, Lima JA (2008) Screening high-risk patients with computed tomography angiography. Circulation 117:1318–1332 Discussion 1332

    Article  PubMed  Google Scholar 

  24. Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR, Liu K, Shea S, Szklo M, Bluemke DA, O’Leary DH, Tracy R, Watson K, Wong ND, Kronmal RA (2008) Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 358:1336–1345

    Article  CAS  PubMed  Google Scholar 

  25. Abedin M, Tintut Y, Demer LL (2004) Vascular calcification: mechanisms and clinical ramifications. Arterioscler Thromb Vasc Biol 24:1161–1170

    Article  CAS  PubMed  Google Scholar 

  26. Ehara S, Kobayashi Y, Yoshiyama M, Shimada K, Shimada Y, Fukuda D, Nakamura Y, Yamashita H, Yamagishi H, Takeuchi K, Naruko T, Haze K, Becker AE, Yoshikawa J, Ueda M (2004) Spotty calcification typifies the culprit plaque in patients with acute myocardial infarction: an intravascular ultrasound study. Circulation 110:3424–3429

    Article  PubMed  Google Scholar 

  27. Schmid M, Pflederer T, Jang IK, Ropers D, Sei K, Daniel WG, Achenbach S (2008) Relationship between degree of remodeling and CT attenuation of plaque in coronary atherosclerotic lesions: an in vivo analysis by multi-detector computed tomography. Atherosclerosis 197:457–464

    Article  CAS  PubMed  Google Scholar 

  28. Pohle K, Achenbach S, Macneill B, Ropers D, Ferencik M, Moselewski F, Hoffmann U, Brady TJ, Jang IK, Daniel WG (2007) Characterization of non-calcified coronary atherosclerotic plaque by multi-detector row CT: comparison to IVUS. Atherosclerosis 190:174–180

    Article  CAS  PubMed  Google Scholar 

  29. Pflederer T, Schmid M, Ropers D, Ropers U, Komatsu S, Daniel WG, Achenbach S (2007) Interobserver variability of 64-slice computed tomography for the quantification of non-calcified coronary atherosclerotic plaque. Rofo 179:953–957

    CAS  PubMed  Google Scholar 

  30. Becker CR, Nikolaou K, Muders M, Babaryka G, Crispin A, Schoepf UJ, Loehrs U, Reiser MF (2003) Ex vivo coronary atherosclerotic plaque characterization with multi-detector-row CT. Eur Radiol 13:2094–2098

    Article  PubMed  Google Scholar 

  31. Marwan M, Ropers D, Pflederer T, Daniel WG, Achenbach S (2009) Clinical characteristics of patients with obstructive coronary lesions in the absence of coronary calcification: an evaluation by coronary CT angiography. Heart 95:1056–1060

    Article  CAS  PubMed  Google Scholar 

  32. Kitagawa T, Yamamoto H, Horiguchi J et al (2009) Characterization of noncalcified coronary plaques and identification of culprit lesions in patients with acute coronary syndrome by 64-slice computed tomography.JACC. Cardiovasc imaging 2(2):153–160

    Google Scholar 

  33. Feuchtner G, Postel T, Weidinger F et al (2008) Is there a relation between non-calcifying coronary plaques and acute coronary syndromes? A retrospective study using multislice computed tomography. Cardiology 110(4):241–248

    Article  PubMed  Google Scholar 

  34. Hoffmann U, Bamberg F, Chae CU (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain. The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol 53:1642–1650

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Johns Hopkins Ciccarone Preventive Cardiology Center, Baltimore, Maryland, USA

    Khurram Nasir, Juan J. Rivera & Roger S. Blumenthal

  2. Division of Cardiology, Seoul National University Bundang Hospital, Seongam-si, Republic of Korea

    Yeonyee E. Yoon, Sung-A Chang, Dong-Joo Choi & Hyuk-Jae Chang

  3. Radiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongam-si, Republic of Korea

    Sang-iI Choi & Eun-Ju Chun

  4. Division of Cardiology, Harbor-UCLA Medical Center Research and Education Institute, Torrance, CA, USA

    Matthew J. Budoff

Authors
  1. Khurram Nasir
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Juan J. Rivera
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yeonyee E. Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sung-A Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sang-iI Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Eun-Ju Chun
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dong-Joo Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Matthew J. Budoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Roger S. Blumenthal
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hyuk-Jae Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Khurram Nasir.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nasir, K., Rivera, J.J., Yoon, Y.E. et al. Variation in atherosclerotic plaque composition according to increasing coronary artery calcium scores on computed tomography angiography. Int J Cardiovasc Imaging 26, 923–932 (2010). https://doi.org/10.1007/s10554-010-9625-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-010-9625-0

Keywords

Search

Navigation