Abstract
Coronary artery calcium is a marker of sub-clinical atherosclerosis and it is deposited via an active process similar to bone formation. Sequential non-contrast CT has been proposed as a method to accurately quantify and monitor progression of calcification. While interventions have generally failed to slow progression of calcification, it has become apparent that continued progression of CAC is associated with an increased risk of myocardial infarction and cardiac death. As a consequence, researchers have implemented sequential cardiac CT to follow the progression of coronary artery calcium in a variety of clinical settings and in some cases have reported encouraging results.
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References
Strong JP, Malcom GT, McMahan A, Tracy RE, Newman III WP, Herderick EE, Cornhill F. Prevalence and extent of atherosclerosis in adolescents and young adults. The Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA. 1999;281:727–35.
Bostrom K, Watson KE, Horn S, Wortham C, Herman IM, Demer LL. Bone morphogenic protein expression in human atherosclerotic lesions. J Clin Invest. 1993;91:1800–9.
Fitzpatrick LA, Severson A, Edwards WD, Ingram RT. Diffuse calcification in human coronary arteries: association of osteopontin with atherosclerosis. J Clin Invest. 1994;94:1597–604.
Shanahan CM, Cary NR, Metcalfe JC, Weissberg PL. High expression of genes for calcification-regulating proteins in human atherosclerotic plaques. J Clin Invest. 1994;93:2393–402.
Proudfoot D, Davies JD, Skepper JN, Weissberg PL, Shanahan CM. Acetylated low-density lipoprotein stimulates human vascular smooth muscle cell calcification by promoting osteoblastic differentiation and inhibiting phagocytosis. Circulation. 2002;106:3044–50.
Collett GD, Canfield AE. Angiogenesis and pericytes in the initiation of ectopic calcification. Circ Res. 2005;96:930–8.
Subbotin V. Neovascularization of coronary tunica intima (DIT) is the cause of coronary atherosclerosis. Lipoproteins invade coronary intima via neovascularization from adventitial vasa vasorum, but not from the arterial lumen: a hypothesis. Theor Biol Med Model. 2012;9:11.
Bini A, Mann KG, Kudryk BJ, Schen FJ. Noncollagenous bone matrix proteins, calcification and thrombosis in carotid artery atherosclerosis. Arterioscler Thromb Vasc Biol. 1999;19:1852–61.
Kronmal RA, McClelland RL, Detrano R, Shea S, Lima JA, Cushman M, Bild DE, Burke GL. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2007;115(21):2722–30.
Erbel R, Lehmann N, Churzidse S, Rauwolf M, Mahabadi AA, Möhlenkamp S, Moebus S, Bauer M, Kälsch H, Budde T, Montag M, Schmermund A, Stang A, Führer-Sakel D, Weimar C, Roggenbuck U, Dragano N, Jöckel KH; on behalf of the Heinz Nixdorf Recall Study Investigators. Progression of coronary artery calcification seems to be inevitable, but predictable – results of the Heinz Nixdorf Recall (HNR) study. Eur Heart J. 2014;pii:ehu288. [Epub ahead of print].
Pandey AK, Blaha MJ, Sharma K, Rivera J, Budoff MJ, Blankstein R, AlMallah M, Wong ND, Shaw L, Carr J, O'Leary D, Lima JA, Szklo M, Blumenthal RS, Nasir K. Family history of coronary heart disease and the incidence and progression of coronary artery calcification: Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2014;232:369–76.
Wong ND, Nelson JC, Granston T, Bertoni AG, Blumenthal RS, Carr JJ, Guerci A, Jacobs Jr DR, Kronmal R, Liu K, Saad M, Selvin E, Tracy R, Detrano R. Metabolic syndrome, diabetes, and incidence and progression of coronary calcium: the Multiethnic Study of Atherosclerosis study. JACC Cardiovasc Imaging. 2012;5:358–66.
Lehmann N, Möhlenkamp S, Mahabadi AA, Schmermund A, Roggenbuck U, Seibel R, Grönemeyer D, Budde T, Dragano N, Stang A, Mann K, Moebus S, Erbel R, Jöckel KH. Effect of smoking and other traditional risk factors on the onset of coronary artery calcification: results of the Heinz Nixdorf recall study. Atherosclerosis. 2014;232:339–45.
Stary HC. Natural history of calcium deposits in atherosclerosis progression and regression. Z Kardiol. 2000;89 Suppl 2:28–35.
Williams JK, Sukhova GK, Herrington DM, Libby P. Pravastatin has cholesterol-lowering independent effects on the artery wall of atherosclerotic monkeys. J Am Coll Cardiol. 1998;31:684–91.
Stary HC. The development of calcium deposits in atherosclerotic lesions and their persistence after lipid regression. Am J Cardiol. 2001;88(2A):16E–9.
Daoud AS, Jarmolych J, Augustyn JM, Fritz KE. Sequential morphologic studies of regression of advanced atherosclerosis. Arch Pathol. 1981;105:233–9.
Clarkson TB, Bond MG, Bullock BC, Marzetta CA. A study of atherosclerosis regression in Macaca mulatta. IV. Changes in coronary arteries from animals with atherosclerosis induced for 19 months and then regressed for 24 months or 48 months at plasma cholesterol concentrations of 300 or 200 mg/dl. Exp Mol Pathol. 1981;34:345–68.
Agatston AS, Janowitz WR, Hildner JR, Zusmer NR, Viamonte Jr M, Detrano R. Quantification of CAC using ultrafast computed tomography scanning. J Am Coll Cardiol. 1990;15:827–32.
Sangiorgi G, Rumberger JA, Severson A, Edwards WD, Gregoire J, Fitzpatrick LA, Schwartz RS. Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segements using non-decalcifying methodology. Electron beam computed tomography and coronary artery disease: scanning for coronary artery calcification. J Am Coll Cardiol. 1998;31:126–33.
Callister TQ, Cooil B, Raya S, Lippolis NJ, Russo DJ, Raggi P. Coronary artery disease: improved reproducibility of calcium scoring with electron-beam CT volumetric method. Radiology. 1998;208:807–14.
Rumberger JA, Kaufman L. A rosetta stone for CAC risk stratification: agatston, volume, and mass scores in 11,490 individuals. AJR Am J Roentgenol. 2003;181:743–8.
McCollough CH, Ulzheimer S, Halliburton SS, Shanneik K, White RD, Kalender WA. CAC: a multi-institutional, multimanufacturer international standard for quantification at cardiac CT. Radiology. 2007;243:527–38.
Hokanson JE, MacKenzie T, Kinney G, Snell-Bergeon JK, Dabelea D, Ehrlich J, Eckel RH, Rewers M. Evaluating changes in coronary artery calcium: an analytic method that accounts for interscan variability. AJR Am J Roentgenol. 2004;182:1327–32.
Jukema JW, Bruschke AV, van Boven AJ, Reiber JH, Bal ET, Zwinderman AH, Jansen H, Boerma GJ, van Rappard FM, Lie KI. Effects of lipid lowering by pravastatin on progression and regression of coronary artery disease in symptomatic men with normal to moderately elevated serum cholesterol levels. The Regression Growth Evaluation Statin Study (REGRESS). Circulation. 1995;91:2528–40.
Brown G, Albers JJ, Fisher LD, Schaefer SM, Lin JT, Kaplan C, Zhao XQ, Bisson BD, Fitzpatrick VF, Dodge HT. Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med. 1990;323:1289–98.
Levine GN, Keaney Jr JF, Vita JA. Cholesterol reduction in cardiovascular disease: clinical benefits and possible mechanisms. N Engl J Med. 1995;332:512–21.
Callister TQ, Raggi P, Cooil B. Effects of HMG-CoA reductase inhibitors on coronary artery disease. N Engl J Med. 1998;339:1972–7.
Budoff MJ, Lane KL, Bakhsheshi H, Mao S, Grassmann BO, Friedman BC, Brundage BH. Rates of progression of CAC by electron beam tomography. Am J Cardiol. 2000;86:8–11.
Achenbach S, Dieter R, Pohle K, Leber A, Thilo C, Knez A, Menendez T, Maeffert R, Kusus M, Regenfus M, Bickel A, Haberl R, Stienbeck G, Moshage W, Daniel WG. Influence of lipid-lowering therapy on the progression of coronary artery calcification. Circulation. 2002;106:1077–82.
Hoffmann U, Derfler K, Haas M, Stadler A, Brady TJ, Kostner K. Effects of combined low density lipoprotein apheresis and aggressive statin therapy on coronary calcified plaque as measured by computed tomography. Am J Cardiol. 2003;91:461–4.
Taylor AJ, Kent SM, Flaherty PJ, Coyle LC, Markwood TT, Vernalis MN. ARBITER: Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol: a randomized trial comparing the effects of atorvastatin and pravastatin on carotid intima medial thickness. Circulation. 2002;106:2055–60.
Hsia J, Klouj A, Prasad A, Burt J, Adams-Campbell LL, Howard BV. Progression of coronary calcification in healthy postmenopausal women. BMC Cardiovasc Disord. 2004;4:21.
Hecht HS, Harman SM. Comparison of the effects of atorvastatin versus simvastatin on subclinical atherosclerosis in primary prevention as determined by electron beam tomography. Am J Cardiol. 2003;91:42–5.
Hecht HS, Harman SM. Relation of aggressiveness of lipid-lowering treatment to changes in calcified plaque burden by electron beam tomography. Am J Cardiol. 2003;92:334–6.
Wong ND, Kawakubo M, LaBree L, Azen SP, Xiang M, Detrano R. Relation of CAC progression and control of lipids according to the National Cholesterol Education Program guidelines. Am J Cardiol. 2004;94:431–6.
Raggi P, Davidson M, Callister TQ, Welty FK, Bachmann GA, Hecht H, Rumberger JA. Aggressive versus moderate lipid-lowering therapy in hypercholesterolemic post-menopausal women: Beyond Endorsed Lipid Lowering with EBT Scanning (BELLES). Circulation. 2005;112(4):563–71. (In press).
Arad Y, Spadaro LA, Roth M, Newstein D, Guerci A. Treatment of asymptomatic adults with elevated calcium scores with atorvastatin, vitamin C and vitamin E. The St. Francis Heart Study randomized clinical trial. J Am Coll Cardiol. 2005;46:166–72.
Schmermund A, Achenbach S, Budde T, Buziashvili Y, Förster A, Friedrich G, et al. Effect of intensive versus standard lipid-lowering treatment with atorvastatin on the progression of calcified coronary atherosclerosis over 12 months: a multicenter, randomized, double-blind trial. Circulation. 2006;113:427–37.
Houslay ES, Cowell SJ, Prescott RJ, Reid J, Burton J, Northridge DB, Boon NA, Newby DE, Scottish Aortic Stenosis and Lipid Lowering Therapy, Impact on Regression trial Investigators. Progressive coronary calcification despite intensive lipid-lowering treatment: a randomised controlled trial. Heart. 2006;92:1207–12.
Snell-Bergeon JK, Hokanson JE, Jensen L, MacKenzie T, Kinney G, Dabelea D, Eckel RH, Ehrlich J, Garg S, Rewers M. Progression of coronary artery calcification in type 1 diabetes: the importance of glycemic control. Diabetes Care. 2003;26:2923–8.
Anand DV, Lim E, Darko D, Bassett P, Hopkins D, Lipkin D, Corder R, Lahiri A. Determinants of progression of coronary artery calcification in type 2 diabetes role of glycemic control and inflammatory/vascular calcification markers. J Am Coll Cardiol. 2007;50(23):2218–25.
Manson JE, Allison MA, Rossouw JE, Carr JJ, Langer RD, Hsia J, et al. Estrogen therapy and coronary-artery calcification. N Engl J Med. 2007;356:2591–602.
Budoff MJ, Chen GP, Hunter CJ, Takasu J, Agrawal N, Sorochinsky B, Mao S. Effects of hormone replacement on progression of coronary calcium as measured by electron beam tomography. J Womens Health (Larchmt). 2005;14:410–7.
Rath M, Niedzwiecki A. Nutritional supplement program halts progression of early coronary atherosclerosis documented by ultrafast computed tomography. J Appl Nutr. 1996;48:67–78.
Budoff MJ, Takasu J, Flores FR, Niihara Y, Lu B, Lau BH, Rosen RT, Amagase H. Inhibiting progression of coronary calcification using Aged Garlic Extract in patients receiving statin therapy: a preliminary study. Prev Med. 2004;39:985–91.
Kuro-O M. A phosphate-centric paradigm for pathophysiology and therapy of chronic kidney disease. Kidney Int Suppl (2011). 2013;3:420–6.
Maniscalco BS, Taylor KA. Calcification in coronary artery disease can be reversed by EDTA-tetracycline long-term chemotherapy. Pathophysiology. 2004;11:95–101.
Renal Data System US. USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2004.
Longenecker JC, Coresh J, Powe NR, Levey AS, Fink NE, Martin A, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study. J Am Soc Nephrol. 2002;13:1918–27.
Guérin AP, London GM, Marchais SJ, Metivier F. Arterial stiffening and vascular calcifications in end-stage renal disease. Nephrol Dial Transplant. 2000;15:1014–21.
Blacher J, Guerin AP, Pannier B, Marchais SJ, London GM. Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease. Hypertension. 2001;38:938–42.
Raggi P, Boulay A, Chasan-Taber S, Amin N, Dillon M, Burke SK, et al. Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease? J Am Coll Cardiol. 2002;39:695–701.
London GM, Guérin AP, Marchais SJ, Métivier F, Pannier B, Adda H. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant. 2003;18:1731–40.
London GM. Cardiovascular calcifications in uremic patients: clinical impact on cardiovascular function. J Am Soc Nephrol. 2003;14:S305–9.
Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 2004;15:2208–18.
Goodman WG, Goldin J, Kuizon BD, Yoon C, Gales B, Sider D, et al. Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. N Engl J Med. 2000;342:1478–83.
Chertow GM, Burke SK, Raggi P. Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients. Kidney Int. 2002;62:245–52.
Raggi P, James G, Burke S, Bommer J, Taber SC, Holzer H, Braun J, Chertow GM. Paradoxical decrease in vertebral bone density with calcium-based phosphate binders in hemodialysis. J Bone Miner Res. 2005;20:764–72.
Barengolts EI, Berman M, Kukreja SC, Kouznetsova T, Lin C, Chomka EV. Osteoporosis and coronary atherosclerosis in asymptomatic postmenopausal women. Calcif Tissue Int. 1998;62:209–13.
Sirola J, Sirola J, Honkanen R, Kroger H, Jurvelin JS, Maenpaa P, Saarikoski S. Relation of statin use and bone loss: a prospective population-based cohort study in early postmenopausal women. Osteoporos Int. 2002;13:537–41.
Block GA, Spiegel DM, Ehrlich J, Mehta R, Lindbergh J, Dreisbach A, et al. Effects of sevelamer and calcium on coronary artery calcification in patients new to hemodialysis. Kidney Int. 2005;68(4):1815–24.
Block GA, Raggi P, Bellasi A, Kooienga L, Spiegel DM. Mortality effect of coronary calcification and phosphate binder choice in incident hemodialysis patients. Kidney Int. 2007;7:438–41.
Qunibi W, Moustafa M, Muenz LR, He DY, Kessler PD, Diaz-Buxo JA, et al. A 1-year randomized trial of calcium acetate versus sevelamer on progression of coronary artery calcification in hemodialysis patients with comparable lipid control: the Calcium Acetate Renagel Evaluation-2 (CARE-2) study. Am J Kidney Dis. 2008;5:952–65.
Raggi P, Chertow GM, Torres PU, Csiky B, Naso A, Nossuli K, Moustafa M, Goodman WG, Lopez N, Downey G, Dehmel B, Floege J, on behalf of the ADVANCE Study Group. The ADVANCE Study: a randomized study to evaluate the effects of cinacalcet plus low dose vitamin D on vascular calcification in patients on hemodialysis. Nephrol Dial Transplant. 2011;26(4):1327–39.
Ureña-Torres PA, Floege J, Hawley CM, Pedagogos E, Goodman WG, Pétavy F, Reiner M, Raggi P. Protocol adherence and the progression of cardiovascular calcification in the ADVANCE study. Nephrol Dial Transplant. 2013;28:146–52.
Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with human immunodeficiency virus disease. J Clin Endocrinol Metab. 2007;92:2506–12.
Freiberg MS, Chang CC, Kuller LH, Skanderson M, Lowy E, Kraemer KL, Butt AA, Bidwell Goetz M, Leaf D, Oursler KA, Rimland D, Rodriguez Barradas M, Brown S, Gibert C, McGinnis K, Crothers K, Sico J, Crane H, Warner A, Gottlieb S, Gottdiener J, Tracy RP, Budoff M, Watson C, Armah KA, Doebler D, Bryant K, Justice AC. HIV infection and the risk of acute myocardial infarction. JAMA Int Med. 2013;173(8):614–22.
Post WS, Budoff M, Kingsley L, Palella Jr FJ, Witt MD, Li X, George RT, Brown TT, Jacobson LP. Associations between HIV infection and subclinical coronary atherosclerosis. Ann Intern Med. 2014;160:458–67.
Mangili A, Gerrior J, Tang AM, O’Leary DH, Polak JK, Schaefer EJ, Gorbach SL, Wanke CA. Risk of cardiovascular disease in a cohort of HIV-infected adults: a study using carotid intima-media thickness and coronary artery calcium score. Clin Infect Dis. 2006;43:1482–9.
Kingsley LA, Cuervo-Rojas J, Munoz A, Palella FJ, Post W, Witt MD, et al. Subclinical coronary atherosclerosis, HIV infection and antiretroviral therapy: multicenter AIDS Cohort Study. Aids. 2008;22:1589–99.
Guaraldi G, Zona S, Orlando G, Carli F, Ligabue G, Fiocchi F, Menozzi M, Rossi R, Modena MG, Raggi P. Human immunodeficiency virus infection is associated with accelerated atherosclerosis. J Antimicrob Chemother. 2011;66(8):1857–60.
Zona S, Raggi P, Bagni P, Orlando G, Carli F, Ligabue G, Scaglioni R, Rossi R, Guaraldi MG. Parallel increase of subclinical atherosclerosis and epicardial adipose tissue in patients with HIV. Am Heart J. 2012;163:1024–30.
Baker JV, Hullsiek KH, Singh A, Wilson E, Henry K, Lichtenstein K, Onen N, Kojic E, Patel P, Brooks JT, Hodis HN, Budoff M, Sereti I, CDC SUN Study Investigators. Immunologic predictors of coronary artery calcium progression in a contemporary HIV cohort. AIDS. 2014;28(6):831–40.
Alexopoulos N, Katritsis D, Raggi P. Visceral adipose tissue as a source of inflammation and promoter of atherosclerosis. Atherosclerosis. 2014;233:104–12.
Nakanishi R, Rajani R, Cheng VY, Gransar H, Nakazato R, Shmilovich H, Otaki Y, Hayes SW, Thomson LE, Friedman JD, Slomka PJ, Berman DS, Dey D. Increase in epicardial fat volume is associated with greater coronary artery calcification progression in subjects at intermediate risk by coronary calcium score: a serial study using non-contrast cardiac CT. Atherosclerosis. 2011;218:363–8.
Yerramasu A, Dey D, Venuraju S, Anand DV, Atwal S, Corder R, Berman DS, Lahiri A. Increased volume of epicardial fat is an independent risk factor for accelerated progression of sub-clinical coronary atherosclerosis. Atherosclerosis. 2012;220:223–30.
Mahabadi AA, Lehmann N, Kälsch H, Robens Y, Bauer M, Dykun I, Budde T, Moebus S, Jöckel KH, Erbel R, Möhlenkamp S. Association of epicardial adipose tissue with progression of coronary artery calcification is more pronounced in the early phase of atherosclerosis – results from the Heinz Nixdorf Recall study. JACC Cardiovasc Imaging. 2014;7(9):909–16.
Raggi P, Cooil B, Shaw LJ, Aboulhson J, Takasu J, Budoff MJ, Callister TQ. Progression of coronary calcification on serial electron beam tomography scanning is greater in patients with future myocardial infarction. Am J Cardiol. 2003;92:827–9.
Raggi P, Callister T, Budoff M, Shaw L. Progression of CAC and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy. Arterioscler Thromb Vasc Biol. 2004;24:1272–7.
Budoff MJ, Young R, Lopez VA, Kronmal RA, Nasir K, Blumenthal RS, Detrano RC, Bild DE, Guerci AD, Liu K, Shea S, Szklo M, Post W, Lima J, Bertoni A, Wong ND. Progression of coronary calcium and incident coronary heart disease events: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2013;61:1231–9.
Budoff MJ, Hokanson JE, Nasir K, Shaw LJ, Kinney GL, Chow D, Demoss D, Nuguri V, Nabavi V, Ratakonda R, Berman DS, Raggi P. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging. 2010;3:1229–36.
Raggi P, Cooil B, Ratti C, Callister TQ, Budoff M. Progression of coronary calcification and occurrence of myocardial infarction in patients with and without diabetes mellitus. Hypertension. 2005;45:1–6.
Kiramijyan S, Ahmadi N, Isma’eel H, Flores F, Shaw LJ, Raggi P, Budoff MJ. Impact of coronary artery calcium progression and statin therapy on clinical outcome in subjects with and without diabetes mellitus. Am J Cardiol. 2013;111:356–61.
Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary risk factors, and atherosclerotic cardiovascular disease events. The St. Francis Heart Study. J Am Coll Cardiol. 2005;46:158–65.
Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Mohlenkamp S, McCollough CH, et al. CAC screening: current status and recommendations from the European Society of Cardiac Radiology and North American Society for Cardiovascular Imaging. Int J Cardiovasc Imaging. 2008;24(6):645–71.
Zeb I, Li D, Nasir K, Malpeso J, Batool A, Flores F, Dailing C, Karlsberg RP, Budoff M. Effect of statin treatment on coronary plaque progression – a serial coronary CT angiography study. Atherosclerosis. 2013;23:198–204.
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Raggi, P. (2016). Natural History and Impact of Interventions on CAC. In: Budoff, M., Shinbane, J. (eds) Cardiac CT Imaging. Springer, Cham. https://doi.org/10.1007/978-3-319-28219-0_6
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