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Coronary Artery Calcium Scoring in Current Clinical Practice: How to Define Its Value?

  • Prevention (P Natarajan, Section Editor)
  • Published:
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Opinion statement

Detecting subclinical atherosclerosis with coronary artery calcium (CAC) is promising for identifying individuals at risk for cardiovascular events and appears to be a robust tool for guiding initiation of appropriate and timely primary prevention strategies. However, how do we best determine its clinical value? It is clear that traditional risk prediction models based primarily on age, gender, and risk factors are insufficient for ideal personalization of risk estimation. It is now well established from epidemiologic studies that CAC adds to traditional risk scores for a more accurate risk prediction. However, such traditional epidemiology studies have limitations in establishing “clinical value,” and they must be supplemented by additional data before being translated into strong recommendations in clinical practice guidelines. Fortunately, over the last few years, the research around CAC has matured to include data supporting enhanced clinician-patient risk discussions, shared decision-making, flexible risk factor treatment goals, specific clinical decision algorithms, as well as favorable cost-effectiveness analyses. We had moved from a time when we asked “if CAC adds to the risk score” to a time when we are asking “does CAC facilitate a shared decision-making model matching risk, treatment, and patient preferences?” A new risk calculator incorporating CAC into global risk scoring, and 2017 guidelines on the use of CAC published by the Society of Cardiovascular Computed Tomography (SCCT), reflect this new approach. In this article, we review the recent transition to this more clinically relevant CAC research that may support a stronger recommendation for its use in future prevention guidelines.

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References and Recommended Reading

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  1. Cainzos-Achirica M, Desai CS, Wang L, Blaha MJ, Lopez-Jimenez F, Kopecky SL, et al. Pathways forward in cardiovascular disease prevention one and a half years after publication of the 2013 ACC/AHA cardiovascular disease prevention guidelines. Mayo Clin Proc. 2015;90(9):1262–71.

    Article  PubMed  PubMed Central  Google Scholar 

  2. DeFilippis AP, Young R, Carrubba CJ, McEvoy JW, Budoff MJ, Blumenthal RS, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med [Internet]. 2015;162:266–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25686167

    Article  Google Scholar 

  3. DeFilippis AP, Young R, McEvoy JW, Michos ED, Sandfort V, Kronmal RA, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern mult. Eur Heart J [Internet]. 2017;38:598–608. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27436865

    Google Scholar 

  4. Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary. J Am Coll Cardiol. 2010;2010:2182–99.

    Article  Google Scholar 

  5. Stone NJ, Robinson JG, Lichtenstein AH, Goff DC, Lloyd-Jones DM, Smith SC, et al. Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: synopsis of the 2013 American College of Cardiology/American Heart Association cholesterol guideline. Ann Intern Med [Internet]. 2014;160:339–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24474185

    Google Scholar 

  6. Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol [Internet]. 2014;63:2935–59. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24239921

    Article  Google Scholar 

  7. Blaha MJ, Dardari ZA, Blumenthal RS, Martin SS, Nasir K, Al-Mallah MH. The new “intermediate risk” group: a comparative analysis of the new 2013 ACC/AHA risk assessment guidelines versus prior guidelines in men. Atherosclerosis [Internet]. 2014;237:1–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25173946

    Article  CAS  Google Scholar 

  8. • Yeboah J, Young R, McClelland RL, Delaney JC, Polonsky TS, Dawood FZ, et al. Utility of nontraditional risk markers in atherosclerotic cardiovascular disease risk assessment. J Am Coll Cardiol. 2016;67:139–47. This MESA study showed that non-traditional markers, such as CAC, ankle-brachial index, and family history, can predict ASCVD risk. However, CAC was the best marker, as it better-improved discrimination ability of PCE.

    Article  PubMed  PubMed Central  Google Scholar 

  9. •• Blaha MJ, Yeboah J, Al Rifai M, Liu K, Kronmal R, Greenland P. Providing evidence for subclinical CVD in risk assessment. Glob Heart. 2016;11(3):275–85. This review article describes CAC as the single best marker for cardiovascular disease risk prediction based on a series of landmark publications from MESA. MESA CHD Risk Estimator is now available based on these findings.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Möhlenkamp S, Lehmann N, Moebus S, Schmermund A, Dragano N, Stang A, et al. Quantification of coronary atherosclerosis and inflammation to predict coronary events and all-cause mortality. J Am Coll Cardiol [Internet]. 2011;57:1455–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21435514

    Article  Google Scholar 

  11. Mody P, Joshi PH, Khera A, Ayers CR, Rohatgi A. Beyond coronary calcification, family history, and C-reactive protein: cholesterol efflux capacity and cardiovascular risk prediction. J Am Coll Cardiol [Internet]. 2016;67:2480–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27230043

    Article  CAS  Google Scholar 

  12. •• McClelland RL, Jorgensen NW, Budoff M, Blaha MJ, Post WS, Kronmal RA, et al. 10-Year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (multi-ethnic study of atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) study and the DHS (Dallas Heart Stu). J Am Coll Cardiol [Internet]. 2015;66:1643–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26449133. This landmark study resulted in the inclusion of CAC along with other nontraditional risk factors to predict 10-year CHD risk in MESA population. This MESA CHD Risk Calculator (validated in two external cohorts) is valuable for guiding risk-based treatment strategies.

    Article  CAS  Google Scholar 

  13. Lloyd-Jones DM. Coronary artery calcium scoring: are we there yet? J Am Coll Cardiol [Internet]. 2015;66:1654–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26449134

    Article  Google Scholar 

  14. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol [Internet]. 2014;63:2889–934. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24239923

    Article  Google Scholar 

  15. •• Gupta A, Lau E, Varshney R, Hulten EA, Cheezum M, Bittencourt MS, et al. The identification of calcified coronary plaque is associated with initiation and continuation of pharmacological and lifestyle preventive therapies. JACC Cardiovasc Imaging [Internet]. 2017;10:833–42. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1936878X17305193 This study provides evidence that knowledge of CAC might improve dietary and exercise habits and help the patient to initiate and adhere to drug therapy.

  16. •• Martin SS, Sperling LS, Blaha MJ, Wilson PWF, Gluckman TJ, Blumenthal RS, et al. Clinician-patient risk discussion for atherosclerotic cardiovascular disease prevention: importance to implementation of the 2013 ACC/AHA Guidelines. J Am Coll Cardiol [Internet]. 2015;65:1361–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25835448. This paper reviews guideline recommendations for clinician-patient risk discussion and general concepts of shared decision-making and decision aids.

    Article  Google Scholar 

  17. •• Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr [Internet] Elsevier Ltd. 2017;11:157–68. https://doi.org/10.1016/j.jcct.2017.02.010. An important paper on shared decision-making. This statement from Society of Cardiovascular Computed Tomography (SCCT) discusses harms and benefits of statin treatment or CAC scoring versus no treatment or no testing.

    Article  Google Scholar 

  18. Nasir K, Bittencourt MS, Blaha MJ, Blankstein R, Agatson AS, Rivera JJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association cholesterol management guidelines: MESA (multi-ethnic study of atherosclerosis). J Am Coll Cardiol [Internet]. 2015;66:1657–68. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26449135

    Article  CAS  Google Scholar 

  19. • Mortensen MB, Fuster V, Muntendam P, Mehran R, Baber U, Sartori S, et al. A simple disease-guided approach to personalize ACC/AHA-recommended statin allocation in elderly people: the BioImage study. J Am Coll Cardiol [Internet]. 2016;68:881–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27561760. Showed that most old individuals were eligible for statin treatment according to the recent guidelines only because of their age. The absence of CAC could spare a considerable portion of elderly individuals from statin treatment.

    Article  Google Scholar 

  20. Pursnani A, Massaro JM, D’Agostino RB, O’Donnell CJ, Hoffmann U. Guideline-based statin eligibility, coronary artery calcification, and cardiovascular events. Jama [Internet]. 2015;314:134. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26172893

    Article  CAS  Google Scholar 

  21. •• Blaha MJ, Cainzos-Achirica M, Greenland P, McEvoy JW, Blankstein R, Budoff MJ, et al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the multi-ethnic study of atherosclerosis (MESA). Circulation. 2016;133:849–58. This MESA study assessed the role of 13 negative risk markers for predicting the absence of events among asymptomatic individuals to see how they can add to previous risk models for a more accurate risk prediction. The absence of CAC resulted in the greatest downward shift in estimated CVD risk compared with negative results related to other tested risk markers.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. •• Blaha MJ. Personalizing treatment: between primary and secondary prevention. Am J Cardiol [Internet] Elsevier Inc. 2016;118:4A–12A. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0002914916308803. This article explains that a subgroup of patients with advanced atherosclerosis can be considered between primary and secondary prevention and may benefit from a more intensive preventive treatment strategy.

    Article  Google Scholar 

  23. • Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, Silverman MG, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes [Internet]. 2014;7:453–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24803472. A MESA study that showed subgroup of patients with CA≥100 had a net benefit from aspirin treatment with regard to CHD prevention. On the contrary, those with CAC=0 received net harm from aspirin.

    Article  Google Scholar 

  24. • McEvoy JW, Martin SS, Dardari ZA, Miedema MD, Sandfort V, Yeboah J, et al. Coronary artery calcium to guide a personalized risk-based approach to initiation and intensification of antihypertensive therapy. Circulation. 2017;135:153–65. This MESA study showed that CAC could provide flexible treatment goals regarding treatment of hypertension for those with intermediate ASCVD risk and pre-hypertension or mild hypertension.

    Article  CAS  PubMed  Google Scholar 

  25. •• Hong JC, Blankstein R, Shaw LJ, Padula WV, Arrieta A, Fialkow JA, et al. Implications of coronary artery calcium testing for treatment decisions among statin candidates according to the ACC/AHA cholesterol management guidelines. JACC Cardiovasc Imaging [Internet]. 2017;10:938–52. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1936878X17305089. This paper showed that CAC scoring is recommended in the setting of clinician-patient risk discussion.

    Article  Google Scholar 

  26. van Kempen BJH, Ferket BS, Steyerberg EW, Max W, Myriam Hunink MG, Fleischmann KE. Comparing the cost-effectiveness of four novel risk markers for screening asymptomatic individuals to prevent cardiovascular disease (CVD) in the US population. Int J Cardiol [Internet]. 2016;203:422–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26547049

    Article  Google Scholar 

  27. •• Pletcher MJ, Pignone M, Earnshaw S, McDade C, Phillips KA, Auer R, et al. Using the coronary artery calcium score to guide statin therapy: a cost-effectiveness analysis. Circ Cardiovasc Qual Outcomes [Internet]. 2014;7:276–84. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4156513&tool=pmcentrez&rendertype=abstract. Demonstrated that among patients who are at intermediate FRS risk, CAC testing is cost-effective if statins are expensive or markedly affect the quality of life. A “treat-all” strategy was not found to be cost-effective.

    Article  Google Scholar 

  28. •• Roberts ET, Horne A, Martin SS, Blaha MJ, Blankstein R, Budoff MJ, et al. Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the multi-ethnic study of atherosclerosis (MESA). PLoS One. 2015;10:e0116377. Demonstrated that among individuals who are at intermediate ASCVD risk, testing for CAC and treating patients with CAC≥1 is cost-effective compared with treatment based on risk assessment guidelines. Particularly, treating those who had CAC≥100 was cost-effective when accounting for statin side effects and disutility (when the patient would be willing to trade two weeks of perfect health to avoid ten years of treatment).

    Article  PubMed  PubMed Central  Google Scholar 

  29. Stone NJ. Cholesterol guidelines do not endorse “one size fits all”: the strategy begins with a discussion. J Am Coll Cardiol [Internet]. 2015;65:1640–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25908068

    Article  Google Scholar 

  30. Mamudu HM, Paul TK, Veeranki SP, Budoff M. The effects of coronary artery calcium screening on behavioral modification, risk perception, and medication adherence among asymptomatic adults: a systematic review. Atherosclerosis. 2014;236(2):338–50.

    Article  CAS  PubMed  Google Scholar 

  31. • Hecht HS. Coronary artery calcium scanning: past, present, and future. JACC Cardiovasc Imaging. 2015;8:579–96. This paper describes CAC as a test that can improve adherence to medication and lifestyle modification and is cost-effective for some specific populations.

    Article  PubMed  Google Scholar 

  32. Silverman MG, Blaha MJ, Krumholz HM, Budoff MJ, Blankstein R, Sibley CT, et al. Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: the multi-ethnic study of atherosclerosis. Eur Heart J. 2014;35:2232–41.

    Article  CAS  PubMed  Google Scholar 

  33. Navar AM, Stone NJ, Martin SS. What to say and how to say it: effective communication for cardiovascular disease prevention. Curr Opin Cardiol [Internet]. 2016;31:537–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27428113

    Article  Google Scholar 

  34. Carr JJ, Jacobs DR, Terry JG, Shay CM, Sidney S, Liu K, et al. Association of Coronary Artery Calcium in adults aged 32 to 46 years with incident coronary heart disease and death. JAMA Cardiol [Internet]. 2017;2:391. https://doi.org/10.1001/jamacardio.2016.5493.

    Article  Google Scholar 

  35. Paixao ARM, Ayers CR, Rohatgi A, Das SR, de Lemos JA, Khera A, et al. Cardiovascular lifetime risk predicts incidence of coronary calcification in individuals with low short-term risk: the Dallas heart study. J Am Heart Assoc [Internet]. 2014;3:e001280. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25424574

    Article  Google Scholar 

  36. Kavousi M, Desai CS, Ayers C, Blumenthal RS, Budoff MJ, Mahabadi A-A, et al. Prevalence and prognostic implications of coronary artery calcification in low-risk women: a meta-analysis. JAMA [Internet]. 2016;316:2126–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27846641

    Article  CAS  Google Scholar 

  37. Stone NJ, Robinson JG. Potential for net benefit should guide preventive therapy. Circulation [Internet]. 2017;135:630–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28193796

    Article  Google Scholar 

  38. Blaha MJ, Silverman MG, Budoff MJ. Is there a role for coronary artery calcium scoring for management of asymptomatic patients at risk for coronary artery disease?: clinical risk scores are not sufficient to define primary prevention treatment strategies among asymptomatic patients. Circ Cardiovasc Imaging [Internet]. 2014;7:398–408. discussion 408. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24642922

    Article  Google Scholar 

  39. McEvoy JW, Diamond GA, Detrano RC, Kaul S, Blaha MJ, Blumenthal RS, et al. Risk and the physics of clinical prediction. Am J Cardiol [Internet]. 2014;113:1429–35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24581923

    Article  Google Scholar 

  40. Goldman RE, Parker DR, Eaton CB, Borkan JM, Gramling R, Cover RT, et al. Patients’ perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Ann Fam Med [Internet]. 2006;4:205–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16735521

    Article  Google Scholar 

  41. •• Nasir K. Overhauling cardiovascular risk prediction in primary prevention: difficult journey worth the destination. Circ Cardiovasc Qual Outcomes [Internet]. 2015;8:466–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26349838. This Editorial placed emphasis on more flexible treatment goal based on CAC score. Most importantly, it underscores the role of the patient in making informed decisions about treatment. In this context, the absence of CAC can help patients avoid statin treatment.

    Article  Google Scholar 

  42. Pencina MJ, D’Agostino RB, D’Agostino RB, Vasan RS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008;27:157–72.

    Article  PubMed  Google Scholar 

  43. Blaha MJ, Budoff MJ, Defilippis AP, Blankstein R, Rivera JJ, Agatston A, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet. 2011;378:684–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Martin SS, Blaha MJ, Blankstein R, Agatston A, Rivera JJ, Virani SS, et al. Dyslipidemia, coronary artery calcium, and incident atherosclerotic cardiovascular disease: implications for statin therapy from the multi-ethnic study of atherosclerosis. Circulation. 2014;129:77–86.

    Article  CAS  PubMed  Google Scholar 

  45. •• Hecht HS, Shaw LJ, Chandrashekhar Y, Narula J. Coronary artery calcium and shared decision making. JACC Cardiovasc Imaging [Internet]. 2016;9:637–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27151526. This paper discusses the role of CAC as an important topic in shared decision-making. The patient should know that they are unlikely to benefit from statins while they have no CAC. On the contrary, the presence of CAC advocates for initiation of preventive medications.

    Article  Google Scholar 

  46. • Valenti V, Ó Hartaigh B, Heo R, Cho I, Schulman-Marcus J, Gransar H, et al. A 15-year warranty period for asymptomatic individuals without coronary artery calcium: a prospective follow-up of 9,715 individuals. JACC Cardiovasc Imaging. 2015;8:900–9. Studied the role of CAC=0 for identifying individuals that have a very low risk (less than 1%) for CHD.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JWJ, Garcia FAR, et al. Statin use for the primary prevention of cardiovascular disease in adults: US preventive services task force recommendation statement. JAMA. 2016;316:1997–2007.

    Article  PubMed  Google Scholar 

  48. Desai CS, Martin SS, Blumenthal RS. Non-cardiovascular effects associated with statins. BMJ [Internet]. 2014;349:g3743. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25035309%5Cn, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4707717

    Article  Google Scholar 

  49. Swiger KJ, Manalac RJ, Blumenthal RS, Blaha MJ, Martin SS. Statins and cognition: a systematic review and meta-analysis of short- and long-term cognitive effects. Mayo Clin Proc. 2013;88:1213–21.

    Article  CAS  PubMed  Google Scholar 

  50. McEvoy JW, Martin SS, Blaha MJ, Polonsky TS, Nasir K, Kaul S, et al. The case for and against a coronary artery calcium trial: means, motive, and opportunity. JACC Cardiovasc Imaging [Internet]. 2016;9:994–1002. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27491486

    Article  Google Scholar 

  51. Mahabadi AA, Möhlenkamp S, Lehmann N, Kälsch H, Dykun I, Pundt N, et al. CAC score improves coronary and CV risk assessment above statin indication by ESC and AHA/ACC primary prevention guidelines. JACC Cardiovasc Imaging [Internet]. 2017;10:143–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27665163

    Article  Google Scholar 

  52. Blaha MJ, Matsushita K. Coronary artery calcium: need for more clarity in guidelines. JACC Cardiovasc Imaging [Internet]. 2017;10:154–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27665157

    Article  Google Scholar 

  53. Cannon CP, Blazing MA, Giugliano RP, McCagg A, White JA, Theroux P, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med [Internet]. 2015;372:2387–97. https://doi.org/10.1056/NEJMoa1410489.

    Article  CAS  Google Scholar 

  54. Jarcho JA, Keaney JF. Proof that lower is better—LDL cholesterol and IMPROVE-IT. N Engl J Med [Internet]. 2015;372:2448–50. https://doi.org/10.1056/NEJMe1507041.

    Article  CAS  Google Scholar 

  55. Sabatine MS. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med [Internet]. 2017;376(18):1713–22. https://doi.org/10.1056/NEJMoa1615664.

    Article  CAS  Google Scholar 

  56. Kankeu HT, Saksena P, Xu K, Evans DB. The financial burden from non-communicable diseases in low- and middle-income countries: a literature review. Heal Res Policy Syst [Internet]. 2013;11:31. Available from: http://www.health-policy-systems.com/content/11/1/31/abstract%0A%0A, http://www.health-policy-systems.com/content/pdf/1478-4505-11-31.pdf

    Article  Google Scholar 

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Authors and Affiliations

  1. Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA

    Sina Kianoush MD, MPH, Mohammadhassan Mirbolouk MD, Raghavendra Charan Makam MD, MPH, Khurram Nasir MD, MPH & Michael J. Blaha MD, MPH

  2. Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, 1500 San Remo Ave, Suite 340, Coral Gables, FL, 33139, USA

    Khurram Nasir MD, MPH

  3. Division of Cardiology, Johns Hopkins Ciccarone Center Preventive Cardiology Center, Blalock 524C, 600 North Wolfe St, Baltimore, MD, 21287, USA

    Michael J. Blaha MD, MPH

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  1. Sina Kianoush MD, MPH
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Correspondence to Michael J. Blaha MD, MPH.

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Sina Kianoush, Mohammadhassan Mirbolouk, Raghavendra charan Makam, and Khurram Nasir each declare no potential conflicts of interest.

Michael J. Blaha reports grants from FDA, NHLBI, AHA, Aetna Foundation, and Amgen, and personal fees received from FDA, ACC, Amgen, Novartis, MedImmune, and Akcea.

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Sina Kianoush and Mohammadhassan Mirbolouk are co-first authors

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Kianoush, S., Mirbolouk, M., Makam, R.C. et al. Coronary Artery Calcium Scoring in Current Clinical Practice: How to Define Its Value?. Curr Treat Options Cardio Med 19, 85 (2017). https://doi.org/10.1007/s11936-017-0582-y

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