Skip to main content
SpringerLink
Log in

Potential Use of Coronary Artery Calcium Progression to Guide the Management of Patients at Risk for Coronary Artery Disease Events

  • Coronary Artery Disease (PH Stone, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Subclinical coronary artery disease (CAD) is widespread and under-diagnosed. Preventive efforts are required to reduce the burden of this disease and its complications. Imaging of coronary artery calcium (CAC) with cardiac computed tomography is highly specific for the diagnosis of subclinical CAD and can also facilitate treatment decisions in preventive cardiology. Indeed, CAC testing has been recommended by the American Heart Association for asymptomatic patients at intermediate risk for future cardiac events (as defined by clinical risk factors) to refine existing risk estimates. However, the optimal follow-up of those patients who have already undergone CAC testing remains unclear, particularly with regards to repeat CAC testing. The existing literature points to two major considerations for the use of CAC progression in the management of subclinical CAD. On one hand, CAC progression has been used as a surrogate marker to test the efficacy of cardiac preventive medications in halting or regressing CAD. To date, study results have been mostly disappointing and CAC progression appears resistant to medications such as statins. On the other hand, however, CAC progression has potential as a clinical indicator of underlying CAD activity. This may facilitate optimization or up-titration of preventive medications by using CAC progression as a marker of subclinical disease activity. We believe that the data, thus far, argues against the use of a CAC progression as a clinical surrogate marker of preventive therapy efficacy. Further studies with non-statin medications and with concomitant outcome data are needed. However, CAC progression has potential for monitoring subclinical CAD in some patients and may facilitate treatment decisions. In this review we will provide recommendations for repeat CAC testing and discuss when repeat CAC testing may be helpful to assess coronary artery disease progression.

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

Figure 1

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209.

    Article  PubMed  Google Scholar 

  2. Shah PK. Screening asymptomatic subjects for subclinical atherosclerosis: can we, does it matter, and should we? J Am Coll Cardiol. 2010;56:98–105.

    Article  PubMed  Google Scholar 

  3. Wexler L, Brundage B, Crouse J, et al. Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications. A statement for health professionals from the American Heart Association. Writing Group. Circulation. 1996;94:1175–92.

    PubMed  CAS  Google Scholar 

  4. Mintz GS, Pichard AD, Popma JJ, et al. Determinants and correlates of target lesion calcium in coronary artery disease: a clinical, angiographic and intravascular ultrasound study. J Am Coll Cardiol. 1997;29:268–74.

    Article  PubMed  CAS  Google Scholar 

  5. Erbel R, Mohlenkamp S, Moebus S, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol. 2010;56:1397–406.

    Article  PubMed  Google Scholar 

  6. Polonsky TS, McClelland RL, Jorgensen NW, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA. 2010;303:1610–6.

    Article  PubMed  CAS  Google Scholar 

  7. Rozanski A, Gransar H, Shaw LJ, et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial. J Am Coll Cardiol. 2011;57:1622–32.

    Article  PubMed  CAS  Google Scholar 

  8. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:2748–64.

    Article  PubMed  Google Scholar 

  9. Nissen SE, Nicholls SJ, Sipahi I, et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA. 2006;295:1556–65.

    Article  PubMed  CAS  Google Scholar 

  10. McEvoy JW, Blaha MJ, Defilippis AP, et al. Coronary artery calcium progression: an important clinical measurement? A review of published reports. J Am Coll Cardiol. 2010;56:1613–22.

    Article  PubMed  Google Scholar 

  11. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122:e584–636.

    Article  PubMed  Google Scholar 

  12. McEvoy JW. Coronary artery calcium score and cardiovascular event prediction. JAMA. 2010;304:741–2. author reply 2.

    Article  PubMed  CAS  Google Scholar 

  13. Elias-Smale SE, Proenca RV, Koller MT, et al. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010;56:1407–14.

    Article  PubMed  Google Scholar 

  14. Blaha M, Budoff MJ, Shaw LJ, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009;2:692–700.

    Article  PubMed  Google Scholar 

  15. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143–421.

    Google Scholar 

  16. Hecht HS. The deadly double standard (the saga of screening for subclinical atherosclerosis). Am J Cardiol. 2008;101:1805–7.

    Article  PubMed  Google Scholar 

  17. Ambrose MS, Nagy CD, Blumenthal RS. Selective use of coronary calcification measurements in an expanded intermediate risk group. J Cardiovasc Comput Tomogr. 2008;2:209–13.

    Article  PubMed  Google Scholar 

  18. Yoon HC, Emerick AM, Hill JA, Gjertson DW, Goldin JG. Calcium begets calcium: progression of coronary artery calcification in asymptomatic subjects. Radiology. 2002;224:236–41.

    Article  PubMed  Google Scholar 

  19. Min JK, Lin FY, Gidseg DS, et al. Determinants of coronary calcium conversion among patients with a normal coronary calcium scan: what is the “warranty period” for remaining normal? J Am Coll Cardiol. 2010;55:1110–7.

    Article  PubMed  Google Scholar 

  20. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006;113:791–8.

    Article  PubMed  Google Scholar 

  21. Berenson GS, Srinivasan SR, Bao W, Newman 3rd WP, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med. 1998;338:1650–6.

    Article  PubMed  CAS  Google Scholar 

  22. Tirosh A, Shai I, Afek A, et al. Adolescent BMI trajectory and risk of diabetes versus coronary disease. N Engl J Med. 2011;364:1315–25.

    Article  PubMed  CAS  Google Scholar 

  23. Gidding SS. Assembling evidence to justify prevention of atherosclerosis beginning in youth. Circulation. 2010;122:2493–4.

    Article  PubMed  Google Scholar 

  24. Gopal A, Nasir K, Liu ST, Flores FR, Chen L, Budoff MJ. Coronary calcium progression rates with a zero initial score by electron beam tomography. Int J Cardiol. 2007;117:227–31.

    Article  PubMed  Google Scholar 

  25. Hokanson JE, MacKenzie T, Kinney G, et al. Evaluating changes in coronary artery calcium: an analytic method that accounts for interscan variability. AJR Am J Roentgenol. 2004;182:1327–32.

    PubMed  Google Scholar 

  26. Kronmal RA, McClelland RL, Detrano R, et al. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2007;115:2722–30.

    Article  PubMed  Google Scholar 

  27. Budoff MJ, Hokanson JE, Nasir K, et al. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging. 2010;3:1229–36.

    Article  PubMed  Google Scholar 

  28. Raggi P, Callister TQ, Shaw LJ. Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy. Arterioscler Thromb Vasc Biol. 2004;24:1272–7.

    Article  PubMed  CAS  Google Scholar 

  29. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte Jr M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–32.

    Article  PubMed  CAS  Google Scholar 

  30. Callister TQ, Cooil B, Raya SP, Lippolis NJ, Russo DJ, Raggi P. Coronary artery disease: improved reproducibility of calcium scoring with an electron-beam CT volumetric method. Radiology. 1998;208:807–14.

    PubMed  CAS  Google Scholar 

  31. Hong C, Bae KT, Pilgram TK. Coronary artery calcium: accuracy and reproducibility of measurements with multi-detector row CT—assessment of effects of different thresholds and quantification methods. Radiology. 2003;227:795–801.

    Article  PubMed  Google Scholar 

  32. Mao SS, Pal RS, McKay CR, et al. Comparison of coronary artery calcium scores between electron beam computed tomography and 64-multidetector computed tomographic scanner. J Comput Assist Tomogr. 2009;33:175–8.

    Article  PubMed  Google Scholar 

  33. Ghadri JR, Goetti R, Fiechter M, et al. Inter-scan variability of coronary artery calcium scoring assessed on 64-multidetector computed tomography vs. dual-source computed tomography: a head-to-head comparison. Eur Heart J 2011.

  34. DeMets DL, Califf RM. Lessons learned from recent cardiovascular clinical trials: Part I. Circulation. 2002;106:746–51.

    Article  PubMed  Google Scholar 

  35. Callister TQ, Raggi P, Cooil B, Lippolis NJ, Russo DJ. Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography. N Engl J Med. 1998;339:1972–8.

    Article  PubMed  CAS  Google Scholar 

  36. Budoff MJ, Lane KL, Bakhsheshi H, et al. Rates of progression of coronary calcium by electron beam tomography. Am J Cardiol. 2000;86:8–11.

    Article  PubMed  CAS  Google Scholar 

  37. Achenbach S, Ropers D, Pohle K, et al. Influence of lipid-lowering therapy on the progression of coronary artery calcification: a prospective evaluation. Circulation. 2002;106:1077–82.

    Article  PubMed  CAS  Google Scholar 

  38. Houslay ES, Cowell SJ, Prescott RJ, et al. Progressive coronary calcification despite intensive lipid-lowering treatment: a randomised controlled trial. Heart. 2006;92:1207–12.

    Article  PubMed  CAS  Google Scholar 

  39. Schmermund A, Achenbach S, Budde T, 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.

    Article  PubMed  CAS  Google Scholar 

  40. Raggi P, Davidson M, Callister TQ, et al. Aggressive versus moderate lipid-lowering therapy in hypercholesterolemic postmenopausal women: Beyond Endorsed Lipid Lowering with EBT Scanning (BELLES). Circulation. 2005;112:563–71.

    Article  PubMed  CAS  Google Scholar 

  41. Arad Y, Spadaro LA, Roth M, Newstein D, Guerci AD. Treatment of asymptomatic adults with elevated coronary 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.

    Article  PubMed  CAS  Google Scholar 

  42. Burgstahler C, Reimann A, Beck T, et al. Influence of a lipid-lowering therapy on calcified and noncalcified coronary plaques monitored by multislice detector computed tomography: results of the New Age II Pilot Study. Invest Radiol. 2007;42:189–95.

    Article  PubMed  CAS  Google Scholar 

  43. Motro M, Shemesh J. Calcium channel blocker nifedipine slows down progression of coronary calcification in hypertensive patients compared with diuretics. Hypertension. 2001;37:1410–3.

    PubMed  CAS  Google Scholar 

  44. Goodman WG, Goldin J, Kuizon BD, 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.

    Article  PubMed  CAS  Google Scholar 

  45. Chertow GM, Burke SK, Raggi P. Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients. Kidney Int. 2002;62:245–52.

    Article  PubMed  CAS  Google Scholar 

  46. Qunibi W, Moustafa M, Muenz LR, 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;51:952–65.

    Article  PubMed  CAS  Google Scholar 

  47. Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46:158–65.

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Blalock 524C, 600 N Wolfe St, Baltimore, MD, 21287, USA

    John W. McEvoy MB BCh BAO MRPCI, Michael J. Blaha MD, MPH, Khurram Nasir MD, MPH, Roger S. Blumenthal MD & Steven R. Jones MD

Authors
  1. John W. McEvoy MB BCh BAO MRPCI
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael J. Blaha MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Khurram Nasir MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Roger S. Blumenthal MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Steven R. Jones MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John W. McEvoy MB BCh BAO MRPCI.

Rights and permissions

Reprints and permissions

About this article

Cite this article

McEvoy, J.W., Blaha, M.J., Nasir, K. et al. Potential Use of Coronary Artery Calcium Progression to Guide the Management of Patients at Risk for Coronary Artery Disease Events. Curr Treat Options Cardio Med 14, 69–80 (2012). https://doi.org/10.1007/s11936-011-0154-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11936-011-0154-5

Keywords

Search

Navigation