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Coronary Microcalcification

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Cardiovascular Calcification

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Abstract

Although the assessment of myocardial ischemia has been traditionally based on angiographic evaluation of epicardial coronary artery stenosis, it is recognized that the severity of coronary obstruction has a limited prognostic value of subsequent coronary syndromes. Indeed, many patients with clinical features of myocardial ischemia do not have flow-limiting coronary lesions on angiography. However, the absence of angiographic obstructive lesions does not exclude coronary artery structural or functional abnormalities. Such discordance between coronary stenosis and coronary syndromes is due to the complex nature of atherosclerosis, which is no longer considered just a simple lipid-storage disease but includes inflammation, endothelial dysfunction, arterial wall shear stress, immunological activity, arterial remodeling and calcification. Since arterial endothelium regulates vascular permeability and the arterial tone and flow, inflammation-induced endothelial dysfunction has a central role in the initiation and progression of atherosclerosis. Although the endothelium of the entire vasculature is exposed to inflammation, atherosclerotic plaques develop near arterial bifurcation or curved segments. This focal localization is determined by the effect of wall shear stress (WSS). In the presence of cardiovascular risk factors, WSS induces endothelial inflammation and has an essential role in the development and progression of atherosclerotic plaques. Endothelial damage results in increased permeability and subendothelial retention of small and dense low-density lipoprotein cholesterol. Lipid accumulation promotes migration of macrophages which catabolize the lipoproteins within the arterial wall and coalesce into a necrotic core. Also, vascular smooth muscle cells migrate into the intima forming a fibrous cap, mostly collagen. If the inflammation persists, macrophages exert a catabolic effect resulting in the dissolution of collagen, producing a thin-cap fibro-atheroma (TCFA) which makes the plaque unstable. Inflammation also stimulates the aggregation of small crystals of hydroxyapatite giving rise to microcalcification, less than 50 microns in diameter, embedded in the fibrous cap. Microcalcifications exert a mechanical stress within the fibrous cap and may predispose to plaque rupture. The majority of microcalcifications merge into larger layers of calcium which stabilize the plaque. The morphology of atherosclerotic plaques may change over time, undergoing progressive transformation from high-risk to more stable lesions, or subclinical rupture and healing. Such changes in plaque stability are not simply related to local vascular factors but may reflect more systemic factors, such as inflammatory state and blood thrombogenicity. Direct visualization of plaque morphology and extent of atherosclerosis is currently achieved by angiography, non-contrast computed tomography (CT) with measurement of coronary artery calcium (CAC) score, contrast enhanced computed tomographic coronary angiography (CTCA), cardiac magnetic resonance (CMR), intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy (NIRS). Among these, only OCT has the spatial resolution to visualize microcalcifications. Metabolic imaging that could assess disease activity and distinguish between patients with stable disease from those with increased inflammatory activity, is based on positron emission tomography (PET) which may incorporate CT or CMR to provide simultaneous disease activity and morphological information.

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Authors and Affiliations

  1. Internal Medicine, S.Elia Hospital, Caltanissetta, Italy

    Federico Vancheri

  2. Cardiovascular and Interventional Department, S.Elia Hospital, Caltanissetta, Italy

    Giovanni Longo

  3. Radiology Department, I.R.C.C.S. Policlinico San Matteo, Pavia, Italy

    Sergio Vancheri

  4. Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden

    Michael Henein

  5. Brunel University, Middlesex, London, UK

    Michael Henein

  6. St George’s University, London, UK

    Michael Henein

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  1. Federico Vancheri
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  4. Michael Henein
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Correspondence to Federico Vancheri .

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  1. Umeå University, Umeå, Sweden

    Michael Henein

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Vancheri, F., Longo, G., Vancheri, S., Henein, M. (2022). Coronary Microcalcification. In: Henein, M. (eds) Cardiovascular Calcification. Springer, Cham. https://doi.org/10.1007/978-3-030-81515-8_9

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