214 how can calcium score improve your practice
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This document discusses how coronary artery calcium scoring using computed tomography (CT) and levels of the inflammatory marker C-reactive protein (CRP) can be used together to predict cardiovascular risk. It finds that higher calcium scores and CRP levels each indicate greater risk of future heart attacks and cardiac deaths. The combination of an intermediate calcium score and elevated CRP may identify those at intermediate risk who could benefit from more aggressive prevention efforts like closer follow-up or treatment targeting both inflammation and plaques. Together, calcium scoring and CRP testing provide complementary information that can refine clinical decision making for asymptomatic individuals.
214 how can calcium score improve your practice
- 1. Vulnerable Plaque SymposiumVulnerable Plaque Symposium Patients with High CRP & HighPatients with High CRP & High CT Calcium Score are at Higher Risk:CT Calcium Score are at Higher Risk: How Can Calcium ScoreHow Can Calcium Score Improve Your Practice?Improve Your Practice? John A. Rumberger, PhD, MD, FACCJohn A. Rumberger, PhD, MD, FACC Clinical Professor of Medicine, Ohio State UniversityClinical Professor of Medicine, Ohio State University Medical DirectorMedical Director Physician’s Prevention and Wellness CenterPhysician’s Prevention and Wellness Center Columbus, OhioColumbus, Ohio Chicago, ILChicago, IL March 29, 2003March 29, 2003© 2003 John A Rumberger, MD
- 2. 1.25 1.6 1.6 1.8 2.15 2.35 2.5 5 0 2 4 6 8 10 Lp(a) Homocysteine TC Fibr t-PA Ag TC/HDL hs-CRP hs-CRP + TC/HDL RR in men from the Physicians Health Study Risk of MI in Apparently Healthy PeopleRisk of MI in Apparently Healthy People Values in the Highest Quartile Compared to Lowest Quartile
- 3. hs C-Reactive Proteinhs C-Reactive Protein AtAt PRESENTPRESENT the following has been established:the following has been established: o Values in the upper tercile (or quartile) confer a 2+ risk MI/SCDValues in the upper tercile (or quartile) confer a 2+ risk MI/SCD o Marker likely for “endothelial dysfunction”Marker likely for “endothelial dysfunction” o May have a role in “promoting atherogenesis”May have a role in “promoting atherogenesis” o Values altered by:Values altered by: Increased By Decreased ByIncreased By Decreased By Elevated BP ETOH consumptionElevated BP ETOH consumption BMI Aerobic exerciseBMI Aerobic exercise Metabolic syndrome Weight lossMetabolic syndrome Weight loss Hormone use Medications:Hormone use Medications: Chronic infections statins, fibrates,Chronic infections statins, fibrates, Chronic inflammation niacinChronic inflammation niacin
- 4. hs C-Reactive Proteinhs C-Reactive Protein o May or may not be related to the severity or extent of diseaseMay or may not be related to the severity or extent of disease o This could be due to differences in chronicity or “pattern”This could be due to differences in chronicity or “pattern” o CRP may be more related to “acceleration of atherosclerosis”CRP may be more related to “acceleration of atherosclerosis” rather than its extentrather than its extent
- 5. VTVT VT = “vulnerable threshold”VT = “vulnerable threshold” ““vulnerability”vulnerability” TimeTime Patient APatient A Patient BPatient B MI/SCDMI/SCD The “Vulnerable Threshold” CRPCRP CRPCRP CRPCRP © © 2003 John A Rumberger, MD ©
- 6. CT Coronary Artery CalciumCT Coronary Artery Calcium No CalcificationNo Calcification Severe CalcificationSevere Calcification Left Main LAD LCX AoAo LALA PAPA
- 7. Coronary Calcium Area by EBT andCoronary Calcium Area by EBT and Coronary Artery Plaque AreaCoronary Artery Plaque Area 0 2 4 6 8 10 12 14 16 0 2 4 6 8 Square Root Sum of Calcium Areas SquareRootSumof PlaqueAreas Rumberger, Circ 1995:92:2157-62 n = 38n = 38 r = 0.90r = 0.90 p < .001p < .001
- 8. No. of coronary segments/pt. with plaques (IVUS)No. of coronary segments/pt. with plaques (IVUS) 0 1 2 3 4 5 6 7 No. of calcifiedNo. of calcified coronarycoronary segments/pt.segments/pt. (EBCT)(EBCT) 0 1 2 3 4 5 6 7 Y = -0.67 + (0.90 * X) r = 0.86 p < 0.0001 N = 40 patients total of 222 coronary segments examined # of segments with EBT calcium vs. # of segments with any plaque# of segments with EBT calcium vs. # of segments with any plaque Schmermund et alSchmermund et al AJC 1998; 81:AJC 1998; 81: 141-146141-146
- 9. EBT and Coronary Artery CalciumEBT and Coronary Artery Calcium Define the extent of ASO disease?Define the extent of ASO disease? YESYES The amount of calciumThe amount of calcium correlates DIRECTLYcorrelates DIRECTLY toto the amount of measurable coronary disease by:the amount of measurable coronary disease by: 1) direct histopathologic comparison1) direct histopathologic comparison 2) with intravascular ultrasound2) with intravascular ultrasound
- 10. 3 4.4 8.8 0 2 4 6 8 10 Score 0 Score 1-15 Score 16- 80 Score 81- 270 Score >271 Relative Risk for Future CV Events using EBCT:Relative Risk for Future CV Events using EBCT: 926 initially asymptomatic patients926 initially asymptomatic patients 1st Quartile1st Quartile 2nd Quartile2nd Quartile 3rd Quartile3rd Quartile 4th Quartile4th Quartile * AdjustedAdjusted for age, gender, hypertension, past/current smoking, and diabetesfor age, gender, hypertension, past/current smoking, and diabetes Wong and Detrano, et al [Am J Cardiol 2000;86:495-498Wong and Detrano, et al [Am J Cardiol 2000;86:495-498 RelativeRisk(RR)RelativeRisk(RR)
- 11. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients: EBTEBT Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199 0.36 0.51 0.71 0.99 1.38 1.92 2.64 3.62 4.9 6.54 0 1 2 3 4 5 6 7 0 10 20 30 40 50 60 70 80 90 Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score 676 initially asymptomatic patients676 initially asymptomatic patients 3232++7 months f/u7 months f/u AnnualAnnual AbsoluteAbsolute RiskRisk
- 12. EBT CVSEBT CVS (volume score)(volume score) Progression and MIProgression and MI Raggi, Shaw, Callister, Budoff; JACC 2003Raggi, Shaw, Callister, Budoff; JACC 2003 (retrospective analysis)(retrospective analysis) 0 10 20 30 40 50 60 No MI MI MeanChangeinCVS/yearMeanChangeinCVS/year 26+1.5% 47.5+7.5% * n = 833, 2.1+1.4 yr f/u, 45 documented MI (2.2%/yr) Stepwise Cox Model Independent Predictors of MI Elevated cholesterol Diabetes Initial EBT-CVS % Change in EBT-CVS Initially asymptomatic patients with CVS > 30 and repeat EBT Scans
- 13. Coronary Artery CalcificationCoronary Artery Calcification AtAt PRESENTPRESENT the following has been established:the following has been established: o Coronary calcium IS AtherosclerosisCoronary calcium IS Atherosclerosis o The magnitude of the calcium score relates to the severity of ASO diseaseThe magnitude of the calcium score relates to the severity of ASO disease o The calcium score as well as the percentile rank provide informationThe calcium score as well as the percentile rank provide information in which to view risk factors, rather than the other way aroundin which to view risk factors, rather than the other way around o The data on examining progression of CAD with CT are consistent withThe data on examining progression of CAD with CT are consistent with the potential for the calcium score/rank to be used as the “goal” of therapythe potential for the calcium score/rank to be used as the “goal” of therapy
- 14. RR of non-fatal MI/Cardiac Death: EBT Score and hs-CRP 6.3 4.3 1.74.9 1.8 1 0 2 4 6 8 High CAC Med. CAC Low CAC Lowest quartile hs-CRP Highest quartile hs-CRP Park et al. Circ. 2002;106-2073-2077 6.3 RelativeRiskRelativeRisk 6.4 yr. f/u, n = 967 initially asymptomatic, non-diabetic individuals
- 15. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients: EBTEBT 0 1 2 3 4 5 6 7 0 10 20 30 40 50 60 70 80 90 Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score LowLow RiskRisk IntermediateIntermediate RiskRisk HighHigh RiskRisk
- 16. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients: EBTEBT 0 1 2 3 4 5 6 7 0 10 20 30 40 50 60 70 80 90 Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score LowLow RiskRisk IntermediateIntermediate RiskRisk HighHigh RiskRisk CRP CRP
- 17. Clinical Questions in PreventionClinical Questions in Prevention In the asymptomatic individual How aggressive should I be? Primary versus secondary prev. goals How closely should I follow up? Routine versus close & repeat testing
- 18. hs-CRP CAC Range Level of Aggression, f/u < 1 mg/L > 1-3 mg/L > 3 mg/L hs-CRP & CAC Scoringhs-CRP & CAC Scoring Value Range Percentile Range Aggression Clinical f/u Low Low Low Mod. Mod. Mod. High High High <25th Low >25th -<75th Intermed. >75th High <25th Low >25th -<75th Intermed. >75th High <25th Low >25th -<75th Intermed. >75th High Primary Routine Primary Routine Secondary Close Primary Routine Primary Close Secondary Close Primary Close Secondary Close Secondary Close
- 19. hs-CRP & CAC Scoringhs-CRP & CAC Scoring In “intermediate” risk asymptomatic individualsIn “intermediate” risk asymptomatic individuals CAC Scanning with CTCAC Scanning with CT && hs-CRP testinghs-CRP testing areare ComplementaryComplementary to each otherto each other and the combination of bothand the combination of both can be used to refinecan be used to refine Clinical-Decision making in such patientsClinical-Decision making in such patients