Coronary Artery Calcium
Matthew Budoff, MD, FACC
Endowed Chair of Preventive Medicine
Professor of Medicine, UCLA Medical Center
Harbor-UCLA Medical Center
Torrance, CA
Deaths (in Thousands)
Cardiovascular Disease Deaths:
520
United States 1979–1999
Women
500
480
Men
460
440
420
400
NCEP I
NCEP II
NCEP III
3800
79
81
83 85
8
8 91
7 Years
9
9
3
95
American Heart Association. 2002 Heart and Stroke Statistical
Update. Dallas, Texas: AHA, 2001.
97
99
Leading Causes of Death for
All Males and Females
United States: 1996 Mortality
600
Deaths in Thousands
505,930
500
453,297
400
Male
Female
281,898
300
257,635
200
61,589
100
54,485
37,991
51,542
45,736
D
E
34,121
0
A
B
A Total CVD
B Cancer
C Accidents
C
D
E
A
D Chronic Obstructive
Pulmonary Disease
Source: CDC/NCHS and the American Heart Association.
B
F
E Pneumonia/Influenza
F Diabetes Mellitus
CHD - Breast Mortality
30
-3
4
40
-4
4
50
-5
4
60
-6
4
70
-7
4
80
-8
4
90
-9
4
10
0+
35%
30%
25%
Percentage 20%
of Deaths 15%
10%
5%
0%
Age, Years
CAD Mortality
Breast Cancer Mortality
CONVENTIONAL
(Population based) RISK FACTORS
Family History
 Diabetes Mellitus
 Elevated LDL Cholesterol
 Low HDL Cholesterol
 Tobacco Use
 Hypertension
 Obesity/Physical Inactivity

Coronary Artery Scanning
u NORMAL
CONDITION
Coronary Artery Scanning
u SEVERE
CALCIFICATION
DIAGNOSTIC SENSITIVITY
STRESS ECG
NON-INVASIVE
MODALITIES
$300
STRESS ECHO
$900
STRESS THALLIUM $1600
PET SCANNING
$2200
Coronary Calcium with CT
INTRAVASCULAR ULTRASOUND
INVASIVE
CORONARY ANGIOGRAPHY
MODALITIES
0%
20%
45%
60%
70%
DATA TAKEN FROM “THE DAWN OF A NEW ERA NON-INVASIVE CORONARY IMAGING” R. ERBEL HERZ 1996; 21, 75-77
$295
$150
$3,000
$5,000
90%
The challenge in diagnosis of
coronary heart disease
“The majority of people destined to die
suddenly will not have a positive exercise
test. The likely reason that they will die
suddenly is that only a mild, non-flow limiting coronary plaque will have been
present before the sudden development
of an occlusive thrombus.”
- Stephen Epstein
New England Medical Journal 1989
All Cause Mortality and CAC Scores:
Long Term Prognosis in 25,253 patients
0 (n=11,044)
1.00
1-10 (n=3,567)
11-100 (n=5,032)
0.95
Cumulative Survival
101-299 (n=2,616)
10.4 Fold
Increased
Risk
0.90
300-399 (n=561)
400-699 (n=955)
0.85
700-999 (n=514)
0.80
0.75
1,000+ (n=964)
0.70
2=1363, p<0.0001 for variable overall and for each category subset.
0.0
2.0
4.0
6.0
8.0
Time to Follow-up (Years)
10.0
12.0
Budoff, et al. JACC 2007; 49: 1860-70
MESA Study – 6,814 Patients: 3.5 year follow-up
Nonfatal MI & CHD Death
50
Hazard Ratio
40
30
20
10.26
(5.62,18.71)
10
Ref
14.13
(7.91,25.22)
4.47
(2.45,8.13)
0
None
1-100
Fully adjusted – Detrano et al– NEJM - 2008
100-300
>300
NCEP ATP-III : Noninvasive Testing - 2001
“measurement of coronary calcium is an option
for advanced risk assessment.
High coronary calcium scores (e.g., >75th
percentile for age and sex) denotes advanced
atherosclerosis and provides rationale for
intensified LDL-lowering therapy.”
AHA – Circulation 2005
This recommendation - to measure
atherosclerosis burden, in clinically
selected intermediate CAD risk patients
(eg, those with a 10% to 20% Framingham
10-year risk estimate) to refine clinical risk
prediction and to select patients for
altered targets for lipid-lowering therapies.
MEDICARE LCD- California

11. Quantitative evaluation of coronary
calcium to be used as a triage tool for lipidlowering therapy in patients with an
intermediate to high Framingham risk score.

12. Quantitative evaluation of coronary
calcium in patients with an equivocal stress
imaging test or in cases in which discordance
exists between stress imaging testing and
clinical findings.
Blue Shield – February 2005
Blue Shield – February 2005
2013 ACC/AHA Guideline on the
Assessment of Cardiovascular Risk
• After quantitative risk assessment:
assessment of 1 or more of the
following— family history, hs-CRP, CAC
score, or ABI—may be considered to
inform treatment decision making.
PREVENTION GUIDELINES
Goff 2013
“CAC is likely to be the most useful of
the current approaches to improving risk
assessment among individuals found to
be at intermediate risk after formal risk
assessment.”
MESA -CAC Distribution Across Statin Eligibility Groups*
*According to 2013 ACC/AHA Cholesterol Management Guidelines
10 year event rates in CAC 0:
0.5%/year in recommend statins (high intensity)
0.1%/year in consider statins (moderate intensity)
Nasir et al JACC 2015
CAC Distribution Across Statin Eligibility Groups*
*According to 2013 ACC/AHA Cholesterol Management Guidelines
10 year event rates in CAC 0:
0.5%/year in recommend statins (high intensity)
0.1%/year in consider statins (moderate intensity)
Nasir et al JACC 2015
CAC Distribution Across Statin Eligibility Groups*
*According to 2013 ACC/AHA Cholesterol Management Guidelines
10 year event rates in CAC 0:
0.5%/year in recommend statins (high intensity)
0.1%/year in consider statins (moderate intensity)
CAC 0 reclassifies ~ ½ of candidates as not eligible for statins
Nasir et al JACC 2015
EISNER Randomized Controlled Trial
2137 middle-aged + risk factors without CVD
45-79y without CAD/CVD followed 4 years
No Scan
Scan
• Clinical evaluation
• Clinical evaluation
• Questionnaire
• Questionnaire
• Risk factor consultation
• Risk factor consultation
• CAC scan
• Scan consultation
Rozanski. Berman. Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research. JACC 2011;57:1622.
Does CAC scanning improve
outcomes?
Parameters
Change in LDL-C
No SCAN
-11 mg/dL
CACS
-29 mg/dL
P
<0.001
Change in SBP
Exercise
New Lipid Rx
New BP Rx
New ASA Rx
Lipid Adherence
-5 mm Hg
36%
19%
18%
7%
80%
-9 mm Hg
47%
65%
46%
21%
88%
<0.001
0.03
<0.001
<0.001
<0.001
0.04
Rozanski. Berman. EISNER. JACC 2011;57:1622. CACS 0 = 631. CACS>400 = 109.
EISNER Study – Costs
Compared to No Scan Group
P<0.005 for both measures
Rozanski JACC 2011
What do Others
Think?
• In the broad middle, perhaps from 5% to 20% 10-year ASCVD risk,
there is room for the patient-clinician discussion espoused by recent
guidelines which could well be informed by judicious use of CAC
screening.
• Starting with a quantitative risk-based assessment, the patient and
clinician first calculate the 10-year risk. If, after dicussion, they are
uncertain whether the individual patient is likely to benefit from
initiating a statin, obtaining CAC score would be reasonable.
• Finding a CAC score of 0 in someone otherwise thought to be in a net
benefit group is a powerful reason to consider withholding statin
therapy.
• Likewise, the presence of a high CAC score in an individual at only
moderate predicted risk should be a powerful motivator to initiate
and adhere to statin therapy.
Rotterdam – Annals 2012
WHAT CORONARY ARTERY
CALCIFICATION MEANS
Atherosclerosis present in this vessel
 Higher levels of coronary calcium
correlate with higher risks
 Zero calcification (none seen) suggests
a very low probability of obstructive
disease and less than 1% chance of
heart attack and stroke over the next 5
years

ST FRANCIS RANDOMIZED TRIAL
Randomized Double Blind Placebo Controlled Trial of
Atorvastatin in the Prevention of Cardiovascular Events
Among Individuals With Elevated CAC Score
Atorvastatin 20 mg (N=490)
MI
No Prior CVD
Men, Women 50-70 years
Stroke
Placebo (N=515)
CAC >80%
CVD Death
of age-gender
CABG/PTCA
•Mean duration of treatment was 4.3 years.
•Treatment with atorvastatin reduced clinical endpoints by 30%
(6.9% vs. 9.9%), and MI/ Death by 44% (NNT 30)
•Event rates were more significantly reduced in participants
with baseline calcium score >400 (8.7% vs. 15.0%, p=0.046 [42%
reduction]). (NNT 16)
Arad Y et al. J Am Coll Cardiol 2005: 46: 166-172.
2010 ACC/AHA Guideline for Screening
in Asymptomatic Adults
I IIa IIb III
Measurement of CAC is reasonable for
cardiovascular risk assessment in asymptomatic
adults at intermediate risk (10% to 20% 10-year
risk.
I IIa IIb III
Measurement of CAC may be reasonable for
cardiovascular risk assessment persons at low
to intermediate risk (6% to 10% 10-year risk).
I IIa IIb III
In asymptomatic adults with diabetes, 40 years
of age and older, measurement of CAC is
reasonable for cardiovascular risk assessment.
IMPROVED
ADHERENCE
Coronary
Artery Scanning
u SEVERE
CALCIFICATION
The best predictor of a life
threatening illness is the early
manifestation of a life
threatening illness
Sir Geoffrey Rose
Cardiac Epidemiologist
Known for “The Rose Principle”
Contact Us
Phone: (310) 222-4107
 Email: Budoff@ucla.edu
