Big CTA trial shows
coronary plaque risk in low-risk patients
People considered to be at low risk for coronary artery disease aren't so
low-risk after all, according to early results from a large
coronary CT angiography (CTA) screening study in Korea.
one of the heftiest trials to date examining individuals at low
risk of coronary artery disease, researchers from Seoul National
University College of Medicine in Korea examined more than 8,000
low-risk patients and found lots of coronary artery plaque --
and, notably, noncalcified plaque that would not have been found
using coronary artery calcium (CAC) scoring in their population.
risk scores have been shown to underestimate the risk of
coronary artery disease in women and younger individuals, while
overestimating the risk in Japanese-American and Hispanic men.
Framingham often classifies medium-risk and high-risk subjects
as low risk.
risk score assessment categorized participants into three risk
risk: n = 5,326 (66.5%)
risk: n = 1,636 (20.8%)
risk: n = 1,006 (12.8%)
results showed coronary atherosclerotic plaque, including
noncalcified plaque, in significant numbers of patients deemed
low risk based on Framingham scores . Among 5,325 subjects
classified as low risk,
793 (14.9%) had more than one plaque, while 84 subjects
(1.6%) had significant coronary artery stenosis. Importantly,
"442 subjects (0.8%) had significant stenosis caused by
artery calcium progression predicts mortality
new observational study shows coronary artery calcium (CAC)
progression predicts mortality independently of other cardiac
risk factors in people with detectable CAC at baseline.
more calcium progression, the more therapy the person
needs," said Dr. Matthew Budoff, a researcher at Los
Angeles Biomedical Research Institute in Torrance, California.
His team's findings appeared online today in the Journal of
the American College of Cardiology: Cardiovascular Imaging.
"The additional therapy needed must be individualized, so
if the LDL is still above 70 mg/dL, I would recommend additional
statins. If the HDL is < 50 mg/dL, I would consider
niacin," he told Reuters Health in an e-mail.
Budoff and colleagues looked at 4,609 asymptomatic patients who
had undergone repeat CAC measurements with electron beam
tomography at least 10 months apart. Among the 1,743 patients
with a baseline CAC score of zero, there were 52 deaths, and no
significant relation between development of CAC and mortality.By
contrast, of the 2,866 with baseline scores greater than zero,
236 died -- and of the 2,183 with CAC of greater than thirty,
204 died. There was a significant link between CAC progression
and mortality in both groups, with the square root method
providing the best prediction.
adjusting for demographics, baseline CAC values and cardiac risk
factors, progression yielded a hazard ratio of 3.32 (p <
registry CONFIRMs prognostic value of coronary CT angiography in
CT Angiography Evaluation For Clinical Outcomes International
Multicenter (CONFIRM) registry provides unprecedented
statistical power to help answer important questions about the
prognostic value of coronary computed tomography angiography (CTA)
in patients with symptoms of coronary artery disease.
investigator Dr James Min (Weill Medical College
of Cornell University, New York, NY) presented the first findings
from the overall prognosis data from CONFIRM, which has enrolled
about 27 000 patients at 12 centers in five countries so far,
at the recent American
Heart Association (AHA) 2010 Scientific Sessions. The data
"indicate that the findings that we see on CT angiography
mean something, and they actually help us stratify the risk of
individuals into different categories," Min said at the
obstructive disease and nonobstructive disease are ill omens
Importantly, the data showed that the presence of either
nonobstructive or obstructive (>50% stenosis) coronary disease
predicted all-cause mortality. "Nonobstructive coronary
artery disease, for which functional testing might be expected to
be negative, demonstrates a very strong relationship with
[mortality]," Min said. For example, patients with a <60%
stenosis, in whom a stress test would not reveal a coronary
obstruction, are at a 60% increased relative risk of all-cause
death compared with patients with a normal coronary artery.
"We need to start changing our paradigm of what these
[sub-50%] stenoses or what these plaque burdens actually
analysis also found the relationship of CAD to the risk of death
was different for patients over 65 and younger patients. For
nonobstructive and one-vessel disease, the risk was similar across
age groups, but in patients with disease in two or more vessels,
the mortality risk is about twice as high if the patient is under
65 than it is for older patients. Also, women with nonobstructive
or single-vessel disease were at about a 50% higher risk of death
than men with a similar CAD pattern, but disease in two or more
vessels presented about the same risk in both genders.
reclassifies many patients into low-risk category
"If you look at the Framingham score as a comparison, we see
that the low-risk Framingham score fails to identify the real
low-risk patient population," Hadamitzky said. The CONFIRM
score has a linear relationship with the annual CAD event rate. An
increase of 10 points in the CONFIRM score is equivalent to an
increase in the annual death rate of 1%, he explained.
calcium weeds out JUPITER-like patients who will benefit from
statins, beats CRP for risk prediction
it was published and presented two years ago, JUPITER created
quite a stir, particularly since the trial showed that patients
with normal LDL-cholesterol levels but with other risk factors
would be eligible for statin therapy.
half of patients meeting the criteria for statin therapy based
for the Use of Statins in Primary Prevention: An Intervention
Trial Evaluating Rosuvastatin (JUPITER)
have a low risk of cardiovascular events when assessed with
coronary artery calcium (CAC) imaging scans, according to the
results of a new study. Among patients with calcification of the
coronary artery, the risk of cardiovascular events was
significantly greater than those without calcification,
suggesting that CAC assessed by computed tomography (CT) might
be used to further stratify at-risk patients for statin therapy.
Michael Blaha (Johns
Hopkins Medical Institute, Baltimore, MD) said, "If you fit
the JUPITER criteria, which is sort of an older population, and
you have no coronary calcium, your event rate is so low that you
can't expect to get much from a statin in terms of event
reduction in the next five to 10 years. The other patients we
saw had calcium, with 25% of patients having the most calcium,
and their event rate was 20 times that observed in patients
analysis was presented earlier this week at the American
Heart Association (AHA) 2010 Scientific Sessions.
a second analysis comparing hs-CRP vs CAC for risk prediction,
the group found that CRP did not predict events after adjustment
for other risk factors among the 2083 MESA patients who met the
criteria for JUPITER. CAC, on the other hand, had a strong
relationship with clinical events, regardless of CRP status.
think that it is time to move past traditional risk factors and
serum biomarkers and toward incorporation of measures of
subclinical atherosclerosis in risk prediction," said
Blaha. "This makes sense because we are directly measuring
the disease we propose to treat with statins. Measuring
subclinical atherosclerosis can help determine who is more
likely to benefit from statins and who is unlikely to benefit. . . . We
are not saying that everybody needs a CAC scan. However, it is
very helpful in asymptomatic patients in whom the question of
statin benefit is uncertain."
safe to send home patients with negative CTA
with chest pain can be safely sent home from the emergency
room following a negative cardiac computed tomography
angiogram (CCTA), a study published in the October 2010 issue
of the American
Journal of Roentgenology shows.
William Shuman (University
of Washington, Seattle) enrolled 81 patients who had
standard-of-care evaluations for low- to moderate-risk chest
pain and an ECG-gated CCTA in the emergency department.
Of the 70 patients who had negative CCTA results, none had
adverse cardiac event during the one-year follow-up period.
Three of the four patients with 50% or greater stenosis on
their cardiac CT had subsequent cardiac catheterization and
discharge strategy would save money
CCTA has a high negative predictive value, we can save
considerable costs by discharging these patients following the
negative CT scan.
scans can be done in just a few minutes and at a very low
radiation dose to the patient. It makes this particular test
very appealing to both the ordering physician and the patient
compared with alternative methods for evaluating chest
pain," she stressed.
Low Framingham Score May Underestimate Coronary Artery Disease
Risk Compared With the Presence of Calcium
April 22, 2010 — Almost two thirds of women
and one fourth of men with substantial atherosclerosis will be
missed if subjects are excluded from further screening because
they are in the Framingham low-risk category, according to a
report published in the May issue of the American Journal of
Roentgenology."Many coronary events occur in patients
without warning, and the need for an effective screening program
has been recognized for many years. Historically, the Framingham
risk score has been the dominant method of risk stratification in
the United States," write study coauthors Kevin M. Johnson,
MD, from the Department of Diagnostic Radiology, Yale University
School of Medicine, New Haven, Connecticut, and David A. Dowe,
from Atlantic Medical Imaging, Galloway, New Jersey.
In participants with a segment plaque score of 4
or higher, the presence of any calcium was 98% sensitive in men
and 97% sensitive in women. In contrast, a Framingham risk score
of 10% or higher was only 74% sensitive in men and 36% sensitive
in women. The negative likelihood ratio for the presence of
calcium was 0.04 in men and women, whereas the negative likelihood
ratio for a Framingham risk score of 10% or lower was 0.38 in men
and 0.71 in women.
"As our study suggests, the presence of
coronary artery calcium detects more patients with coronary
atherosclerosis than does the Framingham risk assessment
score," Dr. Johnson noted in a written release. "If the
Framingham risk score is used as the 'gatekeeper' in a screening
program for coronary atherosclerosis and the low-risk patients are
dismissed from further study, about two thirds of women and a
quarter of men with substantial atherosclerosis will be
In Patients With Stable Chest Pain, CT Is More
Often Diagnostic Than Exercise ECG
YORK (Reuters Health) Oct 30 - Unlike exercise
electrocardiography (XECG), CT angiography (CTA) is "nearly
always" feasible and diagnostic in patients with stable
chest complaints, researchers say in the October issue of the
XECG is "a well-established and inexpensive procedure...and
has been in widespread clinical use for decades," this test
"is also known for its modest diagnostic accuracy,"
Dr. Koen Nieman and colleagues from Erasmus Medical Center,
Rotterdam, the Netherlands, write.
their recent study, the researchers compared the diagnostic
performance of the two tests in 471 symptomatic ambulatory
to their report, non-diagnostic or inconclusive results were
seen in 0.7% of CT scans and 33% of XECGs.
30% of CT angiograms showed >50% stenosis in at least one
vessel. Thirty-three percent of XECGs were abnormal. Results of
CTA and XECG matched in 68% of patients with interpretable
sensitivity, specificity, and positive and negative predictive
values of CTA for identifying patients with at least 50%
stenosis were 96%, 37%, 67%, and 88%, respectively. For XECG,
the corresponding values were 71%, 76%, 80%, and 66%.
CRP versus Coronary Calcum in Screening for
Several studies have compared various
techniques for risk stratification, including both CAC and CRP.
Four studies comparing predictive abilities of hsCRP to CAC have
demonstrated that CAC remains an independent predictor of
cardiovascular events in multivariable models, while CRP no
longer retains a significant association with incident CHD. This
has been confirmed recently in the MESA trial, which found that
CAC score is a better predictor of subsequent cardiovascular
disease events than CRP and carotid intima–media thickness
(IMT). Carotid IMT is another measure of atherosclerosis and is
also considered to be a nontraditional risk factor.
Characteristics of carotid atherosclerosis have been associated
with cardiovascular disease events, such as cerebral stroke and
myocardial infarction. Multivariable analysis revealed hazard
ratios for CHD were 1.7 (1.1–2.7) for carotid IMT and 8.2
(4.5–15.1) for a CAC score.
Consensus Statement From the Cardiac
Imaging Committee, Council on Clinical Cardiology, and the
Cardiovascular Imaging and Intervention Committee, Council on
Cardiovascular Radiology and Intervention, American Heart
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