Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management

Abstract

Clinicians often use risk factor-based calculators to estimate an individual's risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management.

Figure 1.

Rate of cardiovascular death or myocardial infarction according to the presence, severity and extent of coronary artery disease (CAD). There is a significant difference (p < 0.01) in rates for all comparisons except non-obstructive CAD with segment involvement score >4 and obstructive CAD with segment involvement score (SIS) ≤4. Reproduced from Bittencourt et al with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health. pt, patient.

Figure 2.

Survival free from cardiovascular death or myocardial infarction according to the presence, severity and extent of coronary artery disease. CAD, coronary artery disease; CCTA, coronary CT angiography; CVD, cardiovascular death; MI, myocardial infarction; SIS, segment involvement score. Reproduced from Bittencourt et al with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health.

Figure 3.

Coronary artery calcium (CAC) score prognosis and recommended treatment strategy. Note that the estimated number needed to harm with aspirin use is 442 patients to cause 1 major bleeding episode over a 5-year period. Thus, consider aspirin use in patients with CAC score of 1–100 when anticipated benefit exceeds risk [e.g., when Framingham risk score (FRS) ≥10%]. The amount of calcium is quantified using the Agatston score. CHD, coronary heart disease; CVD, cardiovascular disease.

Figure 4.

coronary artery disease (CAD) severity identified by coronary CT angiography and recommended management. Patients with a normal coronary CT angiography can be safely reassured. Follow-up for preventive therapy is recommended for non-obstructive (<50%) CAD. For obstructive CAD (≥50% stenosis), further testing is recommended to guide management. Adapted from Cheezum et al with permission from Informa Healthcare.

Figure 5.

Event-free survival according to the presence or absence of statin therapy post-coronary CT angiography among patients with non-obstructive coronary artery disease, stratified by extent of disease according to segment involvement score (SIS). CCTA, coronary CT angiography; CV, cardiovascular; MI, myocardial infarction. Reproduced from Hulten et al with permission from Wolters Kluwer Health.