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Coronary Calcium Score
Azza Farag, MD
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Print ISSN: 1687-6652. Online ISSN: 1687-5958
Heart Mirror J 2010; 4(2): 162-163; originally published online November1, 2010
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Vol. 4, No. 2, 2010
Sep 2010: 157-169
Mini-Reviews
162
9. Dorros G, Jaff M, Mathiak L, et al. Multicenter Palmaz stent renal
artery stenosis revascularization registry report: Four-year followup
of 1,058 successful patients. Catheter Cardiovasc Interv 2002;
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10. Levy MS, Creager MA. Revascularization versus medical therapy
for renal-artery stenosis. The ASTRAL investigators. The New
England Journal of Medicine 2009; 361: 1953-1962. Vasc Med
2010; 15(4):343-5.
11. Collins R, Peto R, Gray R, et al. Large-scale randomized evidence:
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DA, editors. Oxford textbook of medicine. 3rd ed. Oxford, UK:
Oxford University Press; 1996. p. 21-32.
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for renal arterial stenosis: Where do we stand? A meta-analysis.
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13. Chrysochou C, Sinha S, Chalmers N, et al. Anuric acute renal failure
and pulmonary oedema: A case for urgent action. Int J Cardiol 2009;
132(1):e31-3.
3. Coronary Calcium Score
Azza Farag, MD
Abbreviations and Acronyms
EBCT : Electron Beam Computed Tomography
MDCT : Multidetector Computed Tomography
Coronary artery disease (CAD) is currently, and will
remain for the foreseeable future, the leading cause of
death and disability worldwide. Although effective plans
and tools are available for treating and delaying CAD
progression, treatments are underutilized because at risk
individuals are not easily identified. To date, in excess of
300 risk factors for CAD have been identified; however,
most of these are not independent of each other and the
number of truly independent risk factors remains small (1).
Coronary Calcium Score:
It is generally accepted that the presence of coronary
calcium correlates directly with coronary atherosclerotic
plaque burden and its detection is an established technique
for cardiovascular risk assessment (2). Its presence per
se as detected by electron beam computed tomography
(EBCT) or multidetector computed tomography (MDCT)
is significantly associated with incident cardiovascular
disease events independent of the traditional risk factors
such as blood pressure, plasma glucose level and cholesterol
levels (3, 4). But does the amount of this calcium could
independently predict adverse cardiac events, is still yet
not clear.
Calcium accumulates in the coronary arteries in an
age-related manner, and the accumulation appears to be
exponential because calcium continuously deposited in
pre-existing lesion; thus all scores must be adjusted for age
as well as for sex. Modification of the Framingham Risk
Chart variable (chronologic age) by a non-chronometric
variable (biologic age) which is the degree of calcium in
the coronary tree is a debatable issue. However, the concept
allows for a re-definition of conceived risk and might serve
for treatment decisions in primary prevention in subjects
with intermediate risk. The more the calcium becomes
apparent, the older is the coronary lesion in a given patients
and the higher is his subsequent risk (5).
It is important to report that coronary calcium scoring
examination does not define the location or severity of any
particular lesion and it is not substitute for the physiological
stress testing or angiography. Individuals with calcium
score over 10, have coronary heart disease and should
receive treatment to reduce the LDL cholesterol to less than
100 mg% as specified in the ATP III guidelines (6). Repeat
scans are suggested every one or two years to monitor
treatment response. Patients with score over 400 should be
considered for further evaluation to rule out an obstructive
lesion with an exercise or pharmacologic stress test.
These patients are at increased risk for the development of
symptomatic cardiac disease (4.8% per year). Individuals
with symptomatic angina and calcium score >400 have an
extremely high (~15% per year) cardiac event rate (2).
Extracoronary Calcification:
It is well established that atherosclerotic vascular
disease is a diffuse process, thus explaining the association
between coronary and extra-coronary atherosclerosis (7).
Recently, few studies involve extracoronary cardiac
calcification mainly the aortic valve, mitral annulus and
thoracic aorta in the risk profile of patients with suspected
coronary artery disease (7-10). The presence of aortic
valve calcium has been shown to be an independent
predictor of advanced coronary artery disease (7) as well
as carotid stenosis (11) reflecting the atherosclerotic
burden rather than just a degenerative change (12). The
prevalence of three-vessel obstructive coronary artery
disease is approaching 50% in patients with mitral annular
calcification (13).
Although, presence and severity of calcification in the
coronaries has been clearly established as an indicator for
an adverse cardiovascular outcome, the prognostic value of
extracoronary cardiac calcification remained not entirely
clear. It is imperative that the independent prognostic value
of these markers for future events of coronary as well as
non-coronary vascular tree (stroke, peripheral vascular
disease) needs to be asserted (14).
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163
Mini-Reviews
Vol. 4, No. 2, 2010
Sep 2010: 157-169
Corresponding Author
Azza Farag, MD
Cardiology Department, Cairo University, Egypt
E-mail: azzzabdelmoniem@yahoo.com
REFERENCES
1. http://newportbodyscan.com/TheHeartScan.shtm
2. O'Rourke RA, Brundage BH, Froelicher VF, et al. American
College of Cardiology/American Heart Association Expert
Consensus Document on electron-beam computed tomography for
the diagnosis and prognosis of coronary artery disease. J Am Coll
Cardiol 2000; 36(1):326-40.
3. Kondos GT, Hoff JA, Sevrukov A, et al. Electron-beam tomography
coronary artery calcium and cardiac events: A 37-month follow-up
of 5635 initially asymptomatic low- to intermediate-risk adults.
Circulation 2003; 107(20):2571-6.
4. Raggi P, Shaw LJ, Berman DS, et al. Prognostic value of coronary
artery calcium screening in subjects with and without diabetes. J Am
Coll Cardiol 2004; 43(9):1663-9.
5. Grundy SM. Coronary plaque as a replacement for age as a risk
factor in global risk assessment. Am J Cardiol 2001; 88(2A):
8E-11E.
6. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Executive Summary of The Third Report of
The National Cholesterol Education Program (NCEP) Expert Panel
on detection, evaluation and treatment of high blood cholesterol in
adults (Adult Treatment Panel III). JAMA 2001; 285(19):2486-97.
7. Yamamoto H, Shavelle D, Takasu J, et al. Valvular and thoracic
aortic calcium as a marker of the extent and severity of angiographic
coronary artery disease. Am Heart J 2003; 146(1):153-9.
8. Allison MA, Cheung P, Criqui MH, et al. Mitral and aortic
annular calcification are highly associated with systemic calcified
atherosclerosis. Circulation 2006; 113(6):861-6.
9. Adler Y, Fisman EZ, Shemesh J, et al. Spiral computed tomography
evidence of close correlation between coronary and thoracic aorta
calcifications. Atherosclerosis 2004; 176(1):133-8.
10. Wong ND, Sciammarella M, Arad Y, et al. Relation of thoracic
aortic and aortic valve calcium to coronary artery calcium and risk
assessment. Am J Cardiol 2003; 92(8):951-5.
11. Adler Y, Levinger U, Koren A, et al. Relation of nonobstructive
aortic valve calcium to carotid arterial atherosclerosis. Am J Cardiol
2000; 86(10):1102-5.
12. Watanabe K, Hiroki T, Koga N. Relation of thoracic aorta
calcification on computed tomography and coronary risk factors
to obstructive coronary artery disease on angiography. Angiology
2003; 54(4):433-41.
13. Adler Y, Herz I, Vaturi M, et al. Mitral annular calcium detected by
transthoracic echocardiography is a marker for high prevalence and
severity of coronary artery disease in patients undergoing coronary
angiography. Am J Cardiol 1998; 82(10):1183-6.
14. Nasir K, Katz R, Takasu J, et al. Ethnic differences between extracoronary
measures on cardiac computed tomography: Multi-
Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2008;
198(1):104-14.
4. The Burden of Atrial Fibrillation
Aly Zaki, MD, MRCP
Abbreviations and Acronyms
ACE-I : Angiotensin converting enzyme inhibitors.
AF: Atrial fibrillation.
ATHENA: Effect of dronaderone on cardiovascular
outcomes in high risk patients with atrial fibrillation or
atrial flutter study.
COCAF : Cost of Care Distribution in Atrial Fibrillation
patients study.
CRT : Cardiac resynchronization therapy.
CV : Cardiovascular
ICD : Internal cardiovertor defibrillator.
NYHA : New York Heart Association
PCI : Percutaneous coronary intervention.
QOL : Quality of life
RFA : Radiofrequency ablation
TE : Thromboembolism/thromboembolic
TRENDS: The relationship between daily atrial
tachyarrhythmia burden from implantable device
diagnostics and stroke risk study.
Despite a plethora of medications and procedures
used in the treatment and prevention of atrial fibrillation
(AF), morbidity and mortality related to the arrhythmia
remain substantial. AF poses a significant burden on
the quality of life of patients as well on the resources of
communities and healthcare providers. From the patients’
perspective, the symptomatic burden of the arrhythmia
often significantly impacts the quality of life. The
economic burden of treating and caring for patients with
AF, including treatment of related complications is both
costly and complex, often requiring specialist medical
care, hospitalization and interventional procedures. This
article briefly reviews the epidemiologic, temporal and
symptomatic burden of AF and the consequent economic
burden imposed by this prevalent arrhythmia.
Epidemiologic, Morbidity and Mortality Burden:
Atrial fibrillation is the commonest sustained
arrhythmia with an overall prevalence reported between
1 and 6% in the general population (1-3). Prevalence
rises to approximately 10% in those older than 80 years
and 15% for those over 90 years old, and data from the
Framingham Heart study estimate that 1 in 4 people above
the age of 40 will have AF at some point in their lives (1).
Furthermore, the reported prevalence of AF may actually
be underestimated seeing as sustained silent AF is likely
more common than previously thought. Indeed, modern
implantable devices such as pacemakers and ICDs show
that up to 50-60% of people older than 65 years have silent
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