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RECENT DEVELOPMENTS IN CORONARY ARTERY CALCIUM Matthew Budoff, MD, FACC, FAHA

RECENT DEVELOPMENTS IN CORONARY ARTERY CALCIUM Matthew Budoff, MD, FACC, FAHA Endowed Chair of Preventive Cardiology Professor of Medicine Director, Cardiac CT Harbor-UCLA Medical Center, Torrance, CA. Disclosure.

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RECENT DEVELOPMENTS IN CORONARY ARTERY CALCIUM Matthew Budoff, MD, FACC, FAHA

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  1. RECENT DEVELOPMENTS IN CORONARY ARTERY CALCIUM Matthew Budoff, MD, FACC, FAHA Endowed Chair of Preventive Cardiology Professor of Medicine Director, Cardiac CT Harbor-UCLA Medical Center, Torrance, CA

  2. Disclosure Financial relationship with commercial interest listed below is not relevant to the CME activity: Dr. Matthew BudoffGrant Support from General Electric

  3. We Can Improve Preventive Screening! New Risk Calculator Black, • External Validation • Discriminating of Low to High Risk Subsets Unimpressive • Risk Overestimation Muntner JAMA 2014;311:1406-15., Cook JAMA Int Med 2014;174:1964-71., Ridker Lancet 2013;382:1762-65.

  4. RANA et al. REGARDS STUDY JACC 2016

  5. I I IIa IIa IIb IIb III III * * I IIa IIb III * Recommendations for Calcium Scoring Methods Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk. Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk). In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment.

  6. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk • If, after quantitative risk assessment, a riskbased treatment decision is uncertain, assessment of 1 or more of the following— family history, hs-CRP, CAC score, or ABI—may be considered to inform treatment decision making. • CIMT is not recommended for routine measurement in clinical practice for risk assessment for a first ASCVD event.

  7. PREVENTION GUIDELINES 2013 “assessing 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.”

  8.  POWER OF ZEROWarranty of a CAC Score 99.6% 99.3% 6,944 (42%) CAC=0 48 deaths Ketlogetswe AHA 2010

  9. Indirect costs associated with job absenteeism For our cohort of firefighters, a total of 163 work shifts were lost for cardiac evaluations in the MDCT arm compared with 787 work shifts in the MPI arm. At an average cost per shift of $602, this represented an estimated job absenteeism cost of $98,126 for the MDCT arm and $473,774 for the MPI arm. Thus, the MDCT pathway saved a total of $375,648 in total job absenteeism costs, equaling $759 in job absenteeism cost savings per firefighter.

  10. A 9-month resource utilization analysis showed a highly significant (P,0.001) 27% reduction in total health care expenditures for patients who underwent CTA first, or $467 cost savings in a 9-month follow-up period. Despite significantly lower total health care expenditures, no differences were observed between the CTA and MPI groups for rates of adverse cardiovascular events, including CAD hospitalizations, CAD outpatient visits, myocardial infarction, and new-onset angina.

  11. CAC and CHF – Rotterdam JACC 2012 • 1897 Patients • 6.8 year follow up • CAC scores were associated with heart failure (p 0.001), with a hazard ratio of 4.1 • Net reclassification index 34.0%.

  12. Shemesh - Ungated Studies8782 patients, 6 year f/u • 1.2% CV death- 0 • 1.8% for a score • of 1–3 • 5.0% for a score of 4–6, • 5.3% for score of 7–12 • A CAC ordinal score of at least 4 was a significant predictor • of CV death (odds ratio 4.7; P <.0001)

  13. EISNER Randomized Controlled Trial 2137 middle-aged + risk factors without CVD45-79y without CAD/CVD followed 4 years No Scan Scan • Clinical evaluation • Questionnaire • Risk factor consultation • Clinical evaluation • Questionnaire • Risk factor consultation • CAC scan • Scan consultation Rozanski. Berman. Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research. JACC 2011;57:1622.

  14. Does CAC scanning improve outcomes? Rozanski. Berman. EISNER. JACC 2011;57:1622. CACS 0 = 631. CACS>400 = 109.

  15. EISNER Study – Costs Compared to No Scan Group P<0.005 for both measures Rozanski JACC 2011

  16. ST FRANCIS RANDOMIZED TRIALRandomized Double Blind Placebo Controlled Trial of Atorvastatin in the Prevention of Cardiovascular EventsAmong Individuals With Elevated CAC Score Atorvastatin 20 mg (N=490) MI Stroke CVD Death CABG/PTCA No Prior CVD Men, Women 50-70 years CAC >80% of age-gender Placebo (N=515) • 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.

  17. Adults younger than 50 years with any CAC, even with very low scores, identified on a CT scan are at elevated risk of clinical CHD, CVD, and death. Selective use of screening for CAC may be considered in individuals with risk factors in early adulthood to inform discussions about primary prevention.

  18. Quantification of CAC score in addition to the guidelines improves stratification between subjects at high versus low risk for coronary events, indicating that CAC scoring helps match intensified risk factor modification to atherosclerotic plaque burden as well as actual risk while avoiding therapy in subjects with low coronary atherosclerosis that have low 10-year event rate.

  19. Atherosclerosis and CHD Jim Fixx, 53 Sir Winston Churchill, 91  J Rumberger

  20. Very High NNT in Almost 50% of Individuals Meeting JUPITER Criteria in MESA

  21. A picture is worth 1000 words

  22. Using the Coronary Artery Calcium Score to Guide Statin Therapy: A Cost-Effectiveness Analysis FRS TC HDL 55 yo woman 7.5% 221 40 55 yo man 7.5% 159 40 Treat if CAC>0 Treat All Women QALY +229 +172 $ per QALY $18,000 $78,000 Men QALY +248 +144 $ per QALY $19,000 $80,000 Pletcher, Greenland. Circ Cardiovasc Qual Outcomes. 2014;7:276-284

  23. Roberts Plos ONE 2015

  24. Testing and Costs Go Down after implementation of NICE – BMJ 2015

  25. Very High NNT in Almost 50% of Individuals Meeting JUPITER Criteria in MESA

  26. Improved Adherence • Positives Effects • Statins • Aspirin • Diet • Weight Loss • Excerise

  27. CONCLUSION CAC assists in matching intensity of therapy to intensity of risk Leads to lower Blood Pressures, Better statin use, lower cholesterol and weight loss Cost Effective - POWER OF ZERO – avoid statins and aspirin in those at very low risk Cost and radiation exposure of a mammogram – without the need for annual testing

  28. Coronary Calcium

  29. Widowmakerthemovie.com

  30. Questions? • Contact Me: • budoff@ucla.edu • (310) 222-4107

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