James Rider, MD FACC Cardiology Associates of Bellin Health

1. Coronary Artery Calcium Scoring James Rider, MD FACC Cardiology Associates of Bellin Health

2. Epidemiology • Coronary disease is the leading cause of death in the U.S • 450,000 deaths yearly from coronary disease • There are 1.2 million new heart attacks yearly in the U.S. • Accounts for 36% of all deaths and exceeds death rates from all cancers and accidental deaths combined • Most people have no symptoms prior to a heart attack

3. Who is at Risk? • Most people who suffer a heart attack do not fall into a “high risk” category • The traditional tools we have to identify who is at risk depend on statistical analysis of large pools of historical data.

4. Quiz • Which of the following is the best predictor of a future heart attack: • A) High blood pressure • B) Diabetes • C) Age • D) High coronary calcium score • E) Smoking • F) High cholesterol

5. Quiz • Which of the following is the best predictor of a future heart attack: • A) High blood pressure • B) Diabetes • C) Age • D) High coronary calcium score • E) Smoking • F) High cholesterol

6. Case Example • 48 year old female executive • Avid distance runner • Total cholesterol 192 • Good cholesterol 41 • Bad cholesterol 124 • Blood pressure 122/71 • Smoked for 1 year while in college • Father died of heart attack at age 54

7. Case Example • What is her risk of a heart attack? • Should she be treated for her cholesterol?

8. Case Example

9. Case Example

10. Framingham Score

11. Goals in Primary Prevention of Cardiovascular Disease • Better identify those at risk for cardiovascular events by directly detecting plaque build-up early • Aggressive treatment of risk factors (cholesterol medication, aspirin, BP control, exercise, diabetes treatment, and quitting smoking) • By intensifying treatment strategies in those at the highest levels of risk this will improve efficacy, safety, and cost-effectiveness of these treatments

12. Is There a Better Tool for Identifying People Who are at Risk? • Routine exercise stress testing • C-reactive protein • Carotid Intimal Medial Thickness • Coronary Calcium Scoring

13. Coronary Calcium • Coronary calcification is found when the arteries harden from plaque build-up • First identified in the 1950’s from plain x-rays • Early generation CT scanners were able to detect calcium but scanner speeds too slow for reliable measurement of calcium in the beating heart • Faster CT speeds improved in the 1980’s to allow measurement of coronary calcium

14. Coronary Artery Calcium Scoring (CACS) • Recent generation CT scanners can image the beating heart in 6-10 seconds, latest generation in ¼ of a second • No IV or dye needed • Entire scanning process takes 5-10 minutes • Protocol designed to minimize radiation exposure • Typical radiation is equivalent to about 2 chest x-rays (about 8-10 times less than a standard CT)

15. Coronary Artery Calcium Scoring (CACS)

16. Coronary Artery Calcium Scoring (CACS)

17. Coronary Artery Calcium Scoring (CACS) • Normal score = 0 • Minimal disease = 1-10 • Mild disease 11-100 • Moderate disease 101-400 • Severe disease >400

18. Criticism for Calcium Scoring • Calcium scoring was criticized in the 1990’s for poor correlation between the amount of calcium and the presence of blockages • This is a fundamental misunderstanding • Coronary calcification = coronary disease • Up to 75% of all heart attacks occur at the site of non-critical blockages (50% blockage or less) and are due to ruptured plaque and clot formation

19. Positive Remodeling Early Late

20. How a Heart Attack Occurs

21. Prognostic Significance Shaw et al. Radiology 2003

22. Case Example • 48 year old executive with a Framingham score of 1% chance of a heart attack in the next 10 years based on statistical models • Coronary calcium score 1206 • Based on calcium score her risk is estimated at 20-30% over the next 10 years • Now identified as a high risk individual and will be treated as a coronary risk equivalent

23. Case Example

24. CACS in Green Bay • Calcium score historically costs $350-400 • Now much more affordable • Bellin Health $50 • Prevea Health $49.95 • Aurora BayCare $100 • Images of the chest are read by the radiologists • Available through a self-referral process based on criteria or through your primary care provider

25. Who Should Have the Test • Recommended by American Heart Association for people at intermediate risk (Framingham score 10-20%) • Can be considered in people who are at low risk (score <10%) but controversial • Criteria for self-referral at Bellin: • Male over age 30 with at least one risk factor • Female over age 40 with at least one risk factor • Controversial in patients at high risk (known diabetes or history of blockages in the arteries of the neck or legs) – these patients should be treated aggressively regardless of calcium score. Might help some of these patients become more motivated to treat risk factors aggressively • Controversial in older patients over age 70

26. Who Should Not Have the Test • History of angioplasty or coronary stents • History of coronary bypass surgery • Very low risk individual • Young patients with no risk factors • Patients who have already had a calcium score

27. What to Do With Test Results • Review results with your primary care provider • Remember the limitations of the test • Does not detect plaque that has not yet hardened • Review your risk factors with your provider and with the calcium score results create an individualized plan to treat your risk factors

28. Take Home Message • Coronary calcium scoring is a powerful tool for helping people identify if they are at risk for a heart attack. • Test is now widely available and affordable. • This test may detect early plaque that does not require treatment with stents or surgery but does requires aggressive treatment of risk factors.