Prevalence and extent of coronary artery disease among patients with a zero calcium score

Nasih Mohsin Ahmed Gardi; Shaween Ziyad Jamil  Al-Talabany; Aras Rafiq Abdullah; Namir  Al-tawil; Shilan Jalal  Abdulla

doi:10.15218/zjms.2022.007

Authors

Nasih Mohsin Ahmed Gardi CT scan Department, Cardiac Centre, Surgical Specialty Hospital, Erbil, Iraq.
Shaween Ziyad Jamil Al-Talabany CT scan Department, Cardiac Centre, Surgical Specialty Hospital, Erbil, Iraq.
Aras Rafiq Abdullah Department of Surgery, College of Medicine, Hawler Medical University, Erbil, Iraq.
Namir Al-tawil Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq.
Shilan Jalal Abdulla CT scan Department, Cardiac Centre, Surgical Specialty Hospital, Erbil, Iraq.

DOI:

https://doi.org/10.15218/zjms.2022.007

Keywords:

Coronary calcium scoring, CT coronary angiography, Coronary artery disease stenosis

Abstract

Background and objective: Coronary artery calcium is a specific indicator of and an independent risk factor for atherosclerosis. However, calcium scoring may miss non calcified plaques, which were indicated to be of clinical importance. This study aimed to identify the presence of non calcified plaques in patients with zero coronary artery calcium score who have been examined with computed tomography coronary angiography and find out any association between the presence of non-calcified plaques and risk factors and presenting symptoms in those patients.

Methods: In this retrospective study, we analyzed the computed tomography images of 9826 consecutive patients attending the cardiac center in Erbil, Iraq, between January 2016 and September 2020. Of these patients, we included 2805 patients with a zero coronary artery calcium score in the study. Coronary calcium-scoring scans were followed by computed tomography coronary angiography (256 MSCT Philips ICT). The coronary artery calcium scores were calculated, and the presence of non calcified plaques and significant stenosis (>50% of vessel diameter) were evaluated.

Results: Of the 2805 patients with a zero coronary artery calcium score, 896 (31.9%) had atherosclerotic plaques; 143 patients (5.1%) had significant coronary stenosis. Among coronary risk factors, diabetes mellitus (OR = 2.1; 95% CI 1.4-3.3), hypertension (OR = 1.3; 95% CI 1.07-1.58)), male sex (OR = 1.9; 95% CI 1.5-2.3) and old age (OR was 3.2 for the age group 35-44 years reaching 27.7 in the age group ≥ 75 years) were significantly correlated with the presence of atherosclerosis and obstructive coronary artery disease.

Conclusion: Although coronary artery calcium scoring is a safe and reliable test to exclude obstructive coronary artery disease, the absence of coronary artery calcium does not absolutely exclude the presence of atherosclerosis. Computed tomography coronary angiography is mandatory for determining the atheroma burden from zero coronary artery calcium score plaques.

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References

Media center. The top 10 causes of death. WHO fact sheet No. 310. (Accessed March 2, 2021, at http://www.who.int/mediacentre/factsheets/fs310/en/).

Munnur RK, Cameron JD, Ko BS, Meredith IT, Wong DT.L. Cardiac CT: atherosclerosis to acute coronary syndrome. Cardiovasc Diagn Ther. 2014;4(6):430–48. https://doi.org/10.3978/j.issn.2223-3652.2014.11.03.

Neves PO, Andrade J, Monção H. Coronary arterycalcium score: current status. Radiol Bras. 2017;50(3):182–9. https://doi.org/10.1590/0100-3984.2015.0235.

Gottlieb I, Miller JM, Arbab-Zadeh A, Dewey M, Clouse ME, Sara L, et al. The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography. J Am Coll Cardiol. 2010;55(7):627–34. https://doi.org/10.1016/j.jacc.2009.07.072.

Bentzon CF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circu Research. 2014;114(12):1852–66. https://doi.org/10.1161/circresaha.114.302721.

Fernandez-Friera L, Garcia-Alvarez A, Guzman G, Garcia MJ. Coronary CT and the coronary calcium score, the future of ED risk stratification. Curr Cardiol Rev. 2012;8(2):86–97. https://doi.org/10.2174/157340312801784989.

Borren N, Maas HEM.A, Ottervanger JP. Stop invasive coronary angiography as the gold standard for the diagnosis of stable angina! Interv Cardiol. 2015;7(5):1–4.

Leipsic J, Abbara S, Achenbach S, Cury R, Earls JP, Mancini JG, et al. SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 2014;8(5):342–58. https://doi.org/10.1016/j.jcct.2014.07.003.

Sosnowski M, Pysz P, Szymanski L, Gola A, Tendera M. Negative calcium score and the presence of obstructive coronary lesions in patients with intermediate CAD probability. Int J Cardiol. 2011;148:16–8. https://doi.org/10.1016/j.ijcard.2009.01.077.

Ergün E, Kosar P, Öztürk C, Babay E, KoçF, Kosar U. Prevalence and extent of coronary artery disease determined by 64-slice CTA in patients with zero coronary calcium score. Int J Cardiovasc Imaging. 2011;27:451–8. https://doi.org/10.1007/s10554-010-9681-5.

Gabriel FS, Gonçalves LF.G, De Melo EV. Atherosclerotic plaque in patients with zero calcium score at coronary computed tomography angiography. Arq Bras Cardiol. 2018;110(5):420–7. https://doi.org/10.5935/abc.20180063.

Mittal TK, Pottle A, Nicol E. Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score. Eur Heart J Cardiovasc Imaging. 2017;18(8):922–9. https://doi.org/10.1093/ehjci/jex037.

Uretsky S, Rozanski A, Singh P, Supariwala A, Atluri P, Bangalore S, et al. The presence, characterization and prognosis of coronary plaques among patients with zero coronary calcium scores. Int J Cardiovasc Imaging. 2011;27:805–12. https://doi.org/10.1007/s10554-010-9730-0.

Ueda H, Harimoto K, Tomoyama S, Tamaru H, Miyawaki M, Mitsusada N, et al. Association between cardiovascular risk factors and the presence of coronary plaque in a zero or low coronary artery calcium score. Int J Cardiol. 2011;147:475–7. https://doi.org/10.1016/j.ijcard.2011.01.026.

Kral BG, Becker LC, Vaidya D. Non calcified coronary plaque volumes in healthy people with a family history of early onset coronary artery disease. Circ Cardiovasc Imaging. 2014;7(3):446–53. https://doi.org/10.1161/CIRCIMAGING.113.000980.

Koulaouzidis G, Charisopoulou D, Jenkins PJ, Koulaouzidis A, McArthur T. Prevalence of non-calcified coronary plaque in patients with calcium score of 0: the silent enemy. Angiology. 2013;64(3):205–10. https://doi.org/10.1177/0003319712440618.

Stocker TJ, Deseive S, Leipsic J, Hadamitzky M, Chen MY, Rubinshtein R et al. Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the prospective multicenter registry on radiation dose estimates of cardiac CT angiography in daily practice in 2017 (PROTECTION VI). Europ Heart J. 2018;39:3715–23. https://doi.org/10.1093/eurheartj/ehy546.

Leipsic J, Labounty TM, Heilbron B, Min JK, Mancini GB, Lin FY, et al. Estimated radiation dose reduction using adaptive statistical iterative reconstruction in coronary CT angiography: The ERASIR study. Am J of Roentgenology. 2010;195(3):655–60. https://doi.org/10.2214/AJR.10.4288.

Halliburton SS, Abbara S, Chen MY, Gentry R, Mahesh M, Raff GL, et al. SCCT Guidelines on Radiation Dose and Dose-Optimization Strategies in Cardio-vascular CT. J of Cardiovasc Comput Tomogr. 2011;5(4):198–224. https://doi.org/10.1016/j.jcct.2011.06.001.