Orlando, Florida – October 7-9, 2011

When to Order a Calcium Score and What to do with the ResultsJennifer Dickerson MD

Assistant Professor of Clinical Internal MedicineDirector, The Ohio State University Echocardiography Laboratory

Disclosures

None

Case Presentation: 65 yo Male

Presents for annual physical No symptoms with activity, exercise 5 days a week

PMHx: hyperlipidemiaMedication: 20mg simvastatin/325mg aspirinSocial Hx: 2ppd tobacco use x 20 years (quit 2009)

Current cigar use 1-2 x monthFm Hx: Father MI age 53, PGM, PGF and Mother MI 60s

PE: BP 168/83 HR 65, BMI 29Unremarkable physical findings.

LipidTotal cholesterol 221LDL 145HDL 41Triglycerides 176

Question:

“So Doc, how’s my heart doing? I don’t want to end up like my parents.”

Your reply“Looks great, keep up the good work. See you next year.”“I would keep your portfolio to short term investments”“Let’s look more closely at your cardiac risk factors”

Framingham Assessment: 19% risk score

ATPIII Executive summary

Atherosclerosis Timeline

FoamCells

FattyStreak

IntermediateLesion Atheroma

FibrousPlaque

ComplicatedLesion/Rupture

Endothelial Dysfunction

0-10 y/o 0-10 y/o 20 y/o and beyond

20 y/o and beyond

40 y/o and beyond40 y/o and beyondAdapted from Pepine AJC 1998

Calcium Scoring

EBCTMDCT

Drawing illustrates how a CT gantry works.

Schilham A et al. Radiographics 2010;30:1057-1067

Calcium scan technique with MDCT

Mahesh M , Cody D D Radiographics 2007;27:1495-1509

Calcium Scoring

Hou

nsfie

ld u

nits

(HU

)

Water 0

Calcium has high signal intensity in CT; based on x-ray attenuation relative to water

Threshhold for calcium scoring typically 130

Agatston score: weighted sum of HU over slices covering the heart

Calcification is one aspect of atherosclerosis

Calcium score indicates:Plaque burden? YesLuminal stenosis? No

JACC: vol 49, 3:2007

Multi-Ethnic Study of Atherosclerosis

NEJM 2008; 358;13:1336-45

Multi-Ethnic Study of Atherosclerosis

Patient selection for Calcium scoring

CAC for intermediate risk patients (10-20% 10 year risk) without symptoms (IIa)CAC may be reasonable for low to intermediate risk patients (6-10%) (IIb)

No data to support use in the young population of men less than 40 and women less than 50.

Greenland et al JACC vol 56, 25, 2010

Patient Case Continued

Calcium score RCA 237LAD 298LM noneCx none

Change treatment to secondary prevention guidelines

Conclusion

Intermediate risk (10-20% 10 yr risk)asymptomatic patientResult might reclassify patient to higher risk status