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Scores >400 are are 10-fold Scores >400 are are 10-fold increased risk; Calcium increased risk; Calcium
imaging should be routineimaging should be routine
Matthew J. Budoff, MD, FACCMatthew J. Budoff, MD, FACCAssistant Professor of MedicineAssistant Professor of Medicine
Division of CardiologyDivision of CardiologyHarbor-UCLA Medical Center
Torrance, CA
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Presenter Disclosure Information
DISCLOSURE INFORMATION:The following relationships exist related to this presentation:
Dr. Budoff is on the Speaker’s Bureau for Imatron, Inc.
Matthew Budoff, MD, FACCHigh Speed CT
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Coronary Artery Scanning
SEVERECALCIFICATION
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20%20%
80%80%
Total Coronary Artery PlaqueTotal Coronary Artery Plaqueand EBCT Coronary Calciumand EBCT Coronary Calcium
80%80%
PlaquePlaqueDetectableDetectableby IVUS,by IVUS,PathologyPathology
Lipid RichLipid Rich
FibroticFibrotic
CalcifiedCalcified 20%20%
80%80%
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926 Asymptomatic Patients followed for over 3 years
All patients who suffered hard events had coronary calcium scores >16 at baseline (sensitivity = 100%)
Increasing scores (plaque burden) associated with increasing event rates
Odds ratios of 8.8 for future events Odds ratio included standard risk factors in a
multivariate model
Prognostic Data
WONG and Detrano
AJC September 2000
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Predictive Power > 75th Percentile
4.9
21 20
8.8 9.6710.8 13.4
0
5
10
15
20
25
Rel
ativ
e R
isk
Detrano Arad Kondos Georgiou Raggi Wong Detrano
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Event Rates Based upon Scores
0.8
21
4148
020
4060
Estimated10 Year Event
Rate
Zero 1 99 100-400 >400EBT Calcium Score
Raggi, AHJ 2001
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Rotterdam Heart Study
2,013 patients Scores of 101-500 were associated with more than
a two-fold increased risk of stroke. Scores above 500 were over three times more likely
to suffer a stroke over the next three years. Age-adjusted odds ratio for MI in subjects with the
highest calcium scores was 7.7 for men, and 6.7 for women
Vliegenthart R et al. Stroke. 2002 and Eur Heart J 2002
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10 Year All-Cause Mortality0
1020
30
% M
orta
lity
0-79 80-159 160-599 >600
Scores
Agatston 2000: AHA Abstract
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CONVENTIONALCONVENTIONAL (Population based) RISK FACTORS (Population based) RISK FACTORS
Family History Diabetes Mellitus Elevated LDL Cholesterol Low HDL Cholesterol Tobacco Use Hypertension Obesity/Physical Inactivity
These risk factors
only explain
50-66%50-66% of cardiac
events
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Over 50% of cardiac events occur in ‘intermediate risk’ patients, as classified by NCEP or Framingham risk analysis
70% of all events occur at mild stenosis (<50%)
Compliance with anti-atherosclerotic therapy is less than 50% at one year
The Challenge in Diagnosis ofThe Challenge in Diagnosis of CORONARY HEART DISEASECORONARY HEART DISEASE
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Stress Testing is not enough
““The majority of people destined to die The majority of people destined to die suddenly will not have a positive exercise test. suddenly will not have a positive exercise test. The likely reason that they will die suddenly is The likely reason that they will die suddenly is that only a mild, non-flow -limiting coronary that only a mild, non-flow -limiting coronary plaque will have been present before the plaque will have been present before the sudden development of an occlusive sudden development of an occlusive thrombus.”thrombus.”
- Stephen Epstein - Stephen Epstein New England Medical Journal 1989New England Medical Journal 1989
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Asymptomatic Patient Algorithm for Asymptomatic Patient Algorithm for Intermediate Risk PatientsIntermediate Risk Patients
Greenland P, et al. Circulation Oct 9, 2001
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Refining Framingham Risk Score
EBT derived “Arterial Age”
a man is as old as his coronaries…
Syndenham 1689
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% of Cases with Calcium Present prior to Cardiovascular Events
0%10%20%30%40%50%60%70%80%90%
100%
RiskFactors
Arad Agatston Georgio
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““the finding of advanced the finding of advanced subclinical subclinical atherosclerosis by noninvasive testingatherosclerosis by noninvasive testing can be helpful for confirming the can be helpful for confirming the presence of high risk persons... and presence of high risk persons... and have utility in selected persons to guide have utility in selected persons to guide intensity of risk-reduction therapy”intensity of risk-reduction therapy”
NCEP ATP-III : Noninvasive TestingNCEP ATP-III : Noninvasive Testing
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Subclinical Atherosclerosis