The document discusses cardiovascular risk assessment in asymptomatic patients, specifically evaluating a 50-year-old asymptomatic smoker using coronary artery calcium scoring. Coronary artery calcium scoring can help reclassify patients' risk levels compared to traditional risk models and may lead patients to modify risk factors or receive preventative treatments. However, calcium scoring has limitations and its ability to improve outcomes beyond risk factor modification requires further study.

1. Cardiac Imaging of
50 Years old Asymptomatic Smoker
Toward a better CV Risk Predcition
Philippe DOUEK
Cardiovascular Imaging Department
Hôpital Louis Pradel
Lyon

2. Prevalence of CV Diseases
Les maladies cardiaques coronaires sont la cause la plus fréquente de décès dans notre
société
⇒ Recherche de techniques non invasives
pour un diagnostic précoce et un suivi fiable

3. CV Risk Assessment
– Risk Score in asymptomatic patients:
• Framingham
• Euroscore
– Useful when selecting the most appropriate candidates
for drug therapies intended to reduce risk

4. CV Risk Assessment
Major risk factors include:
• cigarette smoking
• hypertension (BP greater than or equal to 140/90 mm Hg or on
antihypertensive medication)
• low HDL cholesterol (less than 40 mg/dL),
• family history of premature CHD (CHD in male first-degree relative
less than 55 years; CHD in female first-degree relative less than 65
years)
• age (men greater than or equal to 45 years; women greater than or equal
to 55 years).

5. CV Risk Assessment
• CHD Risk—Low
– Defined by the age-specific risk level that is below average.
– low risk will correlate with a 10-year absolute CHD risk 10%.
• CHD Risk—Intermediate
– moderate risk will correlate with a 10-year absolute CHD risk between
10% to 20%.
• CHD Risk—moderately high risk:
– 2+risk factors plus a 10-years risk for hard CHD less than 10%
•
CHD Risk—High
– Defined as the presence of diabetes mellitus in a patient 40 years of
age, peripheral arterial disease or other coronary risk equivalents
(2+risk factors),
– or the 10-year absolute CHD risk of 20%.

6. Heart Evaluation
50 Years old Asymptomatic Smoker
• CHD Risk—Intermediate
– 2+risk factors
– moderate risk will correlate with a 10-year absolute CHD risk between 10% to 20%.

7. Predicitive Value of Risk Score
Sensitivity: 75 %
Spécificity: 50 %
Spécificity: 80 %
Sensitivity; 50 %
HCL/UCBL

8. CV Risk Assessment:
• CV Risk score failure in 25 à 50% of patients
– CHD Risk—Intermediate
• Conventional risk factors do not explain high or
lower risk in subgroup of patients
– Intensity and duration of smoking
– Age and Duration of Diabetes
– Genomic factors

9. Recommendations (HAS)
Screening for Ischemic heart disease:
• Stress Echo
• Spect Imaging
• Limitations
– Cost efficicacy?
– Operator dependent

10. Atherosclerosis: Plaque rupture -----AMI
10

11. Introduction to CAC Measurement
Coronary remodeling and calcifications
11

12. Introduction to CAC Measurement
• Calcium because of its high density can be easily detected, segmented,
and quantified:
• Coronary calcifications more frequently found in advanced lesions or in
ederly population
• Positive correlation between localisation and amount of Ca and % of
sténosis, but non linear relationship with large confidence interval
• Coronary calcifications could be founded on segment without stenosis
• Relationship between calcified plaque and rupture is unknown
• Statines can decrease or increase coronary calcification burden
•
Greenland et al ACCF AHA expert consensus document on CAC Circulation 2007

13. Agatston Score * Definition:
ü 20 3 mm axiales slices covering the heart
ü Ca ++ Structures < 1 mm2 exclued (noise)
ü Surface above threshold (ROI i, coronaire j): Aij
ü pondération factor fonction maximal density
ü
wij = 1 if 130 HU < CTij Max < 200 HU
2 if 200 HU < CTij Max < 300 HU
3 if 300 HU < CTij Max < 400 HU
4 if 400 HU < CTij Max
ü Lesion Score = wij x Aij
ü Total Score = scores sommation
Mesure HU Maxi = CTij Max
Surface Aij
SAG =
Σij wij Aij
• Agatston AS, et al. Quantification of coronary artery calcium using ultrafast computed tomography.
J Am Coll Cardiol1990;15:827

14. Ca Score : Validation
• MDCT: Technique validation and software plateformes **:
– Dose < 1mSv 2
– New algorithms** :
• Calcium masse score
• Calcium volume score
**Kopp AF, Ohnesorge B, Becker C, et al. Reproducibility and accuracy of coronary calcium
measurements with multi-detector row versus electron-beam CT. Radiology 2002; 225:113-119
**Weiniger M, et al Radiology, 2012; 265, 70-77.

16. Calcium scoring

17. Agatston Score: Exemple
ARCA,1= 53,9 mm2
ARCA,2= 70,1 mm2
CTmax= 536 HU
wRCA,1 = 4
CTmax= 544 HU
wRCA,2 = 4
AG
SRCA =
ARCA,3= 72,0 mm2
ARCA,4= 28,6 mm2
CTmax= 425 HU
wRCA,3 = 4
CTmax= 314 HU
wRCA,4 = 3
869,8

18. Avantages
•
•
•
•
No injection
Low dose
Fast Acquisition
Fast and simple post processing

19. Calcium Scoring
Risk table: SAG by (EB)CT
Calcium Score
0
1 - 10
11 - 100
101 - 400
over 400
Diagnosis
Very low CVD risk
Low CVD risk
Moderate CVD risk
High CVD risk
Very high CVD risk

20. Ca Score : Cohorte Follow up
22% at 10 Y
HCL/UCBL/INSERM U870
Detrano R NEJM 2008

21. RR Ratios According to Level of Risk for CACS
From Average Risk to very high risk
Greenland et al ACCF AHA expert consensus
document on CAC Circulation 2007

22. During a median of 5.8 years of follow-up among a final cohort of 5878, 209
CHD events occurred, of which 122 were myocardial infarction, death from
CHD, or resuscitated cardiac arrest.
• In model 1 (conv FRCV): 69% of the cohort was classified in the highest
or lowest risk categories compared with 77% in model 2 (CACS)
• CACS resulted in a net reclassification improvement = 0.25; 95%
confidence interval, 0.16-0.34; P < .001).
• Using CACS An additional 23% of those who experienced events were
reclassified as high risk, and an additional 13% without events were
reclassified as low risk
HCL/UCBL/INSERM/CNRS
Polonsky TS et al JAMA 2010

23. NRI: (%) of reclassification in population with
intermediary risk (Framingham Score)
Kavousis M et al Ann Int Med 2012

24. Calcium Score: CV Mortality rate
6,8 years follow-up n= 14 759
Critiques:
Quelle valeur prédictive additive
quid des calcifications diffuses
atherome diffus distal
médiacalcose
HCL/UCBL/INSERM / CNRS
Williams M et al JACC imaging 2008

25. n = 14 759 pts x 6,8 Y
Calcium score:
LM Lesions
>6 calcified LM lesions mortality rate 13,6 % / Y
HCL/UCBL/INSERM CNRS
Williams M et al JACC imaging 2008

26. CAC score: Pronostic Value
>10 000 patients refered for Ca Score, 10% diabetes*
Patients score > 400
Patients score 0

27. Ca Score: Additionnal value for CV Risk
•
•
•
•
Lyon, december 212011 PON Gab / Scanner Philips Cardio
Indication : 63 year old smoking,
Stress ECG 2008 –
EIMc 0,92 mm plq+ns
•
Ca Score

28. Ca Score: Additionnal value for CV Risk
•
Result :304

29. Ca Score: Additionnal value for CV Risk
• consequences :
• revérification new stress ecg : • Risk information: High
• Therapy :adjonction ezetrol for goal
LDL decreased from 1,2 g/l to 0,9 g/l
• Aspirine Introduction primary
prevention

30. Ca Score: Additionnal value for CV Risk
•
Indication : Patiente de 65 years old patient
smoker HFh never treated statines intolerance ,
LDL between 3,5 3,8 g/l HDLc 0,45 g/l.
.
•
EIMc 0,80 mm plq+ns
•
•
•
Ca score : 2
No LDL aphéreses
No aspirine

31. A range of noninvasive test options is available for
patients
Ca Scoring
Exercise
ECG
Stress
Echo Excercice
SPECT
PET
MRI
IMT
…

32. Comparison With Other Tests for
CHD Diagnosis
Diagnostic Accuracy Exercise ECG Test
meta-analysis for CAD obstructive disease:
One hundred forty-seven consecutively published reports involving 24 074
patients who underwent both coronary angiography and exercise
testing were summarized.
• Wide variability in sensitivity and specificity was found (mean sensitivity
was 68%, with a range of 23% to 100% and a standard deviation of 16%;
• mean specificity was 77%, with a range of 17% to 100% anda standard
deviation of 17%).
• seven consecutively published reports involving 24 074 patients
• Who
Adams et al al
Gianrossi et Circulation 2005
HCL/UCBL/INSERM /CNRS
Kablack Ziebinska et al Heart 2004

33. Probability POST-test of coronar., %
Diagnostic Accuracy:
Bayesienne Approch
100
85
Stress ECG
Ca ++ Score
50
20
0
54
100
Probability pré-test of coronaropathy, %
Adapted from Diamond GA, Forrester JS. N Engl J Med. 1979;300:1350-1358.

34. Comparison With Other Tests for
CHD Diagnosis
Myocardial Perfusion Imaging and Stress Echocardiography.
24 reported exercise echocardiography results in 2637 patients
27 reported exercise SPECT in 3237 patients
• Exercise echocardiography had a sensitivity of 85% (95% CI 83% to 87%) with a
• 24 reported
• specificity of 77% (95% CI results in 2637 patients
exercise echocardiography 74% to 80%)
• Exercise perfusion yielded a similar sensitivity of 87% (95% CI 86% to 88%) but a
lower specificity of 64% (95% CI 60% to 68%)
Adams et al.Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise
echocardiography or exercise SPECT imaging? A meta-analysis of
diagnostic test performance. JAMA 1998;280
HCL/UCBL/INSERM CNRS

35. IMT Limitations
Adams et al Circulation 2005
HCL/UCBL/INSERM U870
Kablack Ziebinska et al Heart 2004

36. Comparaison of l’IMTc vs Ca Score for identication of
lesions > 50 %
ROC adjusted pour age and sex
HCL/UCBL/INSERM CNRS
Terry JG et al ATVB 200

37. Comparaison Ca Score IMT
Ca score
IMT
morphology
morphology
+
-
LM LAD
Carotid stenosis
Prédiction
++/ quantitative
+/quantitative
Validity
IIa
IIb
duration
10 secs
15-20 mn
reproductibility
+++
+? Inter obs dep +++
cost
++ radio
+ radio ou cardio ou
angeiologue
Coronary Localisation
100,51 +40,38 +1,5 = 142,39 €
75,6€

38. Limitations
•
•
whether to include any newer test in a risk prediction algorithm requires full
consideration of the financial costs (health system).
clinical cost (individual people) exposing potentially healthy populations to
radiation in a screening program requires careful considerations of the
balance of risks and benefits.
HCL/UCBL/INSERM /CNRS

39. The EISNER Study
Early Impact of Coronary Artery Calcium Scanning on Coronary
Risk Factors and Downstream Testing

40. Impact of Coronary Artery Calcium Scanning on Coronary
Risk Factors and Downstream Testing
The EISNER (Early Impact of Coronary Artery Calcium
Scanning onCoronary Risk Factors and Downstream Testing
• Méthods:
– Randomisation of 2137 < 80 ans - before risk facor consulattion:
– Primary criteria: : risk factor change

41. The EISNER Study
HCL/UCBL/INSERM U870
Rozanski et all JACC 2011

42. !
Cedar mount sinai LA population!!
HCL/UCBL/INSERM CNRS
Rozanski et all JACC 2011

43. Impact of Coronary Artery Calcium Scanning on Coronary
Risk Factors and Downstream Testing
The EISNER (Early Impact of Coronary Artery Calcium
Scanning onCoronary Risk Factors and Downstream Testing
•
Results summary: at 4 years
•
With CA score:
• TA systolique LDL cholestérol, abddominal perimeter and weight decrease
• Proportional response to ca sore
– Without Ca score
Framingham score increase
– No significative impact on other medical test, medication and cost in mean
• More d’exams and medications if Ca score> 400
• Less si Ca score= 0

44. Recommendations: Asymptomatic
Patient
• Calcium scoring
– Appropriate if intermediate risk A(7)
• If high CAC
– Reclassification to a higher risk status
– Subsequent patient management modified
Greenland P et al. Circulation 2007
Oudkerk et al. Int J Cardiovasc Imaging 2008

45. Recommendations: Asymptomatic
Patient
• Calcium scoring
– Appropriate if intermediate risk A(7)
– Appropriate if low risk and Family history of
premature CHD A(7)
• CTA
– Inapropriate
• but, U(4) in high risk patient
Greenland P et al. Circulation 2007
Oudkerk et al. Int J Cardiovasc Imaging 2008

46. CTA Indications
§ Coronary artery diseases
ü Detection of CAD in
ü (A) symptomatic patients
ü With(out) known CAD
ü Preoperative Coronary Assessment Prior to Noncoronary Cardiac
Surgery
ü Use of CTA in the Setting of Prior Test Results
ü By pass graft control
ü Stents control
ü Assessment of anomalies of coronary arterial and other thoracic
arteriovenous vessels
§ Cardiac diseases; evaluation of cardiac sructures and function
ü Heart failure
ü Electrophysiological procedure
ü Cardiac anatomy:
ü Congénital heart diseases
ü Tumor

47. Detection of CAD in Symptomatic Patients
Without Known Heart Disease
• ECG non diagnostic/ impossible stress
– Low risk A(7)
– intermédiate risk A(8)
– High Risk U(4)

48. Asymptomatic Patient
• Seoul National University study
– 1000 volunteers patients, mean age of 50 year old , 63%
men
• 215 patients +, 40 (4%) with lésions non Ca
• 52 patients (5%) st >50%
• 21 patients (2%) st>70%
– Mean follow up 17 month
• 15 MACE (all CT +) dont 14 revascularizations
– Non négligeable prevalence
Choi EK et al. JACC 2008;52:366

49. Axial cardiac CT images in 63-year-old man.
Kim T J et al. Radiology 2010;255:369-376
©2010 by Radiological Society of North America

50. Axial cardiac CT images in 63-year-old man with solitary pulmonary nodule that is visible in full FOV
only.
Kim T J et al. Radiology 2010;255:369-376
©2010 by Radiological Society of North America

51. Axial full-FOV thoracic CT image in 57-year-old woman shows right upper lobe nonsolid
nodule (arrow), which was not visible on full-FOV cardiac image (not shown).
Kim T J et al. Radiology 2010;255:369-376
©2010 by Radiological Society of North America

52. Axial full-FOV thoracic CT image in 64-year-old man with left-side chest pain shows left upper
lobe spiculated mass (arrow) with pleural retraction.
Kim T J et al. Radiology 2010;255:369-376
©2010 by Radiological Society of North America

53. Lung Cancer Detected at Cardiac CT:
Prevalence, Clinicoradiologic Features, and Importance of Full–FOV Images
•
Materials and Methods:
– retrospective study between January 2004 and December 2007.
– Patients known to have lung cancer at the time of cardiac CT were excluded.
– The rates of lung cancer detection at three FOVs—limited and full FOV at cardiac scanning
and full FOV at thoracic scanning—were compared by using McNemar testing.
•
Results:
– The prevalence of lung cancer detected at CT was 0.31% (36 of 11654 patients, 16 [44%] never
smokers) and was higher in patients suspected or known to have coronary artery disease
(0.43% [24 of 5615 patients]) than in asymptomatic screening-examined patients (0.20% [12 of
5924 patients]) (P = .0457).
– Adenocarcinoma was the most common (in 31 [86%] of 36 patients) histologic subtype.
– Of 34 non–small cell lung cancers, 23 (68%)—including 16 stage IA cancers—were resectable.
– Four (11%) and 19 (53%) of the 36 CT-depicted cancers were visible in limited and full FOV
at cardiac scanning, respectively, and 17 (47%) were visible in full FOV at thoracic scanning
only.
•
•
•
Conclusion:
– The prevalence of lung cancer at cardiac CT was 0.31%; and 68% of these malignancies were
at a resectable stage.
– Use of a limited FOV at cardiac scanning led to a large majority (89% [32 of 36 cancers]) of
the lung cancers detected at full thoracic scanning being missed; thus, inclusion of the entire
chest at cardiac CT is advisable.

54. Take Home message
Stratification of indermediary risk +++++ Ca Score
=

55. Thank you…