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  1. 1. Scores >400 are are 10-foldScores >400 are are 10-fold increased risk; Calciumincreased risk; Calcium imaging should be routineimaging should be routine Matthew J. Budoff, MD, FACCMatthew J. Budoff, MD, FACC Assistant Professor of MedicineAssistant Professor of Medicine Division of CardiologyDivision of Cardiology Harbor-UCLA Medical Center Torrance, CA
  2. 2. 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, FACC High Speed CT
  3. 3. Coronary Artery Scanning SEVERE CALCIFICATION
  4. 4. 20%20% 80%80% Total Coronary Artery PlaqueTotal Coronary Artery Plaque and EBCT Coronary Calciumand EBCT Coronary Calcium 80%80% PlaquePlaque DetectableDetectable by IVUS,by IVUS, PathologyPathology Lipid RichLipid Rich FibroticFibrotic CalcifiedCalcified 20%20% 80%80%
  5. 5. 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
  6. 6. Predictive Power > 75th Percentile 4.9 21 20 8.8 9.67 10.8 13.4 0 5 10 15 20 25 RelativeRisk Detrano Arad Kondos Georgiou Raggi Wong Detrano
  7. 7. Event Rates Based upon Scores 0.8 21 41 480204060 Estimated 10 Year Event Rate Zero 1 99 100-400 >400 EBT Calcium Score Raggi, AHJ 2001
  8. 8. 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
  9. 9. 10 Year All-Cause Mortality 0102030 %Mortality 0-79 80-159 160-599 >600 Scores Agatston 2000: AHA Abstract
  10. 10. 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
  11. 11. 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
  12. 12. Stress Testing is not enough ““The majority of people destined to dieThe 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 isThe likely reason that they will die suddenly is that only a mild, non-flow -limiting coronarythat only a mild, non-flow -limiting coronary plaque will have been present before theplaque will have been present before the sudden development of an occlusivesudden development of an occlusive thrombus.”thrombus.” - Stephen Epstein- Stephen Epstein New England Medical Journal 1989New England Medical Journal 1989
  13. 13. Asymptomatic Patient Algorithm forAsymptomatic Patient Algorithm for Intermediate Risk PatientsIntermediate Risk Patients Greenland P, et al. Circulation Oct 9, 2001
  14. 14. Refining Framingham Risk Score EBT derived “Arterial Age” a man is as old as his coronaries… Syndenham 1689
  15. 15. % of Cases with Calcium Present prior to Cardiovascular Events 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Risk Factors Arad Agatston Georgio
  16. 16. ““the finding of advancedthe finding of advanced subclinicalsubclinical atherosclerosis by noninvasive testingatherosclerosis by noninvasive testing can be helpful for confirming thecan be helpful for confirming the presence of high risk persons... andpresence of high risk persons... and have utility in selected persons to guidehave 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
  17. 17. Subclinical Atherosclerosis