Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Budoff shape-1105

201 views

Published on

SHAPE Society

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Budoff shape-1105

  1. 1. Predictive Value of Coronary Calcium Scoring Matthew Budoff, MD, FACC, FAHA Associate Professor of Medicine UCLA School of Medicine Director, Cardiac CT Harbor-UCLA Medical Center, Torrance, CA Conflict of Interest: Speakers Bureau General Electric
  2. 2. Prevalence of Conventional Risk Factors in Patients with Coronary Heart DiseasePrevalence of Conventional Risk Factors in Patients with Coronary Heart Disease (N = 87,869)(N = 87,869)
  3. 3. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – No one is born with atherosclerosis
  4. 4. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – There is a gradual, silent build up over time x x x x x x x x x
  5. 5. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – Finally, acute event occurs x x x x x x x x x x x
  6. 6. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – Sx onset -- Permanent damage x x x x x x x x x x x Time 1 1/3 - Angina 1/3 - Acute MI 1/3 - Sudden Death
  7. 7. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – x x x x x x x x x x x 1st Event Realistic Goal – DELAY PROGRESSION x x x x x x x x x x x x x x x x x x x x x x x x x x x
  8. 8. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – x x x x x x x x x x x 1st Event Prevention- Primary vs. Secondary x x x x x x x x x x x x x x x x x x x x x x x x x x x CARDIOLOGISTS
  9. 9. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – x x x x x x x x x x x 1st Event Prevention- Primary vs. Secondary x x x x x x x x x x x x x x x x x x x x x x x x x x x PRIMARY CARE
  10. 10. Time 0 1 2 2x A.S. x Coronary atherosclerotic burden – x x x x x x x x x x x 1st Event Concept -- EARLY 2ry PREVENTION x x x x x x x x x x x x x x x x x x x x x x x x x x x The Problem begins HERE NOT HERE
  11. 11. Potential Prognostic Potential of Cardiac CT Use a calcium score to screen patients with moderate (intermediate) Framingham risk Positive CAC scans indicate incremental risk Alters therapeutic goal (LDL, BP, etc) Identify patients who do not need further cardiac medication (scores of zero) Consider serial imaging as ongoing management tool (progression)
  12. 12. Prediction of Cardiac Events in AsymptomaticPrediction of Cardiac Events in Asymptomatic Patients by EBTPatients by EBT The St. Francis Heart Study, ACC 2003The St. Francis Heart Study, ACC 2003 SFHS 3SFHS 3 0.12 0.7 2 2.4 3.3 0 0.5 1 1.5 2 2.5 3 3.5 0 > 0 > 100 > 200 > 600 Baseline EBT Calcium ScoreBaseline EBT Calcium Score AnnualEventRate(%)AnnualEventRate(%) Calcium Score >100 vs <100 RelativeRisk 9.5 Any Event 10.7 Cor. Event 9.9 MI/ SCD
  13. 13. 2.7 2 2 1 2.47 3.55 6.15 12.29 0 2 4 6 8 10 12 14 RelativeRisk DM Smoke HTN <10 10-100 101-400 401-1000 >1000 EBT Coronary Calcium ScoreEBT Coronary Calcium Score All Cause Mortality [NDR]All Cause Mortality [NDR] n = 10,377n = 10,377 asymptomatic men and womenasymptomatic men and women f/u = 5.0f/u = 5.0++3.5 yrs.3.5 yrs. Shaw, Raggi et al Radiology 2003 EBT found to be independent and incremental to risk factors All Cause Mortality in PatientsAll Cause Mortality in Patients Without Known CADWithout Known CAD
  14. 14. EBT 5 year All-Cause Mortality – Shaw et al
  15. 15. 0.00 2.00 4.00 6.00 8.00 10.00 12.00 Time to Follow-up (Years) 0.75 0.80 0.85 0.90 0.95 1.00 0.00 1.00 2.00 3.00 4.00 5.00 Time to Follow-up (Years) 0.75 0.80 0.85 0.90 0.95 1.00 Near- and Long-Term Survival from 2 Cohorts – over 35,000 patientsn=10,377 n=25,257 99.4% 97.8% 95.2% 90.4% 81.8% 99.4% 97.8% 94.5% 93.0% 76.9% χ2 =1503, p<0.0001, interaction p<o.0001 CAC Score (5 Yr Mortality = 1.2%) (12-Yr Mortality = 2.1%) Difference 0-10 99.4% 99.4% 0.0% 11-100 97.8% 97.8% 0.0% 101-400 95.2% 94.5% 0.7% 401-1,000 90.4% 93.0% 0.6% >1,000 81.8% 76.9% 4.9%
  16. 16. Cooper Clinic Study - 10,782 Patients: 3.5 year follow-up 0 10 20 30 40 50 None 1--16 17--96 97--409 >409 None 1--16 17--96 97--409 >409 AdjustedOddsRatio Adjusted age, history of diabetes, hypertension, elevated cholesterol, over weight 44.3 (22-87) 2.9 (1.2-6.7) 5.2 (2.4-11) 13.4 (6.7-26.5) Ref All CHD (n=278) Nonfatal MI & CHD Death 2.7 (0.8-9.3) 6.0 (2.1-17) 9.7 (3.6-26) 21.1 (7.8-57) Ref
  17. 17. Taylor et al – PACC Study – JACC 2005 2000 patients, mean age 43 Coronary calcium was associated with an 11.8-fold increased risk for incident coronary heart disease (CHD) (p 0.002) in a Cox model controlling for the Framingham risk score. In young, asymptomatic men, the presence of coronary artery calcification provides substantial, cost-effective, independent prognostic value in predicting incident CHD that is incremental to measured coronary risk factors.
  18. 18. Calcium Versus Framingham
  19. 19. RR of MI/SCD: EBT Score and hs-CRP 0 1 2 3 4 5 6 7 High CAC Med. CAC Low CAC Low hs-CRP High hs-CRP Park et al. Circ. 2002;106-2073-2077
  20. 20. AHA – Circulation 2005 Given the evolving literature since the last ACC/AHA Expert Consensus statement (2000), current data indicate that CAD risk stratification is possible with CAC measures. Specifically, low CAC scores are associated with a low adverse event risk, and high CAC scores are associated with a worse event-free survival. This recommendation to measure atherosclerosis burden, in clinically selected intermediate–CAD risk patients (eg, those with a 10% to 20% Framingham 10- year risk estimate) to refine clinical risk prediction and to select patients for altered targets for lipid-lowering therapies.
  21. 21. RAGGI - ATVB
  22. 22. Arad et al. JACC 2005 In the largest study reported to date, multiple logistic regression, demonstrated only age (p 0.03), male gender (p 0.04), LDL cholesterol (p 0.01), HDL cholesterol (p 0.04), and two-year change in calcium score (p 0.0001) were significantly associated with subsequent CAD events. Thus, increasing calcium scores were most strongly related to coronary events. NOT PREDICTIVE: Baseline CAC, CRP
  23. 23. Potential Uses of Cardiac CT Use a calcium score to screen patients with moderate (intermediate) Framingham risk Positive EBT scans indicate incremental risk Alters therapeutic goal (LDL, BP, etc) Identify patients who do not need further cardiac evaluation (scores of zero) Consider serial imaging as ongoing management tool (progression) Improve compliance Non-invasive Angiography
  24. 24. Coronary Artery Scanning SEVERE CALCIFICATION
  25. 25. Percentage of individuals maintaining Statin therapy at 3.6 years according to various levels of baseline CAC No CAC CAC 1-99 CAC 100-399 CAC>400 0 10 20 30 40 50 60 70 80 90 100 44 63 75 90
  26. 26. EBT Coronary Calcium

×