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Role of MDCT in Coronary
Calcifications
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of
Medical Sciences / Hospital
radiombz@gmail.com
Special Thanks :Clinical Cardiac CT Anatomy and Function Ethan J. Halpern, MD
CT Technique for Calcium Scoring
• Calcium scoring is based on the identification
of high density material within the coronary
circulation on a non contrast CT scan.
• Once the location of coronary calcium is
identified on a CT examination, an automated
program is used to compute a calcium score.
The Agatston method has been traditionally
used to score the amount of coronary calcium
with CT.
Coronary Calcium Score
• No calcium
• Mildly elevated—0-100
• Moderately elevated—100-400
• Severely elevated—> 400
Role of mdct in coronary calcifications Dr. Muhammad Bin Zulfiqar
• Fig. 1.1 Coronary calcium and calcium scoring. Axial
image through the level of the left anterior descending
artery demonstrates the presence of calcification in the
proximal portion of this vessel (arrows).
• Coronary calcification versus annular calcification. (Right) Noncontrast
axial image at the level of the left main coronary artery demonstrates
focal calcification within the left coronary artery (arrow), as well as focal
calcification of the aortic root (arrowhead). (Left) Axial image at the
level of the mitral valve demonstrates focal calcification of the left
anterior descending artery (white arrowhead), as well as focal
calcification of the mitral annulus (black arrowhead). The mitral annulus
is deep to the circumflex artery, which is found along the left
atrioventricular groove.
Mild Calcification of LCA
• Mild calcification of the left coronary artery without
significant stenosis.
• Calcium scoring study demonstrates calcification in the left
main coronary artery, as well as the proximal left anterior
descending artery (LAD). Continued
Mild Calcification of LCA
• Calcification in the left main and LAD arteries is color-coded by the
automated calcium detection algorithm. No other coronary
calcification was noted. The total Agatston calcium score of 116.4
suggests an increased risk of a cardiac event relative to an individual
with no coronary calcium.
Continued
Mild Calcification of LCA
• CT angiogram performed following the calcium
scoring study demonstrates calcified plaque in
the proximal LAD (arrow) without significant
stenosis in the LAD.
Two Vessel Coronary Calcium
• Two-vessel coronary calcium without significant stenosis.
• (Right) Axial image through the proximal left coronary artery
demonstrates the presence of calcification in the proximal left anterior
descending artery (LAD).
• (Left) LAD calcium is color-coded by the automated detection algorithm.
Continued
Two Vessel Coronary Calcium
• (Right) Axial image at a slightly lower level demonstrates calcium within
the mid circumflex artery along the left atrioventricular groove. Note the
difference in position between this circumflex calcification and the mitral
annular calcification.
• (Left) Calcium in the circumflex artery is color-coded. Although the
calcified plaque involves two vessels, the total calculated Agatston calcium
score of 70.2.
Moderate Three Vessel Calcifications
• Moderate three-vessel calcification without significant stenosis.
• (Right) Axial image demonstrates heavy calcification in the proximal left
anterior descending artery (LAD).
• (Left) LAD calcium is color-coded by the automated detection algorithm
Continued
Moderate Three Vessel Calcifications
• (Right) A small calcified plaque is present in
• the proximal right coronary artery (RCA).
• (Left) RCA calcium is color-coded by the
automated detection algorithm Continued
Moderate Three Vessel Calcifications
• (Right) Axial image at the level of the RCA origin (arrow) demonstrates the
calcium within the circumflex artery.
• (Left) Circumflex calcium is color-coded by the automated detection algorithm.
The overall Agatston calcium score of 418.5 suggests that the risk of a coronary
event is significantly higher compared with that of a patient without coronary
calcium.
Continued
Moderate Three Vessel Calcifications
• CT angiogram of the left
coronary artery with
orthogonal curved
maximum intensity
projection (MIP)
reconstructions
demonstrates calcified
plaque along the proximal
LAD, without significant
stenosis. Positive
remodeling is
demonstrated in
• the proximal LAD (arrow).
Continued
Moderate Three Vessel Calcifications
• Orthogonal curved MIP images of the RCA
demonstrate calcification in the proximal portion
of this vessel (arrow), without significant
narrowing. Continued
Moderate Three Vessel Calcifications
• Orthogonal curved MIP
images through the
circumflex artery, again
demonstrate the
presence of focal
calcified plaque (arrow)
with positive
remodeling, and
without significant
stenosis.
Markedly elevated calcium score
• Markedly elevated calcium score with associated stenosis
in the right coronary artery (RCA). (Right) Axial image
demonstrates extensive calcification of the proximal left
coronary artery and left anterior descending artery (LAD).
(Left) LAD calcium is color-coded.
Continued
Markedly elevated calcium score
• (Right)Axial image at a slightly lower level
demonstrates calcium within both the LAD and
circumflex arteries. (Left) Calcium within the LAD
and circumflex arteries is color-coded. Continued
Markedly elevated calcium score
• (Right) Axial image at a slightly lower level demonstrates
calcification in the LAD, circumflex, and RCA. Mild calcification is
also identified in the posterior mitral annulus (arrowhead). (Left)
Calcium in the three major coronary arteries is color-coded. The
mitral annular calcification is labeled in pink and is not included in
the calcium score. The total Agatston calcium of 2726.1 is markedly
elevated, suggesting increased risk for a coronary event.
Continued
Markedly elevated calcium score
• Orthogonal curved
maximum intensity
projection (MIP) images of
the LAD obtained with CT
angiography demonstrate
diffuse calcification. Calcified
plaque appears to fill most of
the LAD lumen on short axis-
images (arrowhead).
Conventional coronary
angiography demonstrated
only mild disease in the LAD.
Continued
Markedly elevated calcium score
• Orthogonal curved MIP
images through the
circumflex artery demonstrate
diffuse calcified plaque. Short-
axis images demonstrate
extensive calcified plaque
(arrows), as well as
noncalcified plaque with
ulceration (arrowhead).
Conventional arteriography
demonstrated only mild
disease in the circumflex
artery.
Continued
Markedly elevated calcium score
• Markedly elevated calcium score
with associated stenosis in the
right coronary artery (RCA).
Orthogonal curved MIP images of
the RCA demonstrate diffuse
calcified and noncalcified plaque.
Of the three major coronary
arteries, the RCA was the least
suspicious for significant stenosis
on CT angiography.
• Nonetheless, conventional
arteriography demonstrated
moderate to severe stenosis in the
midportion of the RCA. This area
was treated by angioplasty. The
accuracy of coronary CT
angiography is degraded in
patients with markedly elevated
calcium scores.
Take Home Message
• Coronary artery calcium scoring provides a
quick, noninvasive method for risk assessment
of coronary heart events.
• Calcium scoring is most appropriate in the
asymptomatic population with a coronary
heart disease risk of 10 to 20% based on the
Framingham risk calculation or in patients
with other risk factors not considered in the
Framingham analysis.
Role of mdct in coronary calcifications Dr. Muhammad Bin Zulfiqar

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Role of mdct in coronary calcifications Dr. Muhammad Bin Zulfiqar

  • 1. Role of MDCT in Coronary Calcifications Dr. Muhammad Bin Zulfiqar PGR IV FCPS Services Institute of Medical Sciences / Hospital radiombz@gmail.com Special Thanks :Clinical Cardiac CT Anatomy and Function Ethan J. Halpern, MD
  • 2. CT Technique for Calcium Scoring • Calcium scoring is based on the identification of high density material within the coronary circulation on a non contrast CT scan. • Once the location of coronary calcium is identified on a CT examination, an automated program is used to compute a calcium score. The Agatston method has been traditionally used to score the amount of coronary calcium with CT.
  • 3. Coronary Calcium Score • No calcium • Mildly elevated—0-100 • Moderately elevated—100-400 • Severely elevated—> 400
  • 5. • Fig. 1.1 Coronary calcium and calcium scoring. Axial image through the level of the left anterior descending artery demonstrates the presence of calcification in the proximal portion of this vessel (arrows).
  • 6. • Coronary calcification versus annular calcification. (Right) Noncontrast axial image at the level of the left main coronary artery demonstrates focal calcification within the left coronary artery (arrow), as well as focal calcification of the aortic root (arrowhead). (Left) Axial image at the level of the mitral valve demonstrates focal calcification of the left anterior descending artery (white arrowhead), as well as focal calcification of the mitral annulus (black arrowhead). The mitral annulus is deep to the circumflex artery, which is found along the left atrioventricular groove.
  • 7. Mild Calcification of LCA • Mild calcification of the left coronary artery without significant stenosis. • Calcium scoring study demonstrates calcification in the left main coronary artery, as well as the proximal left anterior descending artery (LAD). Continued
  • 8. Mild Calcification of LCA • Calcification in the left main and LAD arteries is color-coded by the automated calcium detection algorithm. No other coronary calcification was noted. The total Agatston calcium score of 116.4 suggests an increased risk of a cardiac event relative to an individual with no coronary calcium. Continued
  • 9. Mild Calcification of LCA • CT angiogram performed following the calcium scoring study demonstrates calcified plaque in the proximal LAD (arrow) without significant stenosis in the LAD.
  • 10. Two Vessel Coronary Calcium • Two-vessel coronary calcium without significant stenosis. • (Right) Axial image through the proximal left coronary artery demonstrates the presence of calcification in the proximal left anterior descending artery (LAD). • (Left) LAD calcium is color-coded by the automated detection algorithm. Continued
  • 11. Two Vessel Coronary Calcium • (Right) Axial image at a slightly lower level demonstrates calcium within the mid circumflex artery along the left atrioventricular groove. Note the difference in position between this circumflex calcification and the mitral annular calcification. • (Left) Calcium in the circumflex artery is color-coded. Although the calcified plaque involves two vessels, the total calculated Agatston calcium score of 70.2.
  • 12. Moderate Three Vessel Calcifications • Moderate three-vessel calcification without significant stenosis. • (Right) Axial image demonstrates heavy calcification in the proximal left anterior descending artery (LAD). • (Left) LAD calcium is color-coded by the automated detection algorithm Continued
  • 13. Moderate Three Vessel Calcifications • (Right) A small calcified plaque is present in • the proximal right coronary artery (RCA). • (Left) RCA calcium is color-coded by the automated detection algorithm Continued
  • 14. Moderate Three Vessel Calcifications • (Right) Axial image at the level of the RCA origin (arrow) demonstrates the calcium within the circumflex artery. • (Left) Circumflex calcium is color-coded by the automated detection algorithm. The overall Agatston calcium score of 418.5 suggests that the risk of a coronary event is significantly higher compared with that of a patient without coronary calcium. Continued
  • 15. Moderate Three Vessel Calcifications • CT angiogram of the left coronary artery with orthogonal curved maximum intensity projection (MIP) reconstructions demonstrates calcified plaque along the proximal LAD, without significant stenosis. Positive remodeling is demonstrated in • the proximal LAD (arrow). Continued
  • 16. Moderate Three Vessel Calcifications • Orthogonal curved MIP images of the RCA demonstrate calcification in the proximal portion of this vessel (arrow), without significant narrowing. Continued
  • 17. Moderate Three Vessel Calcifications • Orthogonal curved MIP images through the circumflex artery, again demonstrate the presence of focal calcified plaque (arrow) with positive remodeling, and without significant stenosis.
  • 18. Markedly elevated calcium score • Markedly elevated calcium score with associated stenosis in the right coronary artery (RCA). (Right) Axial image demonstrates extensive calcification of the proximal left coronary artery and left anterior descending artery (LAD). (Left) LAD calcium is color-coded. Continued
  • 19. Markedly elevated calcium score • (Right)Axial image at a slightly lower level demonstrates calcium within both the LAD and circumflex arteries. (Left) Calcium within the LAD and circumflex arteries is color-coded. Continued
  • 20. Markedly elevated calcium score • (Right) Axial image at a slightly lower level demonstrates calcification in the LAD, circumflex, and RCA. Mild calcification is also identified in the posterior mitral annulus (arrowhead). (Left) Calcium in the three major coronary arteries is color-coded. The mitral annular calcification is labeled in pink and is not included in the calcium score. The total Agatston calcium of 2726.1 is markedly elevated, suggesting increased risk for a coronary event. Continued
  • 21. Markedly elevated calcium score • Orthogonal curved maximum intensity projection (MIP) images of the LAD obtained with CT angiography demonstrate diffuse calcification. Calcified plaque appears to fill most of the LAD lumen on short axis- images (arrowhead). Conventional coronary angiography demonstrated only mild disease in the LAD. Continued
  • 22. Markedly elevated calcium score • Orthogonal curved MIP images through the circumflex artery demonstrate diffuse calcified plaque. Short- axis images demonstrate extensive calcified plaque (arrows), as well as noncalcified plaque with ulceration (arrowhead). Conventional arteriography demonstrated only mild disease in the circumflex artery. Continued
  • 23. Markedly elevated calcium score • Markedly elevated calcium score with associated stenosis in the right coronary artery (RCA). Orthogonal curved MIP images of the RCA demonstrate diffuse calcified and noncalcified plaque. Of the three major coronary arteries, the RCA was the least suspicious for significant stenosis on CT angiography. • Nonetheless, conventional arteriography demonstrated moderate to severe stenosis in the midportion of the RCA. This area was treated by angioplasty. The accuracy of coronary CT angiography is degraded in patients with markedly elevated calcium scores.
  • 24. Take Home Message • Coronary artery calcium scoring provides a quick, noninvasive method for risk assessment of coronary heart events. • Calcium scoring is most appropriate in the asymptomatic population with a coronary heart disease risk of 10 to 20% based on the Framingham risk calculation or in patients with other risk factors not considered in the Framingham analysis.

Editor's Notes

  1. For each focus of calcified coronary plaque, plaque area and maximum attenuation are measured on each CT slice. An attenuation cofactor is assigned to each plaque based on CT attenuation measured in Hounsfield units (HU). The cofactor is assigned as 1 for 131 to 200 HU, 2 for 201 to 300 HU, 3 for 301 to 400 HU, and 4 for greater than 400 HU. The area of each plaque is multiplied by the appropriate attenuation cofactor to achieve a calcium score. Although an Agatston score may be computed for each coronary vessel, the scores of all the individual plaques in all the vessels are generally summed to obtain a single total Agatston calcium score for risk analysis. The Agatston method does have its shortcomings. Modern CT units are capable of submillimeter resolution, but the Agatston score uses attenuation cofactors determined at a 3-mm slice thickness. Depending on which adjacent tissues are included in this slice thickness, cofactors in the Agatston method may be altered by partial volume averaging. A volumetric method has been proposed that is less dependent on volume averaging and slice thickness.21 Mass scores have also been defined to combine the volume and density of coronary calcium in a manner that is relatively more independent of slice thickness and spatial resolution. Although volumetric scores of coronary calcium may be more representative of the total plaque burden, volume scores may differ from the Agatston score.22 More recently, calcium scoring methods have been proposed that combine both the spatial distribution and the amount of calcified plaque to improve risk assessment.23 Although these newer methods may provide improved risk stratification, most clinicians continue to use the Agatston method for calcium scoring because of the large amount of published data relating the risk of coronary events to the Agatston score.
  2. Coronary artery calcium scoring provides a quick, noninvasive method for risk assessment of coronary heart events. Calcium scoring is most appropriate in the asymptomatic population with a coronary heart disease risk of 10 to 20% based on the Framingham risk calculation or in patients with other risk factors not considered in the Framingham analysis. In these patients, a coronary calcium score greater than 100 suggests that the patient should be moved to a higher-risk status. A calcium score in the range of 0 to 10 may suggest that the risk is lower than that projected by the Framingham risk score alone. Serial calcium scoring tests to follow up on therapies have not been validated at this time. The executive statement from a working group of the NHLBI issued in December 2005 suggests a modified Framingham risk score with additional risk indicators, including calcium scoring. Incorporation of the coronary calcium score and other tests for subclinical atherosclerosis, together with traditional risk assessment, should improve preventive therapy for future coronary events.