0:02

Hello and welcome to Noon Conference, hosted by modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Brian Gora for a lecture entitled Coronary Artery Calcium

0:22

Scoring Indications, applications, and Clinical Impact.

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Dr. Sharra completed his radiology residency at the Western

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Pennsylvania Hospital

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and his cardiac imaging fellowship at Massachusetts General

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Hospital, where he now leads the cardiovascular imaging

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section as academic chief.

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He's also served as division chief and program director

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and has directed the cardiac CT

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and MRI programs for over a decade.

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He's past president of the SCCT

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and has over 200 peer review publications in the field

0:52

of cardio cardiovascular imaging.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may

1:00

have on today's topic.

1:01

Please remember to use that q

1:03

and a feature to submit your questions so we can get to

1:05

as many as we can before time is up.

1:07

With that, we're ready to begin today's lecture. Dr.

1:10

Gura, please take it from here.

1:13

Um, well, thanks for joining me, uh,

1:15

during your valuable lunch break here.

1:17

Um, I was asked to talk about coronary artery calcium

1:19

scoring, and we'll talk about indications, applications,

1:23

and some clinical impact, and please ask questions

1:25

because such, actually a, despite a narrow, um, exam,

1:29

there's a fair amount of, um, literature to, uh,

1:33

to inform a lot of the things we do.

1:35

Um, so a brief outline, it'll be kinda the what, why, who,

1:37

when, how, we'll touch on how to interpret.

1:40

We'll talk about incidentals if there's time.

1:42

You kind of know that stuff. I suspect what not to do, um,

1:45

and some miscellaneous issues and,

1:47

and talk about clinical impact,

1:49

and it won't be quite in that order.

1:50

We'll just kind of touch on each of these things.

1:53

Any time you do a presentation in cardiology,

1:56

you have to show an iceberg.

1:57

It's a, it's a, it's law.

1:59

Um, I'm kidding,

2:00

but actually it is very fitting in the field of coronary,

2:04

um, calcium scoring

2:05

because the calcium is really only the tip

2:08

of the iceberg that we're imaging.

2:09

Um, and what I mean by that is, um,

2:11

there's a whole process which has been carefully worked out,

2:14

uh, with lots of science over the years,

2:17

and the, uh, accumulation of plaque

2:19

and coronary arteries, um, is extremely, uh,

2:23

a long process and iterative.

2:24

But what we're actually imaging is just one little piece

2:27

of this, the calcium deposition

2:28

that happens within significant, uh, uh, arterial plaques.

2:33

Um, and just that one feature is the entire

2:35

basis of the field.

2:37

Um, and so this is an image

2:38

of a coronary calcium scoring scan done recently.

2:41

And you can see here we've, uh, summed up the,

2:44

the total amount of calcium on this particular image.

2:46

Um, and then you do something called an AGATSTON score.

2:48

We'll get more into that, but, um,

2:50

you're basically just totalling up, uh, the calcium,

2:52

which actually appears larger than it is in real life, um,

2:56

due to a CT artifact.

2:57

Um, so it's a very carefully targeted exam just to look at

3:00

that one piece of things.

3:01

So how did we get here?

3:03

Um, in the 1970s and eighties electron BMCT was created.

3:06

Um, that was actually an interesting scanner

3:08

because there were no moving parts.

3:10

Um, so what you, um, have is almost like a cathode ray tube,

3:14

which is now become an artifact of history as well.

3:16

But, um, an electron gun would be deflected,

3:19

and the only moving part in that scanner was the deflector.

3:21

Um, and that would aim at 180 degrees of this, uh,

3:24

target ring that would then create an x-ray beam

3:27

and then be received on the detector ring.

3:30

And the target was actually to do coronary CT angiography.

3:33

Um, but in reality, uh, the number of slices

3:36

that could be acquired in a reasonable time

3:38

and with a reasonable thickness ended up

3:40

about three millimeters.

3:41

Um, it was a really good temporal resolution

3:43

of 100 milliseconds.

3:44

Um, contrast that to multi detector CTA,

3:47

which shortly followed in the 1990s,

3:49

and that was a spinning gantry.

3:51

Um, and you could get between two

3:53

and now up to 320 slices at a time.

3:56

Uh, the resolution was about a half millimeter in the z um,

4:00

uh, up it actually even smaller now in the Z axis with, uh,

4:03

photon counting cts.

4:04

Um, but that's a detector type.

4:06

Uh, anyway, the, uh,

4:07

single source scanners started at about 250 millisecond,

4:11

two temporal resolution.

4:12

So, um, more than twice as bad as the,

4:16

uh, electron beam scanner.

4:17

But now some scanners with dual sources are down

4:19

to 66 millisecond temporal resolution.

4:22

And what that means is we can

4:24

translate the parameters roughly.

4:26

And so if you acquire things the way they were, uh,

4:29

initially done on the electron beam cts, which is

4:31

where all the data started to come from, you can kind

4:34

of standardize technique and, and infer it's about the same.

4:37

Um, but the electron beam scanner has not been manufactured

4:40

for quite some time.

4:41

I believe a few are still in existence.

4:43

Um, but multi detector cts are pretty much everywhere,

4:46

and I don't think you can buy a scanner

4:48

that's not multi detector with some rare exceptions.

4:51

So we've laid down a nice base of data.

4:53

Um, obviously coronary CT angiography is now a thing.

4:57

So, um, the looking at the actual artery

4:59

with contrast has become commonplace.

5:01

But the, uh, the persistent epidemiologic data that informs,

5:05

uh, calcium scoring

5:06

and a lot of what we'll talk about today was actually

5:08

started by this older technology,

5:10

and that's why it, um, is done at three millimeters

5:12

and at, uh, say 120, uh, KVP.

5:15

So, um, Dr. Sson still alive.

5:17

I had lunch with him, uh, I I guess I do every year at this

5:19

Society of Cardiac CT meeting.

5:21

Um, so this is me, him and, uh, Dr.

5:23

Verani, one of the preeminent cardiac,

5:25

but the preeminent cardiac pathologist in the world.

5:28

Uh, but Dr. Tsin and, uh, Dr.

5:30

Janowitz developed the Tsin Janowitz score, uh,

5:33

and Aden's a cardiologist.

5:34

Janowitz is a radiologist, uh,

5:36

good example of working together.

5:38

And they standardized the technique to 120 kv, uh,

5:41

three millimeter slices just

5:42

because that's what that scanner could acquire.

5:44

Uh, they used ECG gating and,

5:46

and really we do prospective triggering.

5:48

So just sampling one phase of the cardiac cycle, um,

5:51

and you use a workstation

5:52

and you select calcified plaques in the coronary arteries.

5:55

Um, and often now there's ais that can click on it for you.

5:59

You do want to validate that they didn't accidentally, uh,

6:02

score something that's not the arteries,

6:03

say the mitral valve or a a bone.

6:06

Um, they use a density factor.

6:08

And the density factors were established of, um,

6:10

density is from 130 to 199.

6:12

Um, and, uh, hounds field units that got a score of one, uh,

6:16

200 to 2 99 were given a two, 300 and above three,

6:20

and then 400 above four.

6:21

Um, and then, so for example,

6:23

if you had an eight square millimeter spec, um,

6:25

with 400 hounds field units, you'd multiply

6:27

that square millimeters times the, uh, the score

6:30

for high density plaque,

6:31

and that would give you a calcium score for

6:33

that plaque of 32.

6:34

Um, and then you'd sum up all the plaques,

6:36

and the workstation will do this for you.

6:38

There's a lot of different workstations, uh,

6:40

and that's how you get this calcium score.

6:42

Um, they're not agatston units,

6:43

they're just the agatston method of calcium scoring.

6:46

So it's a unitless number and there's broad ranges,

6:49

but the, uh, uh,

6:50

and really with infinite, um, uh, up upper bound, um,

6:54

but the broad range is bucket down into none or zero, um,

6:58

and then up to a hundred, up to 300,

7:01

and then a thousand, even over a thousand, um,

7:04

you should expect slight variability

7:05

even on the same equipment.

7:07

Um, so if you were to, um, take a calcium score of,

7:12

of yourself, not get off the table,

7:14

not do anything different, just repeat the scan within a

7:17

minute or two, you can get up to 10% variability.

7:19

And a lot of that has to do with the fact

7:21

that we usually only trigger in one cardiac cycle phase.

7:24

And so slight motion artifacts and blurring can happen.

7:27

But broadly, this works pretty well.

7:29

Um, and the, the scores translate to, um,

7:32

to meaningful epidemiologic, um, outcomes.

7:36

Um, so whom should we, uh, oh, by the way, I,

7:40

one day I was talking to Dr.

7:41

Janowitz, uh, of the AGAs and Janowitz score,

7:43

and I said, why did you use 130 hounds field units?

7:46

Uh, and his answer was, it just seemed to make sense.

7:49

So there's nothing magical about these

7:50

buckets or these scores.

7:52

Um, and if you had a plaque that's 129 hounds field units,

7:55

you could also say, Hey, maybe that's a little blurring

7:58

and it underscored, or maybe, um, you know, uh, uh,

8:02

something that on a different day

8:03

or with a different body thickness might, might, uh,

8:06

bump into that, uh, weighting that we consider.

8:09

But things below 130 hound field units, not, not count,

8:11

counted as calcified, uh, plaque by the agates

8:14

and method, okay?

8:16

So whom to offer, uh, coronary artery calcium screening.

8:19

Um, you really should be using it in intermediate

8:21

cardiovascular risk, asymptomatic adults.

8:24

So that's a class two a indication by most guidelines,

8:27

and we'll go through those in more detail.

8:29

Um, you would, you would also use it in low

8:32

to intermediate risk asymptomatic adults,

8:33

and that's a little less, uh, evidence behind that.

8:36

Low risk asymptomatic people, even less evidence.

8:39

So that's considered kind

8:40

of not necessarily the best patient.

8:41

And then, um, if you have risk factors that augment such

8:45

as diabetes or age, um, that kind of brings you back into

8:48

that intermediate risk.

8:49

And so you really wanna do it in people

8:51

that's gonna change management.

8:52

You don't wanna do it in very low risk in, in,

8:54

in high risk patients,

8:55

because that won't change your management.

8:57

Um, you should not be doing it in symptomatic people.

8:59

So in, in, uh, those whom not to offer calcium screening,

9:02

if you already know they have established coronary disease,

9:05

especially if they've already had a stent,

9:07

so percutaneous coronary intervention

9:09

or a cabbage, it's not meaningful, that was not titrated for

9:12

that, and you already know they have disease,

9:14

there's no scenario where that patient does not qualify for,

9:17

uh, for medications.

9:18

Um, in very low risk patients, you might not do it

9:21

because it might not reclassify the patient.

9:22

So if you weren't gonna give them meds, um,

9:24

it's very unlikely that this is gonna change your

9:27

management, although, um, trials are being done to look

9:30

for those outliers.

9:31

Uh, but that's not an established indication at this time.

9:34

Um, and then same reason, high risk.

9:36

You won't reclassify anyone downward.

9:38

Same as kind of looking at a post, say, cabbage patient.

9:41

Um, the extremes

9:42

of age are considered not favorable for calcium scoring.

9:45

There is a little bit of radiation, um,

9:47

and the yield being lower in the, in the very young.

9:49

Um, and the baseline risk goes up so high in the elderly

9:53

that, um, say above age 75, 80, it's probably unlikely

9:57

that you're gonna down classify someone purely on the basis

9:59

of age, bringing a lot of risk to the equation, regardless

10:02

of the calcific burden

10:03

of plaque that they might or might not have.

10:05

Um, and if you have symptoms, there's better tests.

10:09

So, coronary CTA is here, it's everywhere,

10:11

maybe not everywhere, but, um, it's becoming ubiquitous.

10:14

Um, and there's all kinds of things

10:17

that aren't calcified in your coronary arteries

10:19

that can cause blockages, uh, in addition to plaque.

10:21

So those are things, and we'll,

10:23

we'll show some examples later, but you wouldn't wanna, um,

10:26

you, you wanna use it very, very selectively in symptoms.

10:29

Uh, I think really it shouldn't be used at all in symptoms,

10:31

but there are some, uh, papers that talk about that.

10:35

Um, so what makes, uh,

10:38

a test in ID any test an ideal screening test, um,

10:40

you want it to be very sensitive,

10:43

and ideally it would be very specific, uh,

10:45

and you would want it to be accurate, cheap,

10:48

widely available, safe and actionable.

10:50

And calcium score checks a lot of these boxes.

10:53

Um, so the initial data was really collected

10:57

and then published in the, in the,

10:58

uh, eighties and nineties.

11:00

Um, and these initial scanners were validated, uh,

11:03

by looking at calcium scanning against,

11:05

uh, invasive angiography.

11:07

And that's not the pathway we go by anymore.

11:09

Um, and also remember that the,

11:12

the world's changed since the nineties.

11:14

So the types of plaques we get, the types

11:16

of coronary disease we get have evolved,

11:17

but still, there's a large amount of data

11:19

and it, um, uh, it, it first was done in just broad strokes,

11:22

and then they started breaking it down by, um,

11:25

by gender and by race.

11:27

Um, it is worth pointing out that a lot of the data,

11:29

even in the MESA trial, um, has kind

11:32

of curious race choices.

11:33

So, uh, terms we don't really use anymore, um, uh, in,

11:37

in most of society like white, black, Hispanic, and Chinese.

11:40

Uh, Hispanic is not really a race. Uh, Chinese is only one.

11:44

Uh, it's really a nationality.

11:46

Um, but that's the way the data was collected.

11:48

Um, and again, the data was rearward looking, so as,

11:51

as the population evolves, it,

11:53

it may not be quite as applicable.

11:54

Um, also, data was not initially collected

11:57

below age of, I think, 45.

11:59

Um, there are some data now.

12:00

So if you use things at the extremes of age,

12:02

you won't have normative databases.

12:03

But you can see, uh, these graphs kinda on the right,

12:06

show you very well that, um,

12:08

atherosclerotic burden is a disease of aging.

12:11

And it's a kind of a, uh, something

12:14

with strong association, uh, to age.

12:16

And there are differences, um, uh, between the, the, um,

12:20

the sexes and, um, at least in the sampled cohorts,

12:24

uh, between races.

12:25

Um, that being said, most things shake out regardless of,

12:29

of, uh, demographics, uh, based on those buckets

12:32

of 0 100, 300, um, and, uh, greater than a thousand.

12:37

This has made its way into preventive guidelines

12:39

as recently as 2018.

12:41

Um, so this is a complex chart.

12:42

If you're a cardiologist, you're very familiar with it.

12:44

If you're a radiologist, uh, just, uh, be strong.

12:48

But the, um,

12:49

what you do when you're looking at primary prevention,

12:51

so someone that has not had any known, um, uh,

12:54

heart disease, and you're thinking about offering, uh,

12:58

medication as part of your recommendations to prevent, uh,

13:01

atherosclerosis, obviously, if there's someone very young,

13:03

for instance, in this age, zero to 19, you can kind

13:06

of stop there with just lifestyle recommendations.

13:09

Um, and if you do have, um, really strong genetic,

13:12

it's a rare thing, but familial hypercholesterolemia,

13:15

you'd wanna, um, add medications.

13:17

Um, and even in the, uh, the intermediate age groups,

13:20

imaging is not brought in,

13:21

but in this kind of broad range of age, 40 to 75 years old,

13:26

um, you look at the lipid values

13:28

and you do a risk calculator.

13:29

Um, and again, these risk calculators are,

13:31

while rearward looking, give you a percentile.

13:33

And so, um, in the about 7.5 to 20% of, um,

13:38

uh, five year risk, then you, uh, you would consider, uh,

13:41

risk discussions and you might use,

13:44

consider using coronary art, calcium, um,

13:47

scanning selectively, um,

13:48

because that can help you make a decision in this

13:51

intermediate risk group, the high risk group,

13:52

they don't recommend doing calcium scoring

13:54

because it's not gonna change, uh,

13:56

the recommendation for medical therapy.

13:58

Um, and then the results, uh, drive the decision.

14:00

So calcium score of zero is thought to be reassuring.

14:04

Again, these are all asymptomatic people.

14:06

Symptoms take you, they're not even on this chart.

14:08

Uh, this is just prevention.

14:09

Um, so calcium score

14:11

of zero can consider not using a statin, um,

14:14

and then maybe scanning in a couple years.

14:16

We'll get to that in a moment. Uh, calcium scoring of up

14:18

to a hundred, it's pretty favorable,

14:20

but you can, um, uh, augment with a statin

14:23

and then over 100, uh,

14:25

you should definitely initiate statin therapy.

14:27

But depending on the patient's tolerance for risk

14:30

and willingness to engage in a med, you might say, Hey,

14:32

any calcium at all might be enough, um,

14:34

to offer a medication.

14:37

Um, and here's the, uh, uh, the, the text of the guideline,

14:40

but if the calcium score is zero, it's reasonable

14:42

to withhold statin therapy.

14:44

But certainly don't just discard the patient.

14:46

Think about reassessing in five or even 10 years.

14:49

Um, and, and, uh, a calcium scoring scan, um,

14:53

doesn't require the world's best scanner.

14:55

Those scanners have been around since the eighties.

14:57

Well, multi detector since the, uh,

14:59

the late nineties, early two thousands.

15:01

So, um, the idea would be that, you know,

15:03

the best camera is the one that you have with you.

15:05

Um, the, really any multi detector scanner should be able

15:08

to do at least some form of calcium scoring.

15:10

So the thought that this could be the thing that we use

15:13

to screen the world, um,

15:14

although we, we wouldn't image everybody,

15:16

but if we want to make ubiquitous, uh,

15:18

calcium scoring scanning, it's a pretty reasonable thing.

15:21

That's in, in distinction

15:22

to coronary CTA, which takes a lot of skill.

15:24

It takes a much, um, higher, uh, grade of scanner

15:28

and, uh, careful technique.

15:30

Um, so they're easily processed and acquired.

15:32

Um, really any MDCT scanner, um, you do need ECG gating.

15:37

Um, you want to use the automated tools, which really,

15:39

there's so many vendors now with pretty high accuracy,

15:42

and it's, it's pretty standardized.

15:44

Um, and actually you can train a

15:45

technologist to process this.

15:47

You'd wanna give oversight and always check, um,

15:49

or if you're using an ai as, as we do, um,

15:52

just validate that it, it worked well.

15:53

And I would say the ais are getting pretty good, 90, 95%

15:56

of the scans with the, uh, the, the software we're using.

15:59

Um, I can verbatim trust the results.

16:02

The most common things that it might

16:04

mis assign the left main

16:05

and the LED, which are clinically not that important, uh,

16:08

on the, uh, uh, on the decision to medicate,

16:11

but would be embarrassing to confuse the two in a report.

16:15

Um, hey, what about the extremes of age?

16:17

Well, in, in 20 to 30 year olds, uh,

16:19

Mike Baha at Johns Hopkins has done a lot of,

16:22

um, great work in this.

16:23

And, and you can go to,

16:25

I think CAC tools.com, just Google it.

16:28

Um, but now we do have, um, some, uh, some prevalence data

16:32

for people under 30.

16:34

And it turns out actually people with risk factor,

16:36

as a third of them have, um,

16:37

have plaque even below the age of 30.

16:39

Uh, so that, that's very important

16:41

because until we had this data, we didn't really have a way

16:45

to contextualize finding plaque in somebody

16:48

below the age of 45.

16:50

And, um, it, it tells you a lot about risk factors

16:53

and, uh, in western society, how much, uh,

16:56

aosis we generate, but also, it's never good

16:58

to have calcification in your coronary arteries.

17:01

Uh, that, so it's,

17:02

while it's a late finding in plaque rupture and re rupture

17:05

and, uh, and calcium, uh, uh, accumulation, uh, it's nice

17:09

to be able to put it into context that, that, uh, uh,

17:12

where this person falls now that we've gotten this image.

17:15

And, and so if you do make a report of somebody

17:17

outside the extremes of age, um, then you might want to go

17:21

to those risk calculators

17:22

and at least point the patient to that

17:24

or point the referring physician.

17:25

I don't like putting percentile scores in the reports

17:27

because this is an individual patient.

17:30

Um, but it helps bring it into context.

17:32

The idea of repeat scanning has been looked at.

17:36

And, um, this is a, a very elegant study where, um, patient

17:41

patients were offered two scans.

17:42

So first of all, a scan at at baseline,

17:45

and if it was negative cell calcium score of zero,

17:47

they had very low events, right?

17:49

0.7% event rate, so lower than risk factors would suggest.

17:53

Um, so it's a downgrade of risk,

17:54

but a, as you, uh, saw in the earlier slides, uh,

17:58

coronary calcium accumulates with age.

18:00

And so, uh, five years

18:02

seemed like a reasonable time to look.

18:03

And when they did that, they found that about a third

18:05

of patients just under a third, um, progressed from zero

18:09

to non-zero over that five year period,

18:11

and the event rates changed.

18:13

So obviously over time, even the people without calcium can,

18:16

can have coronary events,

18:18

but that those that develop calcium have that tip

18:20

of iceberg marker that you can pick up

18:23

and you can, um, you can then

18:26

think about increasing medical therapy

18:28

and offering more lifestyle changes

18:30

because they definitely have a marker of increased risk.

18:32

Uh, again, you see those, uh, you know,

18:34

it's not, not quite races.

18:35

Um, so we're not sure, um, uh, exactly how to apply this

18:39

to people that don't fit these exact categories,

18:41

but it really doesn't matter.

18:42

It's just zero non-zero. That's what I take from this.

18:45

And, uh, you know, being below, well, here,

18:47

here you even see the, um, uh,

18:49

the calcium score of a hundred.

18:50

So zero a hundred, um, 300 in a thousand are your,

18:54

are key key markers.

18:57

Um, this is not directly applicable to those

18:59

of you doing calcium score in isolation.

19:02

Uh, uh, but one of our faculty, Mar Avari did some, uh,

19:06

machine learning on, um, on the promise trial participants,

19:10

which is a very large cohort.

19:12

And a lot of these patients got a calcium score as part

19:15

of their coronary CTA.

19:16

That's certainly how we practice at Mass General

19:18

and all our affiliates, we always

19:19

start with a calcium score.

19:21

And, um, it turns out that there's no better predictor

19:25

of obstructive coronary disease than the calcium score.

19:28

So calcium is just one piece of that, uh, puzzle.

19:31

Um, and looking directly at the disease, this, by the way,

19:34

I could show you six versions of this paper.

19:36

Some of them done, um, in the

19:38

ones in the internal medicine literature

19:40

where they looked manually at, um, calcium scores

19:43

and compared it to all the other types

19:45

of risk assessment tests like carotid intimal thickness

19:48

or cold water tests,

19:49

and all the fancy things that we don't do

19:51

as much of in radiology.

19:53

Um, there is no better marker

19:55

of potential coronary otosclerosis,

19:57

let alone coronary disease

19:59

than looking at the calcium score.

20:00

And that's why we start every scan with that is, it's a,

20:02

it's a better predictor than mining the chart.

20:04

And you can make all the fancy scores

20:06

and all the, uh, um, the complex models you want,

20:09

but take a look, and it's non-contrast.

20:11

It's really low radiation, it's patient's already here.

20:13

So we do it as part of the coronary CTA,

20:16

but that means we don't report a percentile score

20:19

because those percentile scores were developed in

20:21

asymptomatic people at intermediate risk

20:23

and without known coronary disease, without diabetes,

20:26

and without, um, uh, I forget the last one.

20:29

But the, uh, the point being that, um, that the,

20:33

the normative data only applies to asymptomatic people

20:36

that were in these large trials of screening,

20:38

whereas if you're here with symptoms

20:40

as the promised trial participants were, uh,

20:42

that doesn't quite apply.

20:45

Um, I wanted to double click on a couple

20:47

of the large recent studies just to give us,

20:50

uh, a little context.

20:51

I could probably spend about six hours

20:54

and not go through all the literature.

20:55

Um, but the SKA trial is a nice one.

20:58

Um, it was, it was done, uh, in Europe,

21:01

and they looked at, uh, 394,000 people in a certain region.

21:06

And then they invited, um, they, they sent a questionnaire

21:08

and said, would you like to be in this trial?

21:10

Part of which was screening.

21:12

They got 87, almost 88,000 recipients.

21:15

Respondents, uh, excluded some people with, uh,

21:18

known disease and

21:19

or if they've already had, um, uh, imaging.

21:22

And then they, they found, um, some eligible 43,000

21:27

some odd patients, and then they randomized

21:29

those and they had three arms.

21:30

So I just wanna focus on the 14,000.

21:33

So a giant study, uh,

21:35

or so patients in the intervention arm

21:38

that were offered a coronary artery calcium, uh, scoring,

21:41

uh, CT to look at risk.

21:43

And they bucketed exactly those buckets.

21:45

You've heard me, heard me say a few times.

21:46

So below a hundred, a hundred to 3 99, and then over 400.

21:49

And so, um, the, uh, the idea of using the,

21:53

the CT calcium score result to kind of broadly assign risk.

21:56

They didn't worry if you were below a hundred versus zero,

21:57

but they still, uh, and,

21:58

and that's the way that things kind of go.

22:00

If you have a score of over 300, I believe, um,

22:02

for most literature, it's almost the same

22:04

as you having had a prior event of a, probably a small one,

22:06

but it's still consider the prevention

22:09

as if you've already had an event.

22:10

But anyway, so low, medium

22:11

and high calcium score is a pretty easy way to think of it.

22:14

And then, um, then they applied the Dutch, uh,

22:17

so the relevant country, um,

22:19

cardiovascular risk management guidelines in patients

22:21

with coronary heart disease.

22:23

And so then they offered statins,

22:24

and occasionally it was ACE

22:25

inhibitors followed it at five years.

22:27

So, um, the, uh, uh, the patients that were surveyed, um,

22:32

and then they did a deep dive on what happened clinically.

22:34

Um, and you can see that, um, patients

22:37

that were increased risk, so a calcium score

22:39

that was significant, um, 94% got a consult

22:43

with a general practitioner versus only

22:45

63% in their risk score.

22:47

So no imaging, but just risk factors.

22:50

So for better, for worse, practically people respond more

22:54

to an imaging result and, uh, significantly more.

22:56

And if you don't start the preventive medication,

22:59

you can't prevent the event.

23:00

So the initiation of therapy was more than double in the arm

23:03

that got a calcium score

23:05

and the self-reported compliance was very high.

23:07

You hear these slogans like Seeing is believing,

23:09

or you gotta image the disease to really know.

23:11

Um, I think that's true. Uh, it's,

23:13

it's a very pragmatic trial design.

23:15

It's not like we're actually looking at

23:17

events with this result.

23:18

But it does tell you that that, um,

23:20

calcium scoring in the willing and those that qualified

23:24

and consented, uh, was helpful.

23:27

Um, another trial that you should know about,

23:30

'cause it's just massive and, uh,

23:32

fairly recent is the DANKO trial.

23:34

So that looked at a bunch of screening procedures,

23:36

and I'll only talk about one of them,

23:37

but, um, they basically decided to screen

23:40

and see if we could, you know,

23:41

the number one killer in the western world is still

23:43

cardiovascular disease.

23:44

So let's look for AFib aneurysms peripheral disease, uh,

23:50

carotid calcium, coronary calcium screen for diabetes and,

23:53

and hyper cholesterol.

23:54

So that, those are the things you do with lab values.

23:57

And then they did some novel stuff,

23:59

but basically all these tools, except the novel stuff is,

24:01

and even some of the novel stuff

24:03

is now clinically available.

24:04

So does screening, um, lead

24:07

to better outcomes when we look?

24:10

Um, and then they, they gave management advice, uh,

24:13

based on the aortic diameter that you see on a ct,

24:15

and they did the calcium scoring scan.

24:17

They also did some stuff to look at peripheral art disease,

24:19

and then they had, um, kind of trial advice about how

24:23

to medicate, um, massive trial.

24:26

So they, they screened

24:27

and then invited 10,000 some odd patients.

24:30

Um, and they had, uh, tripled the number of controls,

24:34

and they looked at people that are already on, uh,

24:35

some medications just by appropriate care

24:38

or by incidental, um, prior detection.

24:41

And then they, um, uh,

24:44

they looked at the screening findings.

24:45

So, um, how many people had calcium

24:47

scoring above the meeting?

24:49

Median 50%, no surprise there.

24:51

And then all these other, um, types of, uh,

24:53

findings like peripheral disease or aneurysms.

24:55

So aneurysms are more rare,

24:57

but they obviously are bad actor.

24:59

Um, and then 37% were started on, uh, preventive medication.

25:04

So here's the, um, the New England Journal paper

25:07

with a five-year mota mortality.

25:09

And just looking at the, the calcium scoring, um, part

25:12

of it makes it even more stark,

25:13

but there's not a significant, uh, difference.

25:18

It was trend but not significance in all cause mortality.

25:22

So that pretty comprehensive, uh, screening at five years

25:26

and applied very broadly in a large cohort of patients

25:30

did not on balance cause a decrease in all cause mortality.

25:34

So if you're a calcium scoring, um, advocate,

25:36

you might be a little sad 'cause you say, Hey, um,

25:39

we're not improving healthcare or any by doing this,

25:42

and this is with, um, standard advisement of medication.

25:46

However, um, when you start to look at subgroups things, uh,

25:49

uh, bring you array of sunshine here.

25:52

So, um, when they looked the additional analysis,

25:54

they stratified by age.

25:55

This was a fairly, um, aged, uh, cohort.

25:58

Uh, by the way it's only men,

25:59

and I'll get to why in a moment.

26:01

But, um, they, in overall, in men above 70 years old,

26:05

it didn't make a difference.

26:06

And it may be 'cause you're just starting to medicate late,

26:08

if that's the fi first time you get it,

26:10

and it's a slow disease of aging.

26:12

Um, but in the men age, 65 to 69,

26:15

which the low age group in this, uh, cohort, um,

26:18

it was an improvement in healthcare with a hazard ratio

26:20

of 0.89, um, confidence external roles did not cross one.

26:24

So they actually saw a significant decrease in

26:27

that younger group, maybe

26:28

because you had a little more time

26:29

to get ahead of the disease.

26:31

Um, and in the post hoc analysis then you can make some

26:34

inferences that screening reduces your major adverse

26:37

cardiovascular events.

26:39

So mace by 7%, which is significant.

26:41

And it was in that smaller yo younger age group.

26:44

Um, and the interventions that

26:46

that made the big difference statins.

26:48

So, um, more statin use in the screening group

26:51

and more aspirin use when appropriate.

26:53

And then aneurysm repair, which we can get into.

26:55

And yeah, actually I would say in large aorta is something I

26:59

see constantly on these, um, uh, calcium scoring scans.

27:03

And, uh, before even getting into non-cardiovascular

27:07

incidental findings like lung nodules, the, um, uh,

27:10

which you have to report if you're doing the, the,

27:12

uh, exams ethically.

27:13

Um, but the aneurysms are stuff

27:15

that often people don't know, especially in the

27:16

ascend uh, aorta.

27:18

Okay? So the conclusions of that first five year paper,

27:21

or that after more than five years,

27:22

broad cardiovascular craning did not significantly reduce

27:25

the incident of death from any cause among men, 65

27:27

to 74 years of age.

27:30

But the trends in the younger, um,

27:31

and they're gonna look again at 10 years,

27:33

these are very expensive and time consuming trials to do.

27:36

Um, and, uh, the challenge challenges that they noted,

27:39

the authors noted here were

27:41

that all cause modality reduction is difficult

27:43

to reach into screening study.

27:44

Um, it's a broad screening.

27:46

It wasn't just aimed at calcium scoring.

27:47

So we didn't select to really analyze calcium scoring

27:51

in isolation per se.

27:52

So it's not exactly a true primary prevention cohort.

27:56

So we're not really preventing disease.

27:58

And those that wouldn't, don't have any known,

28:00

uh, disease or risk factors.

28:02

Uh, but it is an important thing

28:03

because you could see that, um, the, uh,

28:06

the medical conservatives would say, Hey, uh,

28:09

screening doesn't work, but there's more nuance in here.

28:12

By the way, why didn't they not include women?

28:14

That just seems like not very 2005 of them.

28:17

Um, they did a pilot study

28:19

and they looked at 2000 randomly selected men

28:21

and women in the younger cohort of 65 and, and over.

28:25

And, um, they found that there was a much lower yield,

28:28

which you saw in the initial graphs from the 1990s.

28:31

Um, so the calcium score that was high was 38%

28:34

of the scans in, in men,

28:35

but only 11% in the women lower rates of aneurysms,

28:38

peripheral disease and atrial fibrillation.

28:40

So the yield would be that much lower,

28:42

and they only had so much money to spend.

28:44

And the, the actuarial, uh, modeling just said it's not

28:49

cost effective to do it in that cohort of that age of women.

28:52

So, uh, not saying don't screen women.

28:55

We know we under diagnose heart disease in women,

28:56

but it happens in a later decade.

28:58

And so the, uh, the utility was thought to be lower.

29:01

And you can see even selecting for men,

29:03

which is an augmented risk population,

29:05

if you just consider all comers

29:07

and then select men, they still weren't successful in,

29:09

in their screening intervention.

29:10

So I think there was something to that.

29:12

Um, but it's very important

29:14

'cause it's really not cool to leave women out

29:17

of this equation, um, for, uh,

29:19

heart disease when we know we're not doing great at, at, uh,

29:22

diagnosing or we're improving, but,

29:24

and women get different disease at different times.

29:26

Uh, but it's important to know that they said due

29:28

to the higher prevalence of severe conditions, screening

29:30

for CV disease seem more prudent in men than women

29:33

and likely not cost effective in women.

29:35

Um, but more to come on that, of course,

29:38

and they did some cost effectness.

29:39

So calcium scoring's not free.

29:41

And also you have to consider all the downstream testing.

29:43

So a study like this, you do a calcium score,

29:46

you find a nodule, and you chase

29:47

that rabbit hole for a while.

29:48

That's part of the cost. Um,

29:50

and this came out cost effectiveness, a willingness to pay

29:54

of 20,000 euros per quality adjusted life here.

29:58

Um, and I believe that was reasonable.

30:01

Um, and then the, the,

30:02

the highest cost effectiveness was in the younger cohort.

30:07

Couple other trials I've looked at just, well,

30:09

what if you looked at calcium scoring versus

30:11

just statins in the water?

30:12

Just giving everybody prevention 'cause it's so common

30:14

and why even try to target things

30:16

and yeah, you might cause some harm

30:18

or you're gonna pay for some statins

30:20

that just end up making expensive, uh, you know, excretions.

30:24

But, um, different results have come out in different

30:27

studies and, you know, just quickly,

30:28

like calcium scoring was, uh, in this study shown

30:31

to be cost effective in men, but not women.

30:33

Um, here in this study, calcium scoring was cost effective,

30:37

uh, when statins are costly.

30:39

So the prevention medicine is, is expensive.

30:41

Here they found calcium scoring to be effective.

30:43

Uh, and it was the dominant strategy here.

30:45

Calcium scoring was not cost effective com compared

30:48

to statins in the water, just all commerce treatment.

30:50

Um, again, cost calcium scoring was cost effective in men

30:54

when there's disutility from, so not willing

30:57

to take statins, but not in women.

30:59

Um, and then calcium scoring is cost effective,

31:01

but similar economic value.

31:02

So a mixed picture overall

31:05

and a, um, uh, evolving data landscape,

31:08

but, um, speaks again to selective use, um,

31:12

which is I think something we

31:13

should all be worried about in radiology.

31:14

So there's really only one green flag

31:16

for calcium scoring across the

31:17

board in, uh, in these studies.

31:19

Um, practical considerations strongly favor calcium scoring

31:22

over coronary CTA,

31:23

because if ca, if cost effectness is hard

31:26

with a cheap non-contrast test that doesn't need an IV

31:28

and doesn't need multiple phases,

31:30

and a, you know, a real expert read these,

31:32

all these studies being pushed

31:34

by the plaque industrial con plex

31:36

where they're talking about, you know, sending things off

31:38

for a detailed analysis, that's gonna be hard to do.

31:41

Um, but a lot of those studies are happening right now,

31:43

and it'll probably be, you know,

31:44

we'll find out who's the best.

31:46

Um, th this is the, i I put the, the, um,

31:50

snapshot from a cac, DRS, so it's an SCCT, um,

31:55

scoring algorithm, which people sometimes use.

31:58

Um, but more of what I want you to take from this is

32:00

that you can look at a chest ct

32:03

and you don't even have to make a calcium score,

32:04

but just a, you know, a small, medium, large amount

32:07

of a calcium that works pretty well.

32:08

So if you have a chest CT

32:10

and there's calcium on it, you might not need

32:11

to do a dedicated calcium scoring scan.

32:13

Um, I, I won't get too much in that here,

32:15

but the opportunistic screening you get from any chest

32:17

imaging, um, may be pretty good

32:19

and it's pretty reproducible.

32:21

So there's a, people have looked at

32:22

that in the lung cancer screening trials

32:23

and just in trials in general.

32:24

So maybe you don't even need to screen if you already have

32:27

that data, and you can make the assumptions

32:29

that you have intermediate or high calcium burden.

32:31

Um, as we've talked about in this lecture, this is the,

32:35

uh, overview image.

32:37

The summary image from the most recent, uh, American College

32:40

of Cardiology chest pain, um, guidelines of 2021,

32:44

which looked at all the different modalities.

32:46

Um, they actually even get into the fact that, um,

32:50

chest pain is not really even a good, um, nomenclature

32:54

because a lot of times there is not chest pain,

32:56

but there is coronary art sclerosis and, um, mis.

33:00

And so, um, the, uh, the end in that kind of sums it up,

33:04

by the way, non-cardiac chest

33:05

pain versus cardiac chest pain.

33:06

We don't use the world atypical chest pain anymore.

33:08

Um, and they, they, uh, really get into the nitty gritty of

33:12

what we should do when, um,

33:14

and I, uh, uh, I think it's important to, um, consider

33:18

that age is still a factor.

33:20

Um, but if you look at all ages, um, when you have symptoms

33:25

and you have chest pain, non-specific chest

33:28

pain is still the most common thing.

33:29

So we don't find it to be due

33:30

to coronary artery sclerosis most

33:32

of the time, regardless of who you are.

33:34

Um, and if you look at even the over 80-year-old age group,

33:37

uh, coronary art sclerosis, yes,

33:38

it's the second most common,

33:40

but it's still a minority

33:41

of patients, and that's why we test.

33:43

So, um, the reason that I have

33:45

to talk about this symptomatic, uh, cohort here is

33:50

that the, the guidelines scraped in some level two

33:54

A evidence and did bring up calcium scoring and

33:59

or ECG stress testing in selected cases

34:01

that are at low risk.

34:03

Um, it's group work, and I would never endorse that.

34:08

Um, if it was it at my hospital

34:11

or for a loved one,

34:13

I don't think you can use calcium scoring effectively,

34:16

and I'll show you why, um, without being a true expert.

34:19

Um, luckily I work in a hospital with a lot of true experts,

34:22

so I depend on them, um, to decide if a calcium score,

34:26

which I would consider looking with one

34:28

or maybe even two eyes closed at the coronaries,

34:31

would be enough to say, you're fine.

34:33

Um, and to be honest, they don't ask me that often,

34:37

so I don't say no to the scan,

34:38

but I am very careful if I find

34:40

that it's a non-expert that referred it.

34:42

Maybe it's a general practitioner

34:44

or someone I just don't know.

34:45

Well, um, that sends a symptom, somebody

34:47

with clear documented symptoms in their chart, um,

34:50

that I pick up on a radiology screen.

34:52

Um, and I'm reading the scan,

34:54

I actually make a note in the calcium scoring impression

34:56

saying, given symptoms, consider a, a alternative testing.

35:00

And it might be a coronary CTA, it might be a stress test,

35:02

it might be a nuclear or an mr.

35:04

Um, but a negative calcium score should not be reassuring,

35:08

um, in the setting of symptoms.

35:11

Um, and so this is the fine print on that guideline.

35:13

It says, observational registered data suggests

35:16

that adding a calcium score can improve risk assessment,

35:18

reduce diagnostic uncertainty,

35:20

help detect atherosclerotic plaque,

35:22

and help gr uh, guide preventive management.

35:24

Those are all true, but it's the weakest form of data.

35:27

These observational registries start off

35:30

with selection bias over

35:31

who got a calcium score in the first place.

35:34

Um, and so we should just be very, uh,

35:37

extreme caution if you see symptoms, um,

35:39

because this should not reassure.

35:42

Um, and I, I, this is I think a nice summary paper from the,

35:46

uh, journal of the American College of Cardiology.

35:48

They'd looked at a calcium scoring as a gatekeeper.

35:51

So the idea of, let's start,

35:52

just look at the calcified plaque

35:53

and then go on if you see any.

35:55

Um, and when you look at MACE rates, um,

35:59

they are lower in people with a calcium score of zero.

36:01

So it's a half a percent in the 19.

36:03

So that's actually a fair number of people, right?

36:05

79,900, um, studies, calcium score

36:08

of zero MACE rates are 0.5, so not zero, but 0.5%.

36:12

Uh, whereas if you have a more than zero calcium score,

36:15

which again, we know is the best

36:16

predictor of disease at all.

36:18

Um, so it's a significantly higher rate,

36:20

but, um, both are low

36:21

and the calcium score of zero is, is not zero.

36:23

Um, then if you look at studies of acute chest pain, one

36:26

of which I'm guilty of contributing to the literature,

36:28

it was a convenient sample,

36:29

but it gets scraped into these analyses.

36:31

So, um, in the setting of acute chest pain, it's 0.8%, um,

36:35

just by virtue of higher risk by being in acute settings.

36:38

And, um, the calcium score of greater than zero,

36:41

it's far higher at 8.5%.

36:43

So, uh, still, what's the level of missed MI you're willing

36:48

to, uh, tolerate?

36:49

Uh, 0.8 seems kind of high.

36:51

If you scan just over a hundred people,

36:53

you'll find one that you've missed.

36:54

So we never stop a scan while the calcium scoring is being

36:59

run as part of A CTA.

37:01

And I cannot endorse, uh,

37:03

coronary calcium scoring in the setting of stable

37:05

or acute chest pain as the only test it in my book.

37:08

It's a risk assessment tool

37:10

to help you decide on statin use, uh, for the most part.

37:14

Um, and I'll read you their fine print

37:17

'cause I feel so strongly about this.

37:18

So second, we investigated a low to intermediate population

37:21

by excluding patients with history of cad.

37:23

Um, is calcium scoring is very limited

37:24

value in this population.

37:26

So selection bias, even in, in, um, in these, uh, trials,

37:30

um, oh, sorry, that's actually a self quote.

37:32

That's our paper where we looked at, uh,

37:34

coronary calcium scoring.

37:36

That was done as part of a CTA in an acute chest pain

37:39

registry of, I think we had

37:40

a thousand patients at that time.

37:41

So we just wanted to remind everybody.

37:43

Yeah, calcium scoring worked okay in an acute chest pain

37:47

cohort, but by definition we weren't scanning people

37:50

that had higher risk, uh,

37:52

because this is early in the days

37:53

of practical clinical coronary CTA,

37:56

so you had a high troponin, you're out,

37:58

or even an intermediate troponin, we don't scan you history

38:01

of stents or bypass wraps

38:02

or anything other kind of, uh, uh, elevated risk history.

38:07

You weren't getting a scan,

38:08

so when you shave all those patients off of it.

38:10

And then, um, oh, and negative initial ECGs as well.

38:14

So looking, um, at an a decreased risk population,

38:18

calcium scoring did pretty well,

38:20

but we didn't send anybody home based on it anyway.

38:22

So anything that, um, behaved differently

38:25

or had a elevated risk that we hadn't uncovered

38:27

yet would not have been missed.

38:29

Um, here is,

38:31

and that's our paper, just I'm highlighting it so that,

38:33

you know, even in our paper,

38:34

we didn't touch a negative predictive value of one, not even

38:37

with a confidence interval.

38:38

So all of these papers, um, are just to the left of the, uh,

38:43

negative predictive value line of one.

38:44

And that's the important thing to know is depending on

38:47

how litigious or comfortable with risk your, um, uh, your

38:53

population is, uh, depends on how willing you can be to,

38:57

to bank on this misquoted, uh, quote of power of zero.

39:01

And so the power of zero with very,

39:03

very careful bounds on it and very careful selection.

39:05

Um, another recent paper that looked at this idea of a lot

39:09

of patients, um, patients with a calcium score

39:12

of greater than zero or zero,

39:14

and then did they have, um,

39:16

obstructive coronary disease when we went on and looked?

39:18

And so you can see here all comers, yeah, there was, most

39:22

of the people with calcium score of greater zero were, were,

39:25

uh, finding obstructive disease,

39:27

but a not insignificant proportion of the patients

39:30

with a calcium score of zero did have a, um, uh,

39:34

an obstructive coronary disease

39:36

finding 'cause they're symptomatic.

39:37

And then if you stratify by age, the,

39:40

the disconnect really happens in the young people.

39:42

So young people tended to have obstructive disease

39:44

that wasn't yet calcified more than half the time.

39:47

So nobody that's using these, um, uh,

39:51

calcium scores for symptomatic patients has any real data

39:55

to base it on, because all the convenient samples

39:58

of screeners were done in the ages of 40 to 70 with,

40:02

with minimal exceptions.

40:03

So the, uh, the, the older patients tended

40:06

to calcify their disease and the younger ones didn't.

40:08

So just remember this and this alone, and,

40:10

and I think it'll, I'll be, I'll be proud of you.

40:12

Um, so they, uh, just take this one thing.

40:16

Now, by the way, 20 thou, 23,700 people, um,

40:19

that are symptomatic is not a small amount.

40:21

So this study found that a sizable proportion

40:24

of obstructive corona disease occurred

40:26

among younger patients without coronary artery calcium.

40:29

Take home point for this whole talk, I would say

40:31

so in my opinion, this is gonna be a nice summary too,

40:34

which is calcium scoring as your only test for stable

40:37

or even acute chest pain is a Rorschach test

40:39

because you can have obstructive disease

40:41

without, uh, having any calcium.

40:43

So carefully apply calcium scoring,

40:46

don't offer it in symptomatic patients.

40:48

Here's a young patient, I believe she was 40

40:51

or 41 years old, um, had this, uh,

40:54

non-contrast scan, no calcium.

40:57

She has a symptom. It totally changes

40:59

the way I look at this study though.

41:00

So it's very reassuring if she's asymptomatic,

41:02

means no evidence of atherosclerosis yet.

41:05

Um, but you can kind of choose your own adventure here.

41:08

Um, her scan could be negative as it was in this patient.

41:12

Um, it could be this 20-year-old athlete

41:15

with a spontaneous coronary dissection

41:16

and an obstructed RCA and an infarct.

41:19

Um, it could be this 44-year-old woman

41:21

that had a really stressful event, a really bad breakup,

41:24

and had a spontaneous dissection of her LAD, uh,

41:27

which we know we miss a lot of.

41:28

This is a 40-year-old, um, woman with a myca,

41:31

so myocardial infarction with a, a

41:33

nor non-obstructive coronary art by calf.

41:35

Um, and it turned out the calf mist

41:37

that the dis LLAD was occluded and the CTA found it later.

41:40

So calcium score was zero, but this was an MI

41:42

and actually a significant one.

41:44

And then this is actually a man, uh,

41:46

I read this scan in the Roman CAT two trial.

41:48

Um, he had a calcium score of zero,

41:49

but he had a, uh, um, I think it was a first diagonal, uh,

41:53

mi, so tiny vessel disease,

41:55

and you're not gonna pick up small vessels barely with ct.

41:58

It was a kind of a heroic call.

42:00

Um, but very important eyeopener

42:02

because the calcium score was not positive.

42:04

And so I think it's very important to, um,

42:06

to just remember context.

42:07

And all of these patients were symptomatic and,

42:10

and none of them, would I have accepted a calcium score

42:13

of zero to be anything of meaning,

42:14

uh, or we would've been burned.

42:16

Don't take my word for it. Take

42:17

the American College of Radiology.

42:19

This is the, um, appropriate nice criteria

42:21

for asymptomatic patients at risk for coronary disease.

42:24

Um, if you look at, uh, the variant with low risk,

42:28

no, no imaging at all needed.

42:30

There's not even calcium scoring.

42:31

If you look at intermediate risk,

42:32

then calcium scoring's appropriate

42:34

and a CTA may be high risk.

42:36

Nothing's definitely appropriate

42:38

because you're probably gonna go on further.

42:40

Um, and that,

42:41

and so this is a, uh, so asymptomatic patients, um,

42:45

a CR guidelines are great 'cause they're simple.

42:47

Um, full disclosure,

42:48

I think I was the lead author on this one,

42:49

which nothing has, uh, changed on it.

42:51

So this just lays it out in stark contrast.

42:54

But the only test that's really good in asymptomatic

42:56

patients, asymptomatic is intermediate

42:58

risk CT coronary calcium.

43:00

Um, contrast that with the acute non-specific chest pain,

43:04

even a low probability, we didn't even

43:07

consider rating calcium scoring

43:09

'cause it would be dangerous to even put it on there.

43:10

So it was not even considered worthy

43:12

of discussion by the expert panel.

43:14

So CTA, if you have symptoms, um, I can tweet it

43:17

until I'm blue in the face and

43:18

I'm sure somebody won't listen.

43:19

But it's really only for asymptomatic patients.

43:21

Intermediate risk, um, guidelines verify this.

43:25

There's a bunch of different guidelines in the cardiology

43:27

literature, um, but basically even calcium scoring,

43:31

as ubiquitous as it is, it's really only a maybe considered

43:34

or should be considered, um, by most guidelines.

43:36

So there's no guideline

43:38

that says everyone should get a calcium score.

43:40

That's just not true. You really have to look at the risk.

43:43

Like I, I like the ACC one

43:44

'cause it just says, Hey, if you're in this intermediate

43:46

risk and it's gonna change your management up

43:49

or down, that's why you could consider it.

43:51

Um, that's probably part

43:52

of the reason we don't always get it paid

43:54

for by all insurances.

43:55

More and more the insurance companies are wise to it.

43:56

But, uh, if any, you know, no green on this slide,

44:00

I think is the, uh, one of the take home points.

44:02

Um, if you look at the, uh, European society guidelines,

44:05

again, it's a maybe considered

44:07

to improve risk classification around decision thresholds.

44:11

Um, and, uh, again,

44:13

the second thing is actually important too.

44:14

The routine collection of other modifiers

44:16

is not recommended.

44:17

So even across the pond, they're kind of feeling similarly,

44:21

um, about use of imaging.

44:23

It's a selected cohort.

44:25

Um, we do have strong evidence for coronary ct,

44:27

but they're all from non-randomized controlled studies.

44:30

So it's a robust imaging biomarker.

44:32

It's a very strong predictor.

44:33

As you've seen, calcium score

44:35

of zero has a very high negative predictive value in

44:38

a very specific context.

44:39

Um, it's got superior

44:40

to discriminatory power over other risk

44:43

factors and other markers.

44:44

You've seen that three ways now.

44:46

Um, there's a significant re risk reclassification,

44:49

but it's mostly in that intermediate risk group

44:51

and it's more costive than statin indication, uh,

44:54

for statin indications than risk factor based management in

44:57

most of the studies we just looked at.

45:00

Um, so in summary, um, effective screening is hard to do

45:03

and to do effectively, but there is a large body of data

45:06

of variable quality to support calcium scoring,

45:08

but only in selected patients.

45:10

The use of calcium scoring is almost completely

45:13

for asymptomatic patients at intermediate risk

45:16

for prevention therapy decision only.

45:18

Um, careful patient selection is the most important

45:21

determinant of the calcium scoring utility

45:23

and, uh, large incremental costs

45:26

and technical challenges for CTA over CAC right now.

45:29

So right now, for all the guidelines

45:31

and all the data we have, calcium scoring

45:33

is the preferred test.

45:34

Um, I'd love to open this up for questions

45:36

because I'm sure I didn't cover something

45:38

or maybe, uh, triggered, uh, a thought in you.

45:41

So I'd love to hear from you and,

45:42

and if you can, um, chime in, I'd be, uh, grateful.

45:45

Thank you for staying to the end.

45:47

Thank you so much for that awesome lecture, Dr. Gre.

45:50

It was fantastic. Thank you.

45:53

We are gonna now open the floor for questions,

45:55

so if you've got them, go ahead and toss those into that q

45:57

and A feature so we can get to them all before we close.

46:02

There is one in there already, if you wanna open that up.

46:07

Um, alternatively I can read it to you if you prefer.

46:11

I see it, I'll, I can read it.

46:12

Um, so, uh, anonymous attendee says,

46:14

how useful is the calcium score in patient

46:16

with renal failure where calcium buildup tends

46:18

to be in the media rather than intima?

46:20

And can CTCA differentiate between the two? Thanks.

46:24

Um, you know, I might have answered this question

46:26

differently last year, um, only

46:28

because you're absolutely right, the burden

46:31

of calcification is much higher, um, in renal failure,

46:35

although it's this idea of phylaxis, I don't know

46:38

that I have, um, any numbers

46:41

or cutoffs to, to give to you to say,

46:43

don't scan at this level.

46:45

So I think it's reasonable to look if it's not known.

46:48

Um, I also, um, used to be much more skeptical,

46:53

skeptical about doing, um, coronary CTAs

46:56

and people that, you know, have a lot of plaque burden,

46:58

but in certain conditions, um, I think it helps,

47:01

for instance, photon counting ct,

47:03

you have much better resolution.

47:05

Um, and so we know we might better, um,

47:08

even if we can't differentiate where the calcium is,

47:10

if we need to rule out obstruction, I think that's helpful.

47:14

And, um, I also think

47:16

that even though we might have non invaluable segments

47:18

actually know this, um,

47:20

when we have really high calcium scoring patients,

47:22

we don't stop the referral if it does come through as a CTA,

47:25

uh, because you can still usually find left main disease

47:28

and the prognostic, uh, significance of left main alone is

47:32

so bad that if you consider that as your one job

47:35

or finding three vessel disease,

47:36

even if you have stuff you can't see if the patient

47:38

has symptoms, it's okay to go on.

47:40

But the, in the context of appropriate calcium scoring use,

47:43

it really ought to be for asymptomatic persons

47:45

that you are going to change your management with.

47:48

So long-winded answer to say

47:51

CTA might be more useful in the most elite forms.

47:55

Uh, let's see, another question from anonymous.

47:58

Uh, would you do a calcium score in a young

48:00

patient any age limit?

48:02

Um, the data you saw there was in the 20 to 30-year-old.

48:06

So I think it's reasonable, um, in people

48:10

that you have a reason to look.

48:12

So I, nobody, I don't think you'll find anybody in the world

48:14

that says that we should scan the world's 20 year olds,

48:17

but somebody with a strong family history

48:19

or that's very worried, um, I think

48:21

that's kind of reasonable.

48:23

Um, but as you saw, the, the people that are going

48:26

to burn you, the ones that have tons of plaque that's not

48:28

yet calcified are the symptomatic people under age 40.

48:32

So very selective use.

48:33

Um, it's really just for, uh, you'd have to have a, a reason

48:37

to augment your, um, risk factors.

48:40

With that. Let's see, another, uh, question.

48:43

How useful would a coronary calcium score CT scan

48:46

be in assessing cardiovascular?

48:47

A 38-year-old asymptomatic

48:49

with significant elevated LP little a,

48:52

which apparently is the, the biomarker du jore

48:55

and it's very, uh, very good at picking up

48:57

some genetic mutations.

48:59

I am not a preventive cardiologist,

49:01

so I think it's important, um, that they weigh in.

49:06

Um, that being said, I 30 eight's pretty close

49:08

to 40 and I think it's okay.

49:10

Um, you've very well articulated in this question

49:12

that they're asymptomatic.

49:14

Um, so I think it's probably reasonable.

49:16

Um, and it's very important that the recipient of

49:18

that score contextualize it

49:20

and confirmed they really are asymptomatic.

49:22

It's really funny, even in non young people,

49:24

how often someone starts with a calcium score

49:27

and then next thing you know, they show up

49:29

and they're getting treadmill tests and other things

49:30

because symptoms kind

49:32

of come outta the woodwork once you know

49:33

you have disease and it's real.

49:34

I don't know what the right answer in that world is,

49:36

but you kind of have to take a face value

49:39

that the patient doesn't have, um,

49:41

symptoms if they say they don't.

49:42

Um, for what that's worth. Let's see. Hot Nasser.

49:48

Uh, do you recommend adding a comment on presence

49:50

of coronary calcium on CT chest studies

49:52

or low dose CT studies performed, uh, with, uh, say PET ct?

49:58

Definitely, yes. It's part of our site macros.

50:01

Um, if you look at guidelines, they will say,

50:03

you should calculate

50:04

or you should comment on like large, moderate and sev

50:09

or so small, moderate and severe,

50:10

or like mild, moderate, severe calcium burden.

50:12

I think that is silly.

50:14

Um, severe in my world is a stenosis descriptor.

50:18

So I say small, medium, large or um, extensive burden.

50:22

I really just don't endorse the guidelines

50:24

that say using the word severe,

50:25

because this may, this is sort

50:27

of like a opportunistic calcium scoring,

50:29

but I, if someone has a high calc burden,

50:32

I think it's worth a comment.

50:34

And also take a look at the demographics, right?

50:36

If you, if you told me that I have a lot

50:39

of calcium in my coronaries.

50:41

We have a lot of y I'm not that young, but I'm not that old.

50:43

So you have a lot of years to get in front of it

50:45

by giving me preventive care

50:46

and, you know, talking about lifestyle.

50:49

And my father who's in his eighties, it's kind

50:51

of expected it would be unlikely

50:53

for him not to have any calcium.

50:54

So, um, whether it's impression worthy is a different animal

50:57

than whether it's worth commenting,

50:58

I think it's a finding just like a lung nodule

51:00

and a, a calcium in your coronaries is more likely

51:03

to kill you than any long nodule, at least in the West.

51:05

So I think it's important to talk about, um,

51:08

but respond and don't react.

51:10

So just, just have a moment of thought.

51:12

If you're like me, you're lucky

51:14

to have a really strong medical record.

51:15

And a lot of smart men, I'm like,

51:17

I'm often the least smart doctor in the equation.

51:19

So I can look at the referring physician's notes

51:21

and I can know, hey, this patient's already had a stent

51:23

or they already are on a statin,

51:25

or they've already talked about risk counseling.

51:27

So in that case then it's still a finding,

51:29

but it's, it's been addressed,

51:31

so it's not likely I'm gonna change their management.

51:33

But if I'm the first to know that they have calcium

51:35

and they're young, that might even make

51:37

it down into my impression.

51:38

So, uh, unfortunately more

51:41

and more we have to contextualize a lot of things

51:43

and maybe AI helps with that.

51:45

Um, and, and, uh, I, I'll welcome that help

51:49

because the nuanced with,

51:51

with your practice medicine is getting

51:52

pretty, pretty important.

51:54

Um, let's see. Anonymous attendee,

51:55

what is the warranty period for a calcium score

51:58

of zero in asymptomatic patients?

52:00

Uh, when would it be reasonable to repeat?

52:02

So the, uh, I think it's five years based on

52:05

that paper, which is pretty robust.

52:06

The, uh, Omar Zey paper, D-Z-A-Y-E-I think it was Jack 2021.

52:11

It was on the slides. Um, so if you have a calcium score

52:14

of zero, it's reasonable.

52:16

Look, again, after five years, I wouldn't look every year.

52:19

Uh, I don't care how much they want to self pay

52:21

for these things, it just, I think you're just unlikely

52:24

to have a high yield and you're more likely to cause fear,

52:27

harm, distil utility or even, you know, miss things.

52:31

Um, let's see.

52:32

Mohammed Mustafa, do you think calcium score will go

52:35

to change in the era of vitamin K two

52:37

and D three administration?

52:39

Um, so like, I think you're asking will the types

52:44

of plaque we get change?

52:45

It's very possible. I think it already has.

52:48

MESA trial is amazing and it's cool

52:49

to see a major trial run, run by, um,

52:52

or led by a radiologist.

52:53

So David bloke is like, you know, we should all be

52:55

proud he's on team radiology.

52:58

That said, I don't, um, I think that the type

53:00

of disease we get evolves

53:01

and I don't know if normative databases will, uh, keep up.

53:04

If you're asking, um, for the therapy, the way we use it,

53:08

I mean, I really hope we keep, we, I think there's more

53:11

and more classes of therapy coming out every day.

53:13

Some of them of infusions or genetic therapies with crispr.

53:17

So if you're an optimist, there's never been a better time

53:20

to have coronary atherosclerosis

53:22

'cause there's more we can do and there's only more coming.

53:24

So I think in that respect,

53:25

like the way we use calcium scoring is important.

53:28

Um, and it may turn out that that's not enough now,

53:30

especially as it moved to younger populations.

53:33

CTA for prevention, not there yet.

53:35

A lot of data need to be collected,

53:37

but it's possible that we find a world

53:39

where we need the noncalcified plaque.

53:41

Um, 'cause that's the more addressable

53:43

and the more likely and the young.

53:45

Which software do we use for scoring?

53:47

Do you rely completely on it?

53:50

Also, there are some calcifications below the threshold

53:52

for software detection, but are there, how do you view them?

53:55

All good questions. We have a couple softwares.

53:57

There's one built in our pacs uh,

53:58

right now we're using, uh, Vistage.

54:00

Um, that may change.

54:02

Um, there's one built into the, so we, uh,

54:06

on our Siemens scanner, there's a package.

54:08

I think the GE scanner came with one.

54:10

There's, um, the one we use from Siemens actually has an

54:14

automated, um, detection algorithm that's kind of nice.

54:17

Every once in a while. It needs a fact check

54:19

'cause it picked up, uh, mitral annular calcification.

54:21

That's the most common pitfall.

54:23

Every once in a while it backs into the aortic root

54:25

and it's really not coronary calc.

54:27

So, um, definitely look at it.

54:29

But even if the glass is nine

54:31

tenths full, I think it's awesome.

54:33

It goes fast. Um, the exact differentiation

54:37

between which vessels is not clinically meaningful.

54:39

Um, so maybe you give like broad strokes

54:42

or you just say, make a comment that like parts

54:44

of the LED were scored as left main

54:45

or you just manually repeat those ones.

54:47

That's what I do. I just take a look

54:48

and if I don't agree, I just redo it.

54:50

But it still saves me work in the majority of cases.

54:52

Um, and then, oh, so the calcifications below the threshold

54:57

for software, and you've heard it from the, well,

54:59

indirectly from the Atkinson and Janowitz from me.

55:03

Um, it's arbitrary that we do a, uh, a threshold

55:06

of 130 hounds field units.

55:08

So you can handle, uh, the, the way that the strict,

55:11

um, methods were written.

55:12

You don't count stuff below one 30.

55:14

Um, but if I see a lot, I might even say, Hey,

55:16

there's atherosclerosis below the threshold

55:19

to be included by the agates and method.

55:21

So if you were looking for any plaque at all, it's there.

55:24

And just know that, you know, that the epidemiologically,

55:27

it's still still buckets into like zero 100, um, th 300,000.

55:32

Um, but that's in the context of a 40

55:36

to 70-year-old patient at, you know,

55:37

intermediate risk without known disease.

55:39

So, bit of a nuance there,

55:42

but I do comment, uh, it's a great question.

55:44

Um, how about using calcium score in setting is setting

55:49

goal threshold of LDL levels?

55:51

Patients aren't a statin. That's harder.

55:53

There's variable data on this

55:54

because people on a statin, um, some studies have showed

55:57

that it creates more calcium

55:59

or you see calcification progress more.

56:01

Uh, and it's variable.

56:03

There's not all studies, not all studies show that.

56:05

Um, but it might be because you're stabilizing plaques.

56:08

Um, it it, the literature's still,

56:10

the jury is still out on that one.

56:11

Um, and the conflicting literature will be

56:13

there forever 'cause it's out there.

56:15

So it, it, we will get more answers.

56:16

But, um, I always tell our trainees I'd rather not have

56:21

calcium if I, if I did have to have it, I'd want to know

56:24

and I'd want to get a treatment

56:26

and my personal threshold's below 100 to, uh, it really,

56:31

and um, also remember that even somebody

56:34

with a calcium score of zero

56:35

that has high lipids will benefit from prevention.

56:37

So you, uh, even your calcium score

56:39

of zero patients aren't done yet.

56:41

That's just one piece of, of the cardiology puzzle.

56:43

Um, and you may not have that data,

56:45

especially if you're in an outpatient center without

56:47

broad records from everywhere.

56:49

Um, Jeffrey Zuckerman has the data supported the use

56:52

of statin therapy to lower events

56:54

and risk in those patients at intermediate risk

56:56

and where statin therapies considered indicated.

57:00

Uh, yes. You just saw it in the, I think the

57:04

SKA trial sort of gets at that.

57:06

And then, uh, the Dan trial, that's exactly what it showed.

57:11

Um, so I think that's, uh, and that's broad strokes.

57:14

That's not everybody. Like I imagine if you included from 40

57:17

to 65, which they did not, that you'd even see.

57:20

My, my inference would be that

57:21

that would be even more powerful information.

57:23

Um, you gotta be on a statin for a while.

57:25

You gotta get the lipids down and keep 'em down.

57:27

Um, 'cause it's a iterative process. Okay.

57:30

John G***o, do you report aortic valve agatston score

57:33

routinely or only if asked?

57:35

That's a great question too. I look,

57:37

we have a qualitative field on our macro.

57:40

If I see it, I score it,

57:41

especially if it looks more than just a little.

57:43

'cause I just don't want to have to get

57:44

the phone call that it comes back.

57:45

The other thing we've noticed of late, there's a lot

57:48

of papers on aortic valve calcium scoring.

57:50

So same method, you're clicking it

57:51

to make sure you include the valve and not the root

57:54

and not the coronaries and not the mitral valve.

57:56

But if you do that and you get an aortic valve calcium

57:58

score, that can be used in settings

58:01

where they're worried about low flow,

58:02

low gradient aortic stenosis.

58:03

So the, the echo is not able to suss out

58:06

or it's indeterminate

58:07

or they think there's a weak ventricle.

58:09

And so if that referral comes in, we don't have it in our,

58:14

um, epic system, we don't have a way

58:16

to order a scan just for your valve.

58:17

So I look for fields in the comments.

58:20

I'd rather not get an email after I read it

58:22

and say, Hey, thanks for commenting,

58:23

but I, I actually wanted the valve, not the coronaries.

58:25

So if I see it, I just do it, it takes a a minute more.

58:28

Um, I'm not aware of an automated software.

58:30

There surely is something somewhere.

58:32

Um, so it, it just takes a couple of, uh, clicks.

58:35

But it some careful looking.

58:37

If you have a really bad scan, it can be difficult

58:39

to know where those structures are.

58:40

So it's really easy to do an aortic valve calcium

58:42

scoring with the CTA.

58:43

So we do it on every TAVR scan.

58:45

Our heart valve team wants that.

58:46

So we just add it in and we have our 3D lab personnel do it.

58:49

And it's, it's not hard for them,

58:51

but having the CTA lets them click in the right places.

58:54

So good questions there. Um, anonymous attendee.

58:57

Does a high calcium score preclude a CTA? Not in my world.

59:01

Uh, it never has. Um,

59:03

and I'd say it even less precludes it now that we have,

59:06

we have a ton of scanners at a ton of sites.

59:07

We only have, uh, limited photon counting scans.

59:11

Um, if I could choose,

59:12

I would steer all the high calcium scores

59:13

to the photon counter and just the best scanners and,

59:16

and, um, but we don't know that.

59:18

'cause often we're getting the calcium score

59:20

during the CTA, we never stop.

59:22

Um, and I, I informally told you my personal results

59:25

locally, we've looked at it, the yield is very high.

59:27

So high calcium score means high likelihood

59:30

or higher likelihood of non invaluable segment,

59:32

but very high likelihood of us finding something.

59:34

And then that's a next step. So even though I can't clear

59:36

the circ, but I can find an RCA severe cath is next.

59:39

Um, so that's how we handle it.

59:41

Um, I also am more willing to take a stent now

59:44

that we have a photon counter, but we

59:46

generally don't block scans.

59:47

But you know, we, we never say no, but we'll say yes,

59:49

but like, yes,

59:50

but you ordered a, uh, uh, A CTA with a stented patient.

59:54

It's a small stent as long as you know

59:56

that I'm not gonna be great for the stent

59:57

and you want me to look for the native arteries in front of

60:00

and behind the stent or in the other ones, as long

60:02

as we're on the same page there, we'll go ahead and do it

60:04

and we might help that patient or spare a cath.

60:06

So some nuance.

60:07

But I think, uh, also patient took a day off of work.

60:10

They already got an IV in

60:11

and you find out the calcium score high on the table

60:13

and I think you're doing them a disservice

60:15

by canceling the scan.

60:17

Just my opinion. You have to go

60:18

by your local expertise and experience.

60:21

Um, but the understanding at, uh, mass General

60:23

and our kind of wide swath of surrounding, uh,

60:26

places we cover is that we just, we never cancel a scan, um,

60:29

for A CTA 'cause the yield's pretty good.

60:32

Um, okay. Anonymous attendee.

60:35

Does the calcium score ever regress? Thanks.

60:39

Uh, I've not seen that regress though.

60:43

It could in theory, some microcalcifications

60:46

and this is stuff done with bone radio, tracers

60:49

and PET have shown differences.

60:51

We don't look at that kind of stuff whether A CTA,

60:53

but, um, I think it's highly unlikely that regresses.

60:56

And so you shouldn't feel sad once you have a calcium score.

60:59

You want to, if you're gonna trend them over time

61:00

or over a five year or just if you know you have it.

61:03

Um, just be glad that you

61:04

know when you have something to treat.

61:05

Um, and just expect that the rate

61:08

of progression should go down

61:10

and you actually might calcify more.

61:12

But if, if you're turning noncalcified plaque

61:14

to calcified plaque, that's a more stable portion of

61:17

that complex algorithm.

61:18

So, um, uh, a weird thing to tell somebody,

61:21

but maybe the calcium score going up is a positive.

61:23

We just don't know. Um, and we can't image that.

61:26

So I, but you wanna be positive

61:27

'cause it's nothing worse than doing a

61:29

test that makes somebody feel bad.

61:31

You want 'em to feel that they have, uh, captured a chance

61:35

to, to treat and prevent, um, Jeffrey Zuckerman again.

61:39

So in an asymptomatic patient

61:40

with a high calcium score, do you always proceed to see?

61:43

Yes, uh, we do. Um, we're lucky.

61:45

We have great scanners and great readers,

61:47

but yeah, we don't, um, uh, we don't stop, uh, ever really.

61:52

Um, I would encourage our, uh, referrers to look

61:57

and if they have a known high calcium score

61:58

to think twice about, um, referring, but I think in this day

62:02

and age, even if just finding

62:03

left main, it's pretty high yield.

62:06

Whew. You got through all those questions.

62:09

Thank you for Thank you so much.

62:10

I love it when people interact.

62:12

I always, it's strange not to see people's faces

62:14

and I'd love to meet you all in person,

62:15

um, if we ever get a chance.

62:17

But, uh, thank you. I really appreciate the engagement.

62:19

Yeah. And thank you so much for, again, for being here

62:21

and giving that awesome lecture and

62:23

for answering all those questions. We really appreciate it.

62:26

Thank You. Yeah. And thanks for everyone else

62:28

for asking such great questions

62:29

and engaging with our faculty today.

62:31

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62:33

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62:36

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62:40

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62:42

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62:44

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62:46

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62:48

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62:50

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62:56

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