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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals
Philip Greenland1, Laurie LaBree, Stanley P Azen
1Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill 90502, USA.
Insights
Coronary Artery Calcium Scoring (CACS) improves coronary heart disease (CHD) risk prediction beyond the Framingham Risk Score (FRS), particularly for intermediate-risk patients. This combined approach aids in guiding preventive strategies for asymptomatic adults.
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Imaging
Background:
- Current guidelines recommend coronary heart disease (CHD) risk assessment for all adults to tailor preventive treatments.
- The Framingham Risk Score (FRS) is a common tool, but its accuracy may be enhanced by additional tests like Coronary Artery Calcium Scoring (CACS).
Purpose of the Study:
- To evaluate if CACS combined with FRS offers superior prognostic information in asymptomatic adults compared to each method alone.
- To determine if this combined approach improves the guidance of primary preventive strategies for individuals with CHD risk factors.
Main Methods:
- A prospective, population-based observational study involving 1312 asymptomatic adults with coronary risk factors.
- Participants underwent computed tomography (CT) for CACS assessment and were followed for up to 8.5 years for CHD events.
- Exclusion criteria included diabetes, missing data, or prior coronary events.
Main Results:
- An FRS >20% significantly predicted myocardial infarction (MI) or CHD death (HR 14.3).
- A CACS >300 was also predictive of events (HR 3.9).
- CACS provided additional risk prediction across FRS categories >10%, but not for FRS <10%.
Conclusions:
- High CACS values can modify CHD risk predictions derived from FRS alone.
- The combined FRS and CACS approach is particularly valuable for refining risk assessment in intermediate-risk patients.
- This integrated assessment aids in more precise clinical decision-making for primary prevention.
Context:
Guidelines advise that all adults undergo coronary heart disease (CHD) risk assessment to guide preventive treatment intensity. Although the Framingham Risk Score (FRS) is often recommended for this, it has been suggested that risk assessment may be improved by additional tests such as coronary artery calcium scoring (CACS).
Objectives:
To determine whether CACS assessment combined with FRS in asymptomatic adults provides prognostic information superior to either method alone and whether the combined approach can more accurately guide primary preventive strategies in patients with CHD risk factors.
Design, Setting, And Participants:
Prospective observational population-based study, of 1461 asymptomatic adults with coronary risk factors. Participants with at least 1 coronary risk factor (>45 years) underwent computed tomography (CT) examination, were screened between 1990-1992, were contacted yearly for up to 8.5 years after CT scan, and were assessed for CHD. This analysis included 1312 participants with CACS results; excluded were 269 participants with diabetes and 14 participants with either missing data or had a coronary event before CACS was performed.
Main Outcome Measure:
Nonfatal myocardial infarction (MI) or CHD death.
Results:
During a median of 7.0 years of follow-up, 84 patients experienced MI or CHD death; 70 patients died of any cause. There were 291 (28%) participants with an FRS of more than 20% and 221 (21%) with a CACS of more than 300. Compared with an FRS of less than 10%, an FRS of more than 20% predicted the risk of MI or CHD death (hazard ratio [HR], 14.3; 95% confidence interval [CI]; 2.0-104; P =.009). Compared with a CACS of zero, a CACS of more than 300 was predictive (HR, 3.9; 95% CI, 2.1-7.3; P<.001). Across categories of FRS, CACS was predictive of risk among patients with an FRS higher than 10% (P<.001) but not with an FRS less than 10%.
Conclusion:
These data support the hypothesis that high CACS can modify predicted risk obtained from FRS alone, especially among patients in the intermediate-risk category in whom clinical decision making is most uncertain.
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