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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Postmortem coronary artery calcium score in cases of myocardial infarction
Katarzyna Michaud1,2, Virginie Magnin3,4, Mohamed Faouzi4,5
1University Center of Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, CH - 1000, Lausanne 25, Switzerland. katarzyna.michaud@chuv.ch.
Insights
Sudden cardiac death from atherosclerotic coronary artery disease can occur even with a zero coronary artery calcium score (CACS) on postmortem CT. Histological analysis reveals fatal plaque characteristics are crucial for understanding these cases.
Area of Science:
- Cardiovascular Pathology
- Radiology
- Forensic Medicine
Background:
- Sudden cardiac death (SCD) due to atherosclerotic coronary artery disease (ACAD) is a leading cause of mortality in Western countries.
- Coronary artery calcium score (CACS) via computed tomography (CT) is an established predictor of coronary events, reflecting atherosclerotic burden.
- Postmortem CT (PMCT) can quantify coronary calcifications, but zero CACS has been observed in severe ACAD cases.
Purpose of the Study:
- To retrospectively evaluate CACS in myocardial infarction cases related to ACAD.
- To investigate the relationship between CACS, histological findings of coronary plaques, and patient demographics.
- To understand discrepancies between PMCT CACS and autopsy findings in fatal ACAD.
Main Methods:
- Retrospective analysis of 36 adult myocardial infarction cases with ACAD, CACS, and histology from 582 autopsies over 2 years.
- CACS calculated using Smartscore 4.0 software on a 64-row CT unit with a specific cardiac protocol.
- Histological examination of coronary arteries to identify plaque rupture or erosion and coronary thrombosis.
Main Results:
- CACS increased significantly with age (p<0.05) but showed no significant correlation with gender, body weight, BMI, or heart weight.
- CACS was significantly higher in cases with plaque rupture (22/28) compared to plaque erosion (6/28) (p<0.01).
- Five cases (13.9%) presented with a CACS of 0-10, despite severe ACAD-related myocardial infarction.
Conclusions:
- A zero or low CACS on unenhanced PMCT does not exclude myocardial infarction related to ACAD.
- Histological examination of coronary plaques is essential to explain the discrepancy between imaging findings and clinical outcomes.
- Fatal coronary plaque characteristics, such as rupture, are critical in ACAD-related SCD.
Abstract:
Sudden cardiac death (SCD) related to atherosclerotic coronary artery disease (ACAD) resulting in myocardial infarction is the most prevalent cause of death in western countries. In clinical practice, coronary artery calcium score (CACS) is considered an independent predictor of coronary events, closely related to atherosclerotic burden and is quantified radiologically by the Agatston score being calculated through computed tomography. Postmortem computed tomography (PMCT) allows the visualization and quantification of coronary calcifications before the autopsy. However, it was reported that some patients who died from severe ACAD had a zero CACS in PMCT. In this study, a retrospective evaluation of CACS in adult's myocardial infarction cases related to ACAD, with available CACS and histological slides of coronary arteries, was performed in order to gain a deeper understanding of coronary calcifications and their role in myocardial infarction cases. The CACS was calculated by using the software Smartscore 4.0 after the radiological examination on a 64-row CT unit using a specific cardiac protocol. Thirty-six cases were identified out of 582 autopsies, recorded during a 2-year study period (29 men, 7 women; age 56.3 ± 11.7). CACS was 0-10 in 5 cases (5 men, 44.8 ± 13.7), 11-100 in 8 cases (6 men, 2 women, 53.1 ± 7.7), 101-400 in 13 cases (11 men, 2 women, 57.4 ± 9.6), and > 400 in 10 cases (9 men, 1 woman, 63.1 ± 11.9). Coronary thrombosis was found in 28 cases, histologically identified as plaque erosions in 6 cases and as plaque ruptures in 22 cases. Statistical analyses showed that CACS increases significantly with age (p-value < 0.05) and does not show significant correlation with gender, body weight, body mass index, and heart weight. CACS was significantly higher in plaque ruptures than in plaque erosions (p-value < 0.01). Zero or low CACS on unenhanced PMCT cannot exclude the presence of myocardial infarction related to ACAD. This paradoxical discrepancy between imaging and autopsy findings can be explained considering the histological aspect of fatal coronary plaques.
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