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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Use of Computed Tomography Coronary Calcium Score for Coronary Artery Disease Risk Stratification During Liver
Sabha Bhatti1, Blanca Lizaola-Mayo2, Mohammad Al-Shoha3
1Division of Cardiology, University of Arkansas for Medical Sciences, 4301 W. Markham Slot #567, Little Rock, AR, 70205, United States.
Insights
Coronary artery calcium scoring (CAC) effectively identifies patients with end-stage liver disease (ESLD) who can safely undergo liver transplantation (LT) without further cardiac testing. A CAC score below 346 reliably excludes significant coronary artery disease (CAD).
Area of Science:
- Cardiology
- Hepatology
- Transplantation Medicine
Background:
- End-stage liver disease (ESLD) is not traditionally a risk factor for atherosclerotic cardiovascular disease (ASCVD).
- However, patients with ESLD often have lifestyle factors increasing ASCVD risk.
- There's a high prevalence of asymptomatic coronary artery disease (CAD) in ESLD patients, posing risks for liver transplant (LT) recipients.
Purpose of the Study:
- To evaluate the role of Coronary Artery Calcium (CAC) scoring in risk stratification for CAD in patients undergoing LT evaluation.
- To determine if CAC can guide the need for further invasive cardiac assessments like left heart catheterization (LHC).
- To assess the safety and efficacy of CAC in managing cardiac risk prior to LT.
Main Methods:
- A prospective study of patients with ESLD referred for LT evaluation.
- Comparison of CAC accuracy against traditional risk factors, troponin I, dobutamine stress echocardiogram (DSE), and single-photon emission computed tomography (SPECT) for detecting significant coronary stenosis (≥70%).
- Correlation of CAC findings with left heart catheterization (LHC) results and 30-day post-LT cardiac outcomes.
Main Results:
- Of 148 patients, 124 (84%) underwent CAC. Significant CAD (≥70%) was identified in 28% of patients undergoing LHC.
- A CAC score <100 was found in 58% of patients, with no post-LT acute coronary syndromes in this group.
- A CAC score <346 demonstrated 100% negative predictive value for significant CAD (≥70%) on LHC, outperforming other methods.
Conclusions:
- Coronary artery calcium (CAC) scoring is a valuable, noninvasive tool for CAD risk stratification in LT candidates.
- Patients with CAC <100 can likely proceed to LT without LHC or stress testing.
- A CAC score <346 effectively rules out significant CAD (≥70%), optimizing the LT evaluation pathway.
Background:
End-stage liver disease (ESLD) is not considered a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, lifestyle characteristics commonly associated with increased ASCVD risk are highly prevalent in ESLD. Emerging literature shows a high burden of asymptomatic coronary artery disease (CAD) in patients with ESLD and a high ASCVD risk in liver transplantation (LT) recipients. Coronary artery calcium score (CAC) is a noninvasive test providing reliable CAD risk stratification. We implemented an LT evaluation protocol with CAC playing a central role in triaging and determining the need for further CAD assessment. Here, we inform our results from this early experience.
Methods:
Patients with ESLD referred for LT evaluation were prospectively studied. We compared accuracy of CAC against that of CAD risk factors/scores, troponin I, dobutamine stress echocardiogram (DSE), and single-photon emission computed tomography (SPECT) to detect coronary stenosis ≥70 (CAD ≥ 70) per left heart catheterization (LHC). Thirty-day post-LT cardiac outcomes were also analyzed.
Results:
One hundred twenty-four of 148 (84%) patients underwent CAC, 106 (72%) DSE/SPECT, and 50 (34%) LHC. CAC ≥ 400 was found in 35 (28%), 100 to 399 in 17 (14%), and <100 in 72 (58%). LHC identified CAD ≥ 70% in 8 of 29 (28%), 2 of 9 (22%), and 0 of 4, respectively. Two acute coronary syndromes occurred after LT in a patient with CAC 811 (CAD < 70%), and one with CAC 347 (CAD ≥ 70%). No patients with CAC < 100 presented with acute coronary syndrome after LT. When using CAD ≥ 70% as primary endpoint of LT evaluation, CAC ≥ 346 was the only test showing predictive usefulness (negative predictive value 100%).
Conclusions:
CAC is a promising tool to guide CAD risk stratification and need for LHC during LT evaluation. Patients with a CAC < 100 can safely undergo LT without the need for LHC or cardiac stress testing, whereas a CAC < 346 accurately rules out significant CAD stenosis (≥70%) on LHC, outperforming other CAD risk-stratification strategies.
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