Scores >400 are are 10-fold Scores >400 are are 10-fold increased risk; Calcium increased risk; Calcium

imaging should be routineimaging should be routine

Matthew J. Budoff, MD, FACCMatthew J. Budoff, MD, FACCAssistant Professor of MedicineAssistant Professor of Medicine

Division of CardiologyDivision of CardiologyHarbor-UCLA Medical Center

Torrance, CA

Presenter Disclosure Information

DISCLOSURE INFORMATION:The following relationships exist related to this presentation:

Dr. Budoff is on the Speaker’s Bureau for Imatron, Inc.

Matthew Budoff, MD, FACCHigh Speed CT

Coronary Artery Scanning

SEVERECALCIFICATION

20%20%

80%80%

Total Coronary Artery PlaqueTotal Coronary Artery Plaqueand EBCT Coronary Calciumand EBCT Coronary Calcium

80%80%

PlaquePlaqueDetectableDetectableby IVUS,by IVUS,PathologyPathology

Lipid RichLipid Rich

FibroticFibrotic

CalcifiedCalcified 20%20%

80%80%

926 Asymptomatic Patients followed for over 3 years

All patients who suffered hard events had coronary calcium scores >16 at baseline (sensitivity = 100%)

Increasing scores (plaque burden) associated with increasing event rates

Odds ratios of 8.8 for future events Odds ratio included standard risk factors in a

multivariate model

Prognostic Data

WONG and Detrano

AJC September 2000

Predictive Power > 75th Percentile

4.9

21 20

8.8 9.6710.8 13.4

0

5

10

15

20

25

Rel

ativ

e R

isk

Detrano Arad Kondos Georgiou Raggi Wong Detrano

Event Rates Based upon Scores

0.8

21

4148

020

4060

Estimated10 Year Event

Rate

Zero 1 99 100-400 >400EBT Calcium Score

Raggi, AHJ 2001

Rotterdam Heart Study

2,013 patients Scores of 101-500 were associated with more than

a two-fold increased risk of stroke. Scores above 500 were over three times more likely

to suffer a stroke over the next three years. Age-adjusted odds ratio for MI in subjects with the

highest calcium scores was 7.7 for men, and 6.7 for women

Vliegenthart R et al. Stroke. 2002 and Eur Heart J 2002

10 Year All-Cause Mortality0

1020

30

% M

orta

lity

0-79 80-159 160-599 >600

Scores

Agatston 2000: AHA Abstract

CONVENTIONALCONVENTIONAL (Population based) RISK FACTORS (Population based) RISK FACTORS

Family History Diabetes Mellitus Elevated LDL Cholesterol Low HDL Cholesterol Tobacco Use Hypertension Obesity/Physical Inactivity

These risk factors

only explain

50-66%50-66% of cardiac

events

Over 50% of cardiac events occur in ‘intermediate risk’ patients, as classified by NCEP or Framingham risk analysis

70% of all events occur at mild stenosis (<50%)

Compliance with anti-atherosclerotic therapy is less than 50% at one year

The Challenge in Diagnosis ofThe Challenge in Diagnosis of CORONARY HEART DISEASECORONARY HEART DISEASE

Stress Testing is not enough

““The majority of people destined to die The majority of people destined to die suddenly will not have a positive exercise test. suddenly will not have a positive exercise test. The likely reason that they will die suddenly is The likely reason that they will die suddenly is that only a mild, non-flow -limiting coronary that only a mild, non-flow -limiting coronary plaque will have been present before the plaque will have been present before the sudden development of an occlusive sudden development of an occlusive thrombus.”thrombus.”

- Stephen Epstein - Stephen Epstein New England Medical Journal 1989New England Medical Journal 1989

Asymptomatic Patient Algorithm for Asymptomatic Patient Algorithm for Intermediate Risk PatientsIntermediate Risk Patients

Greenland P, et al. Circulation Oct 9, 2001

Refining Framingham Risk Score

EBT derived “Arterial Age”

a man is as old as his coronaries…

Syndenham 1689

% of Cases with Calcium Present prior to Cardiovascular Events

0%10%20%30%40%50%60%70%80%90%

100%

RiskFactors

Arad Agatston Georgio

““the finding of advanced the finding of advanced subclinical subclinical atherosclerosis by noninvasive testingatherosclerosis by noninvasive testing can be helpful for confirming the can be helpful for confirming the presence of high risk persons... and presence of high risk persons... and have utility in selected persons to guide have utility in selected persons to guide intensity of risk-reduction therapy”intensity of risk-reduction therapy”

NCEP ATP-III : Noninvasive TestingNCEP ATP-III : Noninvasive Testing

Subclinical Atherosclerosis