Electron Beam Computed Tomography

1
Screening for Heart Disease Which Test is
Best? Matthew Budoff, MD, FACC, FAHA Associate
Professor of Medicine Director, Cardiac
CT Harbor-UCLA Medical Center, Torrance, CA
Name of company GE - speakers bureau (SB)
2
DISCLOSURE STATEMENT

• Matthew Budoff has disclosed the information
  listed below. Any real or apparent conflict of
  interest related to the content of the
  presentation has been resolved.
• Affiliation/
• Financial Interest Organization
• Speakers Bureau General Electric

3
Total Coronary Artery Plaque and EBCT Coronary
Calcium
Calcified
20
20
Plaque Detectable by IVUS, Pathology
80
Fibrotic
80
80
Lipid Rich
4
Risk Stratification by Age
60 of men aged 50-59 92 aged 60-69 are at
least intermediate risk
Men
1 women aged 50-59 9 aged 60-69 are at
least intermediate risk
Women
Ford ES et al, JACC 2004
5
How Good Is NCEP III At Predicting MI in
young? Akosah Et al, JACC 200341 1475-9
222 patients with 1st acute MI, no prior CAD men
lt55 y/o (75), women lt65 (25), no DM
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Calcium Versus PROCAM/Framingham
88
58
54
Myocardial Infarction ()
36
34
10
10
8
2
Becker AHJ 2008
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All Cause Mortality in Patients Without Known CAD
All Cause Mortality NDR n 10,377 asymptomatic
men and women f/u 5.03.5 yrs.
Relative Risk
EBT found to be independent and incremental to
risk factors
DM
Smoke
HTN
lt10
101-400
gt1000
10-100
401-1000
Shaw, Raggi et al Radiology 2003
EBT Coronary Calcium Score
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Prediction of Cardiac Events in
Asymptomatic Patients by EBT The St. Francis
Heart Study, JACC 2005
Annual Event Rate ()
SFHS 3
Baseline EBT Calcium Score
9
Outcome Data St Francis Randomized Trial

• A double-blind, placebo-controlled randomized
  clinical trial of atorvastatin 20 mg daily with
  anti-oxidants versus matching placebos in 1,005
  asymptomatic men and women age 50 to 70 years
  with coronary calcium scores at or above the 80th
  percentile for age and gender. Mean duration of
  treatment was 4.3 years.
• Treatment reduced low-density lipoprotein
  cholesterol by 39.1 to 43.4 (p lt 0.0001), while
  reducing clinical endpoints by 30 (6.9 vs.
  9.9).
• Event rates were more significantly reduced in
  participants with baseline calcium score gt400
  (8.7 vs. 15.0, p0.046 42 reduction).

Arad Y et al. Treatment of Asymptomatic Adults
with Elevated Coronary Calcium Scores with
Atorvastatin, Vitamin C, and Vitamin E The St.
Francis Heart Study Randomized Clinical Trial. J
Am Coll Cardiol 2005 46 166-172.
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All Cause Mortality and CAC Scores Long Term
Prognosis in 25, 253 patients
10.4
Budoff, et al. JACC 2007 49 1860-70
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Cooper Clinic Study - 10,782 Patients 3.5 year
follow-up
Nonfatal MI CHD Death
21.1 (7.8-57)
9.7 (3.6-26)
6.0 (2.1-17)
2.7 (0.8-9.3)
Ref
Adjusted age, history of diabetes, hypertension,
elevated cholesterol, over weight
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Taylor et al PACC Study JACC 2005

• 2000 patients, mean age 43
• Coronary calcium was associated with an 11.8-fold
  increased risk for incident coronary heart
  disease (CHD) (p 0.002) in a Cox model
  controlling for the Framingham risk score.
• In young, asymptomatic men, the presence of
  coronary artery calcification provides
  substantial,
• cost-effective, independent prognostic value in
  predicting incident CHD that is incremental to
  measured coronary risk factors.

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Anand EHJ 2006 510 Diabetics
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CAC and FRS in uncomplicated type 2 diabetes
510 asymptomatic type 2 diabetic subjects Mean
F/U2.3 yrs No event observed with CAC0
Anand DV et al, Eur Heart J. 2006 27(6)713-21.
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CACS Utility Above Beyond Various Risk Factor
Based Risk Algorithms
Becker D et al, American Heart Journal 2008
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CAC vs. Stress Echo Ramakrishna JACC 2006
The occurrence of death/MI was significantly
different in patients with a CACS 100 versus
a CACS 100 but not in patients with normal
exercise WMSI versus abnormal exercise WMSI (p
0.17).
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Following this meta-analysis, 4 additional
prospective studies
South Bay Heart Watch Middle aged, higher risk
PACC Project Aged 40-50, low risk
Taylor et al, JACC 200546807-814
Greenland. JAMA 2004291210-215.
Rotterdam Elderly
St. Francis Middle aged
Guerci et al. JACC 200546158
Vliegenthart. Circulation 2005112572
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MESA Study 6,814 Patients 3.5 year follow-up
Nonfatal MI CHD Death
14.13 (7.91,25.22)
10.26 (5.62,18.71)
4.47 (2.45,8.13)
Ref
Fully adjusted Detrano et al ACC Abstract -
JACC March 07
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MESA CIMT vs. CCA
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C Reactive Protein

• Has not added to ROC curve for prediction of
  cardiovascular events in any study, including
  MESA - NO Incremental Value
• Calcium- has, in every study to date,
  demonstrated incremental value to Framingham risk
  Consistent Incremental Value

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Signs of Subclinical Coronary Atherosclerosis
Measured as Coronary Artery Calcification Improve
Risk Prediction of Hard Events Beyond Traditional
Risk Factors in an Unselected General Population
The Heinz Nixdorf Recall Study 5-Year
Outcome Data
Raimund Erbel 1, Stefan Möhlenkamp 1, Susanne
Moebus 1, Axel Schmermund 4, Nils Lehmann 1,
Nico Dragano 3, Andreas Stang 5, Dietrich
Grönemeyer 2, Rainer Seibel 2, Hagen Kälsch 1,
Martina Bröcker-Preuß 1, Klaus Mann 1, Johannes
Siegrist 3, Karl-Heinz Jöckel 1, for the Heinz
Nixdorf Recall Study Investigative Group
1University Duisburg-Essen, 2 University
Witten-Herdecke, 3 University Düsseldorf, 4
Cardioangiological Center Bethanien, Frankfurt,
5 University Halle-Wittenberg, Germany
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ROC Curve Analysis / C-Statistics
1.0
All Subjects
0.8
0.754
0.667
0.6
ATPIII categories
Sensitivity
0.740
log(CAC1)
0.4
ATPIII cat. log(CAC1)
ATPIII
0.2
log(CAC1)
p0.0001 versus ATPIII
ATPIII log(CAC1)
p0.009 versus ATPIII
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
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Reclassification of ATP III Risk Categories
Using CAC
CAC Score high risk Intermediate risk
low risk
23.1
0 10 20
10-year risk ATPIII Score Risk Assessment
Scheme according to Wilson PWF et al JACC
411889 1906, 2003 with HNR data
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Where to use CAC in practice?

• Family History of premature CAD
• Borderline or mildly elevated cholesterol levels
• Women with atypical chest pain or
  low-intermediate (6-20 10 year risk) CV risk
• Intermediate Framingham Risk (1-3 risk factors)

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(No Transcript)
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Odds ratio of maintaining statin therapy with
various levels of baseline CAC (3.6 yr f/u)
Kalia et al. 2006
28.9
9.3
9.1
5.1
4.2
3.0
2.4
1.9
1.1
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Improving Adherence Taylor et al. JACC 2008
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Accuracy Trial Budoff et al JACC 2008
Open-label, prospective multicenter trial
involving 16 centers

• Inclusion
• Typical or atypical chest pain suspected of CAD
• Referral for elective coronary arteriography

• Exclusion
• Allergy to iodinated contrast
• Creatinine gt1.7 mg/dl
• Irregular heart rhythm
• Heart rate gt100 and/or resting SBP lt100 mm Hg
• Contraindications to ß-blockers, Ca2-blockers,
  NTG

Subjects were NOT excluded for baseline CAC score
or BMI.
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Per Patient Analysis
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Lumen Plaque Burden
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Normal Study
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Coronary CTA Under 1 mSv

• Patient
• Male
• BMI 22
• Cardiac risk factors
• Heart rate 34-38 bpm
• Scan
• Acquisition SnapShot Cine
• Coverage 64X0.625 mm
• Tube 350 mA 100 kVp
• Gantry Rotation 0.35 sec
• X-ray Exposure 0.93 sec
• Radiation Dose 0.95 mSv
• Findings
• LAD Calcifications

Courtesy of Dr. Earls, Fairfax Radiology , USA
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Unadjusted Cox Survival by Number of Vessels with
Severe Stenosis
1.00
lt50 Stenosis (n724)
0.975
1 Vessel (n144), p0.94
0.95
2 Vessel (n63), p0.004
0.925
Cumulative Survival
3 Vessel (n90), p0.001
0.90
0.875
Left Main 50 (n106), plt0.0001
?244, plt0.0001
0.85
0
0.5
1
1.5
2
Time to Follow-up (Years)
R-A plt0.001 (controlling for risk factors chest
pain).
Min et al. JACC 2007
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Summary

• CT angiography appears to perform well to risk
  stratify patients over short- and medium-term
  follow up
• So far, studies have mostly been performed on
  symptomatic persons, so utilizing CT angiography
  for risk stratification in asymptomatic
  populations is still not widely accepted

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Coronary Calcium
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Slides, Questions, Training

• Contact Me
• budoff_at_ucla.edu
• [phone]