Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography

Berman, Daniel S.; Wong, Nathan D.; Gransar, Heidi; Miranda-Peats, Romalisa; Dahlbeck, John; Hayes, Sean W.; Friedman, John D.; Kang, Xingping; Polk, Donna M.; Hachamovitch, Rory; Shaw, Leslee J.; Rozanski, Alan

doi:10.1016/j.jacc.2004.06.042

Cited by 400 publications

(267 citation statements)

References 42 publications

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“…Several studies have shown that the coronary artery calcium score is valuable in identifying patients with a high likelihood of inducible myocardial ischemia (59,60). These studies have consistently observed that the likelihood of ischemia in patients with a calcium score Ͻ100 is negligible, whereas those with a score of Ն400 have a relatively high likelihood of inducible ischemia.…”

Section: What Tests or Sequence Of Tests Should Be Considered? Withmentioning

confidence: 99%

Screening for Coronary Artery Disease in Patients With Diabetes

et al. 2007

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Coronary artery disease (CAD) accounts for a large fraction of the morbidity, mortality, and cost of diabetes. Recognizing this, nearly 10 years ago the American Diabetes Association published a consensus recommendation that clinicians consider a risk factor–guided screening approach to early diagnosis of CAD in both symptomatic and asymptomatic patients. Subsequent clinical trial results have not supported those recommendations. Since the prior consensus statement, newer imaging methods, such as coronary artery calcium scoring and noninvasive angiography with computed tomography (CT) techniques, have come into use. These technologies, which allow quantitation of atherosclerotic burden and can predict risk of cardiac events, might provide an approach to more widespread coronary atherosclerosis screening. However, over this same time interval, there has been recognition of diabetes as a cardiovascular disease (CVD) equivalent, clear demonstration that medical interventions should provide primary and secondary CVD risk reduction in diabetic populations, and suggestive evidence that percutaneous coronary revascularization may not provide additive survival benefit to intensive medical management in patients with stable CAD. This additional evidence raises the question of whether documenting asymptomatic atherosclerosis or ischemia in people with diabetes is warranted. More data addressing this issue will be forthcoming from the BARI 2-D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Until then, for patients with type 2 diabetes who are asymptomatic for CAD, we recommend that testing for atherosclerosis or ischemia, perhaps with cardiac CT as the initial test, be reserved for those in whom medical treatment goals cannot be met and for selected individuals in whom there is strong clinical suspicion of very-high-risk CAD. Better approaches to identify such individuals based on readily obtained clinical variables are sorely needed.

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Section: What Tests or Sequence Of Tests Should Be Considered? Withmentioning

confidence: 99%

Screening for Coronary Artery Disease in Patients With Diabetes

et al. 2007

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“…A number of studies have explored the relationship between CAC scoring and myocardial perfusion imaging (MPI). Among them, one study including low risk patients showed that only 2% of patients with CAC <100 have abnormal MPI studies, compared to 31% of patients with CAC >400 (27,28). A CAC score ≥709 has been suggested as the optimal cutoff for detecting CAD missed by SPECT imaging, improving the sensitivity of SPECT from 76% to 86% (29).…”

Section: Mini-reviewmentioning

confidence: 99%

Progression of coronary artery calcification at the crossroads: sign of progression or stabilization of coronary atherosclerosis?

Rodríguez-Granillo

Carrascosa

Bruining

2016

Cardiovasc. Diagn. Ther.

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Coronary artery calcification (CAC) has been strongly established as an independent predictor of adverse events, with a significant incremental prognostic value over traditional risk stratification algorithms.CAC progression has been associated with a higher rate of events. In parallel, several randomized studies and meta-analysis have shown the effectiveness of statins to slow progression and even promote plaque regression. However, evidence regarding the effect of routine medical therapy on CAC has yielded conflicting results, with initial studies showing significant CAC regression, and contemporaneous data showing rather the opposite. Accordingly, there is currently a great controversy on whether progression of CAC is a sign of progression or stabilization of coronary artery disease (CAD). The finding of inexorable CAC progression despite the implementation of intensive contemporaneous medical therapy suggests that further understanding of this phenomenon should be undertaken before the implementation of CAC as a surrogate endpoint for longitudinal studies, or for prospective follow-up of patients under routine medical treatment.

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“…That is, the prevalence of inducible ischemia was low for CAC scores of less than 100 but increased dramatically for higher CAC scores. In one large observational series, the rate of inducible ischemia approached 20% for patients with CAC scores of $400 (16). The frequency of inducible ischemia is elevated in diabetic patients, patients with metabolic syndrome, and patients with a family history of premature CAD at a lower threshold-CAC scores of $100.…”

Section: Added Value Of Determination Of Coronary Calcium With Stressmentioning

confidence: 99%

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

Shaw

Narula²

2009

J Nucl Med

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This review highlights and compares risk assessment, predictive accuracy, and economic outcomes for 3 commonly applied cardiac imaging procedures: stress myocardial perfusion SPECT or PET and coronary CT angiography (CCTA). This review highlights an expansive evidence base for stress myocardial perfusion imaging and reveals a decided advantage for higher-risk patients, notably those who have established coronary artery disease (CAD). It is likely that the use of CCTA will continue to expand, particularly for patients with more atypical symptoms and patients with a lower likelihood of CAD. Despite a high level of evidence, comparative research is not available across modalities that could definitively drive utilization of cardiac imaging modalities. Evi dence about the accuracy of a variety of noninvasive imaging tests for the identification of at-risk patients with known and suspected coronary artery disease (CAD) has been evolving. Most of the early published research on noninvasive cardiology, from the 1980s and early 1990s, focused on the diagnostic accuracy of a test. More recent research has focused on evaluating the ensuing risk in patients with normal and abnormal cardiac imaging findings. Further exploration has been aimed at the graded or directly proportional relationships between the extent and the severity of imaging risk markers and major adverse cardiovascular events. These relationships highlight a common theme throughout the literature of ever-increasing and worsening cardiac event risk with more extensive and severe imaging abnormalities. More recent topics in the prognosis literature are the utility of new technology, such as coronary CT angiography (CCTA), and its accuracy compared with that of conventional testing, such as stress nuclear imaging. For this report, we compare risk assessment, predictive accuracy, and economic outcomes for 3 commonly applied cardiac imaging procedures: stress myocardial perfusion SPECT or PET and CCTA. We further highlight the potential value of hybrid imaging with PET/CT or even sequential imaging with SPECT plus CT. CORRELATION BETWEEN MYOCARDIAL ISCHEMIA AND CORONARY ANATOMYEarly research focused on the accuracy of stress nuclear imaging for detecting obstructive coronary stenosis. Lessons learned from these evaluations were that the detection of obstructive stenosis was related to the severity of the stenosis, collateral flow, and underlying endothelial function. Documentation of high rates of false-positive results (i.e., ischemia with no obstructive CAD) with stress myocardial perfusion may be related to vascular dysfunction, an early marker of atherosclerosis. In addition, normal stress perfusion results in patients with CAD are related to many factors, including collateral blood flow or prior coronary revascularization. It is for these reasons that much of the recent imaging research has focused on risk determination. However, for discussion purposes, it is helpful to understand the relationship between ischemia and coronary anatomy. INDUCIBLE ISCHEMIA D...

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Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography

Cited by 400 publications

References 42 publications

Screening for Coronary Artery Disease in Patients With Diabetes

Screening for Coronary Artery Disease in Patients With Diabetes

Progression of coronary artery calcification at the crossroads: sign of progression or stabilization of coronary atherosclerosis?

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

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