Coronary calcium score: what it means and how to interpret your results (AMA #5)

And a lot of questions come in about

coronary

artery

calcium

or a CAC, so this is a general question: What's the problem with CAC? Some people say it's a marker, some people say something else, so remove it, so

coronary

. We will see that a coronary

calcium

score

is a CT scan that is done dry, that is, without any contrast, so you lie on the CT table and it is a very quick scan and since there is no contrast every time you see something that's really bright white, which is normally

what

The color contrast would be: you know it's calcium, so there's a scoring system where you can get some anatomical details, not to the point of understanding how much narrowing there is in the arterial lumen, but you can see which arteries, for example, the left main artery, the circumflex artery. the left anterior descending artery the right artery the posterior descending artery and the amount of calcification is then

score

d and ranked according to a percentile so you know this is one of those things that is certainly useful and you know if there is a branch of statistics in the one that medicine innately teaches you is Bayes' theorem where you update

your

probability based on new information.

My problem is not with the calcium score. Its breadth is a school of thought that says, well, a calcium score if it's zero

means

nothing matters. You know you're something like that. unfortunately that is categorically false and the data confirms it, so a negative calcium score, meaning a calcium score of zero, absolutely

means

actuarially at a population level a lower risk of a coronary event and when we say coronary event The term ace is

what

we use to describe it, it can be a major adverse coronary event or a cardiac event, such as a heart attack, stroke or cardiac death, but it is also not zero and this is where it gets a little complicated, almost 50 percent of deaths in the eyes.

They occur in non-calcified areas of the coronary arteries. Now that data is also a little misleading because a lot of those patients still had calcifications elsewhere, so the way I think about calcification is that it tells you how many times you've been broken and what type of repair. what you've done, I mean it's a crude approximation, so a biomarker tells you how bad the neighborhood is that you live in, so if you do a blood test on someone and you know that LP little a is high or that

your

LDL P is high and you have a lot of inflammation all these other things that say you live in a bad neighborhood it's dangerous there's a possibility of a robbery when you see a calcium score that's not zero well that tells you that you already had an advanced injury and that injury had to be repaired because when you and I don't go over stories seven levels of atherosclerosis because it's really complicated and it's hard to do without pictures, we should have a whiteboard last time, yeah, that's right, I can't include in the show notes what are the different types of atherosclerosis lesions, but calcification is an incredibly late repair, so when you have calcification in a coronary artery, I mean, you've had real damage and it's been repaired and that becomes on a risk marker that basically suggests that you should be more aggressive in dealing with this case, but when it's zero it doesn't change the fact that you live in a bad neighborhood and it doesn't change the fact that you may have a lot of arterial damage that just hasn't been addressed. manifested in the calcification stage, so you can have a lot of soft plaque that is still there without calcification, which is still a huge risk marker and that is not detected without you I know what we normally do with patients and it depends on Every case is different, so you know there are times when I just do a calcium score on a patient and if it's zero I don't do anything else, there are other times. when even if it's zero I still have reflux on a coronary angiogram, so a CT angiogram throws up a lot more anatomical detail, including the presence of soft plaque, but even there you know you can, you still can't really see, you know, plaque that is vulnerable. but if a patient has a coronary calcium score of zero and their CT angiogram looks flawless, you know, look, that's a much better sign than anything else that's not in that case, and of course the question arises. question: would you still treat a patient in that situation is a difficult question, but it also depends on your time period, so the younger a patient is with that finding, the less confident you are that you are one of the lucky people who seems largely immune to coronary heart disease where I find these tests the most.

It's actually useful not for young people, but for older people, and I have a patient right now, but I actually just sent her for this scan, she'll probably have it in the next two weeks, you know. very unstable lipid numbers, you know, a complicated apoE state, but metabolically it fits like a fiddle. I mean, she's incredibly healthy, but her lipid numbers couldn't be any worse and you know, I'm trying to decide how aggressive we want to be. In lipid management, she is old enough, which does not mean that she is particularly old. I don't even think she's 60, but she's old enough that if she has a perfect CT angiogram and her calcium score is zero, which by definition is if she has a perfect CT angiogram.

You would know that a period of exposure would be enough. Call it 60 years. I would say something is going on in this woman and you know other factors that are equally important for lipoprotein, endothelial function. The immune response is working enough in your favor to know that maybe it doesn't need to be handled very aggressively even though it's there, in other words, you might live in a really bad neighborhood, but you happen to have a pit bull in front of you. to her. patio that's like keeping the bad guys out mm-hmm so I was thinking we're talking about atherosclerosis and you have coronary artery calcification and from a naive point of view atherosclerosis is the hardening of the arteries if you have a if you have a positive direction and I want to say that we can go through some of the ranges of yes, my score is 25 or my score is 2500 euros, oh yes, I have seen it, I have seen it higher, is there a number that, if it is not zero, does that mean? you have some form of atherosclerosis technically or not black and white is not atherosclerosis, it can be present even without a single hint of calcium and to your question about the number, it really is a function of your age as well and your sex.

So the number is not as important to me as the percentile. It's where you compare yourself to your peers. For example, a calcium score of 6 if you are between 35 and 40 years old would put you in the 75th to 90th percentile, although that is a small calcium load, which is a major problem. a calcium score of 6 if you were 80 years old means you have no calcium, even a calcium score of 6 to 10 if you are 60 years old would be considered quite low, so yes, it has to be taken in the context of age, does it? have you investigated?

I know what it is, Arthur a g'sten, it's the a g'sten score, yeah, and there's some things that they look at, I think it's a couple of the things that they look at, they look at the volume and the density, that's right, do double click on those things and if that would layer further, I mean, I don't use it to layer further, but I think it will become more and more. The interesting thing is that there is more and more data emerging that says that not only calcium load but also calcium density during treatment can be more predictive, so I don't know if this literature has been published, but I have seen it in summary.

Well, here's what we already know: Generally, when a patient has a non-zero calcium score, they are given a statin and, over time, their calcium score expands even though that sounds like a negative. Which turns out to be a good thing as long as they've been on statins, so it appears to be plaque stabilization. I have seen data again. I don't think I've seen this information in published form, but certainly in an abstract form that says that as plaque density or sorry density, calcium increases with statin therapy, that also portends a better outcome or greater stabilization. . Now, very recently, data came out on pcsk9 inhibitors that said the opposite, so patients taking pcsk9 inhibitors, who by definition in the EI and Odyssey studies were also taking statins, actually saw a reduction in plaque volume or calcification and we know that they had positive

results

, so honestly, that tells me that there are a lot of things that we don't know yet and I think that it is I find it difficult to use and not necessarily useful to use cereal calcium scores to making predictions, although you know, I will be corrected by a patient of mine who had a calcium score of you know 10 when it was 20 years ago, so you know before.

He's my patient, but if he looks, please, he's had several calcium scores over the last 20 years and they've gone from 10 to, you know, 40 to 170 to 650 to 1500 to 4000, and this is actually a very interesting case. because this is a patient whose lipid levels aren't horrible, he's not a man because he's obviously been on medication for much of this period of time, he doesn't have an elevated LP, but his family history is really significant for cardiovascular disease, his father . he had his first mi in his 40s, this is a patient, in fact, I told him that if he had bet stupid sums of money, without seeing his labs, he would have a raised LP a little because for all, for all intensive purposes .

He looks like someone who would have a small elevated LP 8 and he doesn't, which again just speaks to the complexity of the disease and there are certainly other genetic factors because clearly this is genetic and we haven't clarified it yet. It's strange when you talk about percentiles. I think I've seen Mesa, the multi-ethnic study on atherosclerosis says they have a calculator. I think you can also look at your risk and you can just look at your risk. Speaking of which, he could have a score of five and that would denote a high risk depending on what it says for his age, what his age actually is compared to someone older, right?

And you can also use other risk factors. Do you smoke? you have high blood pressure again atherosclerosis, you know there are four things that are out of control when you have atherosclerosis and so obviously there are an infinite number of combinations given how multivariate each of those things are, but you know, or if the metabolism is out of control, if the lipoproteins are out of control, if the inflammation is out of control, if the endothelium is not working well, all of those things will predispose you to Staunton. I think it's also fascinating that you can have more stable plaque, which I also think I suggest that when we talk about calcium we could say Oh, calcium is bad, it's not, it's probably a bad sign, but calcification is kind of absolutely correct repair, calcium per se is not the problem, it is. it's that it tells you that something bad has happened and that's so important for people to understand, you know, if anything, calcium is probably doing more good than harm, yeah, it's the fact that you have it that is annoying, yes, annoying, you know, and that's how it is. it's actually looking and it's not a biomarker, it's actually looking at the damage, but in a sense it tells you that the damage has already been done, which can be a predictor of future risk, right, and that's one of my big things. things that bother me when people talk about a calcium score as if they were talking about a biomarker, it's not a biomarker, it's retrospective proof that you have a disease and that damage has already occurred to the artery hmmm, yes, I think that you mentioned it as if you were talking about breakage. ins or something like that, yeah, the thefts that were already in you happened, yeah, which could yeah, okay now if we want to cover this too, but I remember seeing a document recently, actually, we went back and forth a little bit about it with um it was It's the Cooper clinic and we call it like Colorado, we thought it was in Dallas, but okay, yeah, are you right where they looked at the people, what are they talking about, intense extreme exercise, yeah, resistance exercise and they looked at the CAC, didn't they follow it? -above, but they looked at their initial CAC and then they looked at how much exercise they did and they stratified and one of the things that one of the people that I think was involved in the study or worked with us called hearts. of stone, I guess I don't believe in that sense, if this was in JAMA a few months ago, yes, and they showed that they stratified for each of the points where the CAC score was maybe less than 100 compared to the CAC scores greater than 100 and then stratified into three groups of less than 100 and more than 100 and the three groups for each, so there are six in total.

The three for each were, let's say, low exercise, but probably more exercise than the average Joe, you know, medium exercise and then extreme exercise, which is really like at the level of probably when you were training forhaving a channel and things like that and what they found was part of what I think they found with eating almost independently of the CAC is that in terms of exercise, the people who exercise the majority and this is epidemiology, prospective epidemiology we take it with caution , but if we compare someone's overall risk of all-cause mortality or cardiovascular death or things like that, they seem to have much lower rates, but the interesting thing is that there is a small subset and it was relatively small when you actually looked at the end of each one. of these groups was relatively low but there were a significant number of people or should I say a substantial number of people who exercised a lot but were also older, which could reach around 40 push-ups, you could talk about that, so if they were almost ten years older on average, which you know, when you talked about CAC progression, you know they're much more likely to score higher, but they did score higher when their rates were compared, especially just to the general population. , they still had much lower levels of all-cause mortality and cardiovascular death and probably although mace also knows the components, which yes, I mean, I think in part this speaks to the ubiquity of the mechanisms by which the exercise is beneficial, but at the same time it suggests that there will be a subset of people and/or circumstances under which exercise can also be harmful to the heart, now that we know this at the level of you.

James O'Keefe has done a lot of work on this at the level of the electrical system, and the way I explain this to patients is that the heart is a muscle whose electrical system exists inside the wall, so the more often it is stretched and is maintained for long periods of time in said stretching position, the more its electrical architecture is damaged, which is why we see a significantly high incidence of dysrhythmia, almost 10 times higher than that of the general population in highly trained athletes. Atrial fibrillation is a common example, so that type of damage to the heart is understood quite well through its relationship to exercise, but the other thing that I think always needs to be kept in mind is that we don't know what type of cut force a person. is below again, we go back to what I said before, the endothelium is such an important part of this that if you are damaging the endothelium, all things being equal, you can still increase the risk of heart damage, so yes, it is difficult and I would hate for the message of that study to be good, it is better not to exercise and I am right that that is always the risk you run when these types of studies are difficult to read in the newspapers end up in newspapers where the person writing about them You only have 800 words to write something and you also have to include an attention-grabbing headline.

You know that we are a headline that attracts attention and you know that the conclusion is definitely not that. You know you shouldn't exercise, but you know there are more nuances to this, yes, I would say that if I were an extreme athlete and you had that cack below 100 and the kak above 100, all things being equal, I would I would like to be in the under 100 group, but when you look at the over 100 group and compare them to anyone else, you would say I would love to have those types of dolls at least associated, yeah, you know, even with scores like that, Yes Yes.

I think you just like to say kak. I think there's at least a chance that's part of the idea.