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26/11/19
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Rolvoorcoronairekalkscorebijcardiovasculairerisicostra8fica8e
RozemarijnVliegenthart,MDPhD
Adjuncthoogleraarcardiothoracalebeeldvorming
AfdelingRadiologie/MedicalImagingCenterUMCGGroningen
Disclosure belangen spreker: R Vliegenthart Jaarsymposium NVF – 22 november 2019 (potentiële) Belangenverstrengeling Voor bijeenkomst mogelijk relevante relaties met bedrijven
Namen bedrijven:
• Sponsoring of onderzoeksgeld
• Honorarium of andere (financiële) vergoeding
• Aandeelhouder
• Andere relatie, namelijk:
Institutional research grant UMCG-Siemens Healthineers
Disclosures
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Cardiovascularriskes8ma8on
CirculaCon2019;EurHeartJ2016/2019
AHA/ACC2019
ESC2016/2019
Cardiovascularriskassessment
Low Intermediate High
Cardiovascularriskscoring
ReassuranceAdvicehealthylifestyle
Riskmodifierifuncertaintypreven8vetreatment
Intensivetherapy/riskfactormodifica8on
Greenland,NEJM2003;EHJ2016;CirculaCon2016
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www.vp.org;SHAPEtaskforce
Directmeasurementofcoronaryatherosclerosis
Coronarycalciumscoring(CS)
• Sincelateeigh8es,basedonEBT/MDCT
• Direct,non-invasiveevalua8onofatherosclerosisofthecoronaryarteries;~100%specificity
• Closecorrela8ontototalcoronaryplaqueburden
Sangiorgi,JACC1998;Agatston,JACC1990;Voros,JCCT2011
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CTforcalciumscoring
• Standardized,validatedscan/reconstruc8onprotocol• ECG-synchronizedCTacquisi8on• 120kV,2.5-3mmreconstructedslicethickness
• Radia8ondosetypically<1mSv
ECG-synchronizedCTscan
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Coronarycalcifica8ononCT
Areaofvoxels≥130HounsfieldUnits xFactor(voxelwithhighestdensity)
1=130-199HU2=200-299HU3=300-399HU4=≥400HU
Agatston,JACC1990
CSaccordingtoAgatston
!Robustimagingbiomarker,reproducibleandaccurate
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CS0 CS39man,61y woman,75yCS328 CS2141man,72y man,61y
Vliegenthart,JThorImag2012
Severityofcoronarycalcifica8on
N
NomogramCSbyage&gender
Hoff,AmJCardiol2001
N=35,246
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CSbyrace/ethnicity
McClelland,CirculaCon2006
Greenland,JACC2007
CSandCVDrisk:popula8onstudies
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CSandCVDrisk:combined
Greenland,CirculaCon/JACC2007;Detrano,NEJM2008
Predictorinyoungandold,andindifferentraces/ethnici:es
CSandCVDmortalityrisk
Orimoloye,JAHA2018
CACconsorCum,N=42,224;follow-up≤10y;CVDmortality
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Riskcategoriza8on:absolutescore
Calcium
CalciumscoreAtherosclerosis Interpreta8on
NegaCvetest;verylowrisknext5years
Mildrisknext5years
HighCACscore;significantrisk
Lowrisknext5years
Moderaterisknext5years
Riskcategoriza8on:percen8le
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Predic8vevaluevsotherbiomarkers
Kavousi,..Vliegenthart,AnnInternMed2012;Vliegenthart,CirculaCon2005
N = 5,933, Rotterdam Study; f-up 6.8 y; highest vs lowest quartile
Yeboah,JAMA2012andJACC2016
DiscriminatorypowerforCVD
N = 1,330 intermediate risk persons; follow-up ≤10 y
Ø DiscriminatorypowerCShigherthanFraminghamriskscoreandotheratherosclerosismeasures
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Riskreclassifica8on
Elias-Smale, Vliegenthart, et al, JACC 2010
Ø Riskre-classifica8oninintermediateriskcategory52-66%
Rotterdam study N = 2,028 older adults Follow-up 9.2 y
Framingham 10 y risk categories, %
10 y risk based on Framingham + calcium
score
N (%) reclass
<10% 10-20% >20%
<10% N=1287 (63%)
10-20% N=505 (25%)
>20% N=246 (12%)
1094 (85%)
187 (37%)
24 (10%)
167 (13%)
189 (37%)
65 (26%)
26 (2%)
129 (26%)
157 (64%)
193 (15%)
316 (63%)
89 (36%)
CSvsriskfactors
Nasir,CirculaConimg2012
RiskinhighCACscore/noRFs>>CACscore0/mul:pleRFs
44,052asymptoma8cindividuals,meanf-up5.6y(mortality)
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N=71,595,41%CS0,meanf-up4.2yEvents:0.5%forCS0vs4.1%forCS+
Predic8vevalueofCS0
Sarwar,JACCimg2009
Long-termpredic8vevalueComparisonof‘nega8ve’riskmarkers
Blaha, Circulation 2016; Valenti, JACC 2015
CAC score 0: largest downward shift in 10y CVD risk
MESA N = 6,814 Follow-up 10 y
CS0:15ywarrantyperiodagainstmortality
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Mostrecentguidelines
Vonder, under review
ESCprimarypreven8on2016
Eur Heart J 2016; 2019
CS≥300or≥75%:Upwardstra8fica8onCS0:Downwardstra8fica8on
SimilartoESCchroniccoronarysyndromes2019
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AHA/ACCprimarypreven8on2019
Circulation 2019
*unlessdiabetes,familyhistory,smoking
CS≥100or≥75%:Upwardstra8fica8on(sta8n)CS0:*Downwardstra8fica8on
CS0ofpar8cularvaluein:-Pa8entsreluctantto(re-)startsta8n-Olderpa8ents(>55-60y)withlowRFburden-Middle-agedpa8entswith5-7.5%risk
ImpactCS0onsta8ntreatment
Nasir,JACC2015
MESA;N=4,758,follow-up10.3yNodiabetes,LDL70-189mg/dl
CACscore0reclassifiesriskbelowthresholdforsta:ntreatmentin49%ofASCVD5-20%
Ø CSismorecost-savingandeffec8vetoiden8fypersonsinneedofsta8nsthancurrentrisk-factorbasedguidelines
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EffectofCSonsta8ncompliance
Kalla, CAD 2015; Mamudu, Athero 2014
N=2608,follow-up4.1yearsTrendtowardsmoreindividualswithweightlossbyCSSystema8creview:in13/15studies,CSimprovedmedica8onadherence
Ø Mo8va8onaleffectofCSonlifestylechangeandsta8nuse
USPSTF2018statement
JAMA 2018
à DirectevidencefromadequatelypoweredclinicaltrialsonincrementaleffectofCStoimprovehealthoutcomeslacking
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Focusoneffec8venessofcalciumscorescreening:reduc8onmorbidity/mortality,costs,nega8veeffects“Canearlydetec8onofCHDriskbya) Classicalriskfactorsòrb)Calciumscore,followedbytreatment,reducemorbidityandmortalityofCHDinahighriskpopula8on?”• Popula8on:n=39,000,men45-74y/female55-74y• 2ndgenDSCTforCS(Agatston,volume,mass)• SCOREriskscore
Vonder, Acad Radiol 2018
ConclusionsCSforriskstra8fica8on
→Strongestnon-invasivepredictorofcoronaryevents→Standardized,highthrough-puttest→Guidelines:CACscoringinintermediate-risk‘maybeconsidered’/’isreasonable’asriskmodifier
→Implemen8ngCACscoringreducesunder-andovertreatment
→CS0:veryloweventrisk→Impactofcalciumscoringonoutcometbd(Robinsca)