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Overview
Since pathologists and anatomists first began examining the heart, they realized that a connection existed
between deposits of calcium and disease. When x-rays were discovered, calcium was again recognized as a
disease marker. In fact, for most of the 20th century, calcium, because of its density, was the only feature that
stood out on radiographs of the heart. In the 1950s, heart disease became more recognized as a significant cause
of mortality in the United States. Along with this recognition came numerous publications about the ability to
detect calcifications in the coronary arteries with radiography. In some ways, this period can be thought of as the
first age of importance for calcium detection in the heart.
This period came to an end with the widespread acceptance of coronary angiography and other less invasive tests,
such as stress thallium testing. If an actual stenosis or area of ischemia could be detected, attempts to
qualitatively detect calcium with radiography or fluoroscopy seemed primitive. The advent of angioplasty and stent
placement in the treatment of arterial stenoses seemed to herald the end of calcium detection.
Why, then, should this or any other article present information about detecting calcification in the coronary
arteries? The answer is threefold.
First and foremost, calcium is a marker for a diseased artery.
The second is related to the recent revolution in CT scanning. Electron-beam CT (EBCT) was the first technique to
provide a real breakthrough in the quantitation of calcium in the coronary arteries. Although this examination is
valuable, the cost of the machines limited its use, and, by association, its impact. Some time afterward came
helical, or spiral, CT. This technique was further improved with the addition of twin- and even quad-detector arrays.
These machines allowed truly fast, completely noninvasive examination of the average person. During this period
the scanners were still not quite sophisticated enough to allow direct visualization of the coronary arteries while
filled with contrast material. This continued to focus attention on the capabilities and significance of calcium
scoring.
Advances in CT technology have continued with the development of 16- and 64-slice scanners. With these
scanners, more attention was directed to coronary artery CT angiography, but the use of calcium scoring in
preventive cardiology had solidified. The latest scanners are volume-type 320-detector machines that can scan in a
heartbeat two. The questions involving these procedures now have changed from "Can we do this?" to "When
should we do this?"
See the CT scan images of coronary artery calcification below.
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Coronary artery calcification - CT. Cross-sectional image obtained through the heart at the level of the left anterior descending (LAD)
artery. The protocol on the CT machine colors all structures w ith an attenuation of greater than 130 HU pink. No calcium (pink) is present
in the LAD or diagonal branch.
Coronary artery calcification - CT. Image obtained in a patient w ith a large amount of calcium in the left anterior descending (LAD) artery.
Note that other hyperattenuating structures (eg, bone, calcified lymph nodes) are pink. During the scoring process, the radiologist must
circle only those areas that correspond to one of the coronary arteries.
Coronary artery calcification - CT. Image obtained w ithout the threshold set to color the calcium pink. Note the large amount of calcium in
the left anterior descending (LAD) and left circumflex arteries.
Coronary artery calcification - CT. Section caudal to that in the previous image show s calcium in the left anterior descending (LAD)
artery as it courses dow n the front of the heart. The vessel is now depicted in cross section.
Third, according to the American Heart Association, coronary artery disease caused 20% of all deaths in the
United States in 2004, with mortality being 451,326. It is estimated that in 2008, 770,000 people in the United
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States will experience a first heart attack and 430,000 will experience a recurrent attack. In 2004, cardiovascular
disease mortality in women was about 460,000, more than the combined deaths from lower respiratory disease,
Alzheimers disease, accidents, and diabetes mellitus combined.[1]
Types of CT Scanners
The initial investigation of coronary artery calcification with CT was made possible with the development of the
electron-beam CT (EBCT) scanner in the late 1980s. The speed of this machine was vastly superior to that of
existing CT scanners. With this speed, it had the ability to "stop" heart motion enough to allow measurement of
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the amount of calcium in a coronary artery. Another revolution in CT has was the development of ultrafast spiral
CT.[3, 4]
Principles of EBCT
One of the factors that limit the speed of a conventional CT scanner is necessary rotation of the tube around the
patient. EBCT completely avoids this problem because the machine does not have any moving parts. A beam of
electrons is generated and then focused with a series of electromagnets. The beam is directed onto 1 of 4
tungsten targets under the patient. The resultant fan-shaped X-ray beam passes through the patient and is
collected by a 210 arc of detectors above the patient. More than 3,000 detectors are used in this process.
EBCT allows the acquisition of 1.5- to 3-mm sections, with an exposure time of 100 milliseconds. The images are
gated to the end of diastole, and the entire examination is performed during 1 breath hold by the patient. Usually,
40-60 sections are obtained with this method.
Technique
Although each manufacturer has different protocols, the basic techniques are similar. No patient preparation is
required. Blood samples do not have to be obtained, and no contrast material is used. Some manufacturers
recommend the removal of any metal object that may be near the chest region. Examples include metal buttons,
bras with underwires, and necklaces. Metal objects are removed because they cause non-linear x-ray scatter that
can produce artifacts in the images.
Asking patients to practice holding their breath may be helpful, not because a long breath hold is needed (usual
duration, 15-30 s), but because reproducibility of their breath-holding is enhanced. Many centers ask the patient to
complete a risk-assessment questionnaire to aid in the overall interpretation of the study. The patient lies supine
on the scanner gantry with the arms over the head. If the patient cannot raise the arms, an acceptable scan can
be obtained with the patient's arms at his or her sides.
Settings for the scanner depend on the manufacturer's recommendations. A typical protocol for a quad-slice
multidetector CT would be 165 ma, 120 kVp, 0.5 pitch, and quad X 2.5 mm.
The use of cardiac gating is an area of current disagreement. Some manufacturers do not use it at all, while others
disagree about whether it should be used prospectively or retrospectively. Although the addition of gating is not
difficult, it requires more patient preparation than that of the simple CT scanning. Leads must be placed on the
patient's chest; at some centers, the patient may need to wear a hospital gown.
Results
Coronary segments with a luminal obstruction of greater than 50% are likely to have some calcification that is
detectable with electron-beam CT (EBCT). In one trial, a 0 calcium score had a 100% predictive value in the
exclusion of angiographic evidence of obstructive epicardial coronary lesions. The higher the calcium score, the
more likely the presence of angiographic obstructive disease. In another study,[5] a calcium score greater than 371
had a 90% specificity in the detection of a luminal obstruction of greater than 70%. Specificity tends to decrease
with advanced patient age, but it increases with the number of calcified vessels as well as the total calcium score.
[6]
In a study in which calcium scores and thallium stress test results were compared, almost one half of the patients
with scores greater than 400 had a normal thallium stress result.[7] Such testing may not be contradictory in terms
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The Future
Calcium scoring can be accomplished without cardiac gating, but most of the current work is devoted to either
prospective or retrospective gating. At this time, every major manufacturer has or is working on both of these
methods. Retrospective gating may be proven to be the most accurate technique, because it allows the operator
to choose the optimum time during diastole for image selection.[15, 16, 17]
In terms of nontechnical aspects, the most important work being performed now is the formation of large
databases. Only long-term analysis of this data will reveal the ultimate value and role for this procedure.
The most exciting possibility with calcium scoring may be CT angiography in the coronary arteries. As the
scanners become faster and as the 3-dimensional computer postprocessing workstations become more powerful,
this examination may become a reality. Already, preliminary studies are being performed in Europe to evaluate the
feasibility of CT angiography of the coronary arteries.
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References
1. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the
American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. Jan
29 2008;117(4):e25-146. [Medline].
2. O'Rourke RA, Brundage BH, Froelicher VF. American College of Cardiology/American Heart Association
Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of
coronary artery disease. Circulation. Jul 4 2000;102(1):126-40. [Medline].
3. Joshi PH, Blaha MJ, Blumenthal RS, Blankstein R, Nasir K. What is the role of calcium scoring in the
age of coronary computed tomographic angiography?. J Nucl Cardiol. Dec 2012;19(6):1226-35. [Medline].
4. Marwan M, Mettin C, Pflederer T, Seltmann M, Schuhbck A, Muschiol G, et al. Very low-dose coronary
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scanning: a review and guidelines for use in asymptomatic persons. Mayo Clin Proc. Mar 1999;74(3):24352. [Medline].
6. Rumberger JA. Coronary artery calcification: "...empty your cup.". Am Heart J. May 1999;137(5):774-6.
[Medline].
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11. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary
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14. Ratti C, Chiurlia E, Grimaldi T, Malagoli A, Ligabue G, Modena MG. Coronary calcification in
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15. Ozturk E, Kantarci M, Durur-Subasi I, Bayraktutan U, Karaman A, Bayram E, et al. How image quality
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Medscape Reference 2011 WebMD, LLC
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