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Rolvoorcoronairekalkscorebijcardiovasculairerisicostra8fica8e

RozemarijnVliegenthart,MDPhD

Adjuncthoogleraarcardiothoracalebeeldvorming

AfdelingRadiologie/MedicalImagingCenterUMCGGroningen

NVF2019r.vliegenthart@umcg.nl

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)