Review
In the search of coronary calcium

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Abstract

The recognition of coronary artery calcium (CAC) as an indicator of coronary artery disease for more than 30 years has created a great interest in methods for its accurate assessment. In this review we present the imaging techniques capable of detecting CAC and discuss their current status in clinical practice.

The first non-invasive CAC imaging method was chest radiography, although early recognized as insensitive. Fluoroscopy and digital fluoroscopy improved CAC detection compared to plain chest radiography; however, their potential in reliable CAC quantification and detection of small CAC amounts is limited. The evolution of computed tomography (CT) offered new perspectives in the field of CAC assessment. Electron beam and—mainly nowadays—multidetector CT constitute the established CAC scoring techniques. Recent evidence shows that CAC evaluation is feasible even on standard chest CT and CT coronary angiography. Cardiac echocardiography, positron emission tomography and magnetic resonance imaging currently have limited capability of CAC assessment.

Invasive examinations like coronary angiography may reveal CAC, a finding with potential implications in coronary interventions. Intravascular ultrasound and optical coherence tomography have great potential in assessing the extent and pattern of CAC, however, quantification is challenging and they are not suitable for screening. Angioscopy, a demanding and evolving technique, can possibly detect surface CAC.

Further evolution and refinement of CAC detection methods is expected to lead to their more widespread application and even greater usefulness into clinical practice.

Introduction

Coronary artery calcium (CAC) is a constituent of atherosclerosis detected almost exclusively in atherosclerotic arteries [1]. CAC pathophysiology and association with cardiovascular risk have been an area of intense investigation for several years. Specifically, the association between CAC and plaque vulnerability—which is the most important pathophysiological entity leading to acute coronary syndromes—has not been yet fully elucidated. It has been proposed that CAC might serve as a stimulus for plaque disruption [2], whereas other researchers describe the coronary calcification as a ‘healing’ process providing plaque stability after subclinical plaque rupture events [3]. Several studies, though, have shown that CAC amount is predictive of an increased risk for future coronary events [4] and, thus, CAC detection has become an established method for cardiovascular risk assessment, particularly useful in asymptomatic intermediate risk individuals [5].

Various diagnostic techniques, both non-invasive and invasive, providing anatomic information for the presence of atherosclerosis have been used for CAC imaging [Table 1]. The focus of this review is to present CAC detection methods and describe their current position in our armamentarium for accurate detection and more comprehensive assessment of the coronary atherosclerotic plaques.

Section snippets

Chest radiography

The possibility of detecting calcified coronary arteries on plain chest films was described decades ago. However, it was early recognised that chest radiographs are insensitive for CAC detection [6]. In a recent study, plane chest radiography had an at most moderate accuracy for CAC detection when compared with multislice computed tomography (MSCT) suggestive of the limited ability to differentiate between the presence and absence of CAC from conventional chest radiographs [7]. Dual-energy

Coronary angiography

CAC can be seen during routine coronary angiography (CA) even before contrast injection in the vicinity of the coronary arteries and relates to atheroma presence and vessel remodelling [Fig. 1B, Video-2]. Moreover, CAC detection during CA has potential implications in percutaneous coronary intervention (PCI) outcome of calcific lesions, including higher rates of procedural failure, stent under-deployment, lower post-procedural minimal luminal diameter and acute gain, and elevated risk of

Future perspectives—conclusion

During the last 3 decades—through intense research and controversies—significant advancements were made regarding the pathophysiology, clinical significance and imaging methods of CAC.

Since the early reports of CAC detection on plain chest films the evolution of cardiac imaging was enormous and offered more sensitive tools of CAC detection and quantification. Fluoroscopy and digital fluoroscopy initially deemed promising but were soon abandoned. The advent of EBCT and—one decade later—MDCT,

Conflict of interest

The authors have no funding, financial relationships, or conflicts of interest to disclose.

Acknowledgment

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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