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Differences in the association of total versus local coronary artery calcium with acute coronary syndrome and culprit lesions in patients with acute chest pain: The coronary calcium paradox

  • Stefan B. Puchner
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
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  • Thomas Mayrhofer
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
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  • Jakob Park
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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  • Michael T. Lu
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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  • Ting Liu
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang, China
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  • Pal Maurovich-Horvat
    Affiliations
    MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
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  • Khristine Ghemigian
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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  • Daniel O. Bittner
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Cardiology, University Hospital Erlangen, Germany
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  • Jerome L. Fleg
    Affiliations
    Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
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  • James E. Udelson
    Affiliations
    Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA, USA
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  • Quynh A. Truong
    Affiliations
    Department of Radiology and Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
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  • Udo Hoffmann
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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  • Maros Ferencik
    Correspondence
    Corresponding author. Knight Cardiovascular Institute, Oregon Health & Science University, 3180 Sam Jackson Park Rd., Mail Code UHN62, Portland, OR 97239, USA.
    Affiliations
    Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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      Highlights

      • Total coronary artery calcium burden was a good predictor of acute coronary syndrome (ACS) in acute chest pain patients.
      • Culprit lesions of ACS were characterized by significant stenosis and high-risk plaque.
      • Culprit lesions of ACS had smaller amounts of coronary calcium.
      • The prevalence of high-risk plaque was inversely related to segmental coronary calcium score.
      • Local extensive coronary calcium may represent more stable stage of atherosclerosis.

      Abstract

      Background and aims

      Total coronary artery calcium (CAC) burden is associated with an increased cardiovascular risk, while local CAC may represent stable plaques. We determined differences in relationship of total CAC with acute coronary syndrome (ACS) and local CAC with culprit lesions in patients with suspected ACS.

      Methods

      We performed computed tomography (CT) for CAC and CT angiography to assess the presence of significant stenosis and high-risk plaque (positive remodeling, low CT attenuation, napkin-ring sign, spotty calcium) in 37 patients with ACS and 223 controls. Total and segmental Agatston scores were measured. Culprit lesions were assessed in subjects with ACS.

      Results

      Patients (n = 260) with vs. without ACS had higher total CAC score (median 229, 25th-75th percentile 75–517 vs. 27, 25th-75th percentile 0–99, p<0.001), higher prevalence of significant stenosis (78% vs. 7%, p<0.001) and high-risk plaque (95% vs. 59%, p<0.001). In those with ACS, culprit (n = 41) vs. non-culprit (n = 200) lesions, had similar segmental CAC score (median 22, 25th-75th percentile 4–71 vs. 14, 25th-75th percentile 0–51; p=0.37), but higher prevalence of significant stenosis (81% vs. 11%, p<0.001) and high-risk plaque (76% vs. 51%, p=0.005). Significant stenosis (odds ratio 40.2, 95%CI 15.6–103.9, p<0.001) and high-risk plaque (odds ratio 3.4, 95%CI 1.3–9.1, p=0.02), but not segmental CAC score (odds ratio 1.0, 95%CI 1.0–1.0, p=0.47), were associated with culprit lesions of ACS.

      Conclusions

      Total CAC burden was associated with ACS but segmental CAC was not associated with culprit lesions. Our findings suggest that total but not local CAC is a marker of ACS risk and support the hypothesis that extensive local CAC is a marker of plaque stability.

      Graphical abstract

      Keywords

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