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Risk assessments needed before calcium scores introduced to CVD risk factor analysis

ESC Press Statement

A US study addressing coronary artery calcium score (CACS) as a predictor of coronary artery disease (CAD), published in JAMA 28 April 2010 (1), has found that the addition of calcium scores to traditional risk factors significantly improved the classification of risk and placed more individuals in the most extreme risk categories.
Risk Factors and Prevention

Philip Greenland and colleagues, from Northwestern University (Chicago, Illinois), undertook a prospective cohort study of 6,814 people, aged 45 to 84 without known cardiovascular disease. The analysis was part of the Multi-Ethnic Study of Atherosclerosis (MESA), a longitudinal study initiated in 2000 to explore characteristics of sub clinical cardiovascular disease in people of White, African American, Hispanic and Chinese origin. The study set out to consider whether new measures of cardiovascular disease (CVD), including carotid ultrasound, cardiac MRI and arterial compliance benefited different racial groups.

In the current analysis coronary artery calcium was assessed by chest computed tomography (CT), with the clinical teams also collecting information on traditional cardiovascular risk factors. The five year estimated incidence of CAD was calculated for each participant using a Cox proportional hazards model, with model 1 using the standard Framingham risk factors of age, sex, smoking, systolic blood pressure, use of antihypertensive medications and HDL and total cholesterol and race/ethnicity; and model 2 used these standard risk factors plus CACS. At a median follow up of 5.8 years, the results showed that adding CACS led to significant improvements in risk prediction (with a net reclassification improvement of 0.25, 95 % confidence interval, 0.16-0.34; P<.001).

Commenting on the study, European Society of Cardiology (ESC) spokesman Prof José Gonzalez Juanatey, said:  “Although this study clearly shows that adding coronary artery calcium scores to traditional risk factors improves classification, the conclusions need to be considered in the real world where both costs and increased cancer risks need to be taken into account.”

Indeed, an accompanying editorial by John Ioannidis from the University of Ioannina School of Medicine (Greece) and Ioanna Tzoulaki, from Tufts University School of Medicine (Boston, Massachusetts), raised the same issues (2). In the editorial the authors state that CT (the technology used to measure calcium scores) costs between $200 and $600, and that the lifetime excess cancer risk due to radiation exposure from a single examination at age 40 years was 9 cancers per 100,000 men and 28 cancers per 100, 000 women.

Unlike traditional risk factor measurements, such as lipid and blood pressure, Gonzalez Juanatey added, scores of arterial calcium deliver no additional benefit in terms of increasing treatment options open to the patient. “No treatments are available to lower calcium scores, making the justification of screening for calcium harder to make,” he said.

The ESC’s European Prevention Guidelines, published in 2007, currently make no mention of the use of calcium scores. “Before guidelines should be changed randomised studies are needed to show whether undertaking arterial calcium scores actually results in patients living longer and suffering less cardiovascular complications,” said Gonzalez Juanatey, from The University Clinical Hospital of Santiago de Compostela, Spain.


1. TS Polonsky, RL McClelland, NW Jorgensen et al. Coronary Artery Calcium Score and Risk Classification for Coronary Heart Disease Prediction. JAMA, 28 April, 2010, 303: 1610-1616.

2. JP Ioannidis, I Tzoulaki. What Makes a Good Predictor? The Evidence Applied to Coronary Artery Calcium Score. Ibid pp 1646-1647.

Notes to editor

A cardiac CT scan for coronary calcium is a non invasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries. The amount of calcium inside the walls of the coronary arteries is considered a good predictor of future cardiovascular events.

* The European Society of Cardiology (ESC) represents more than 62,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.