Over the last 20 years, cardiac computed tomography (CT) has evolved, with advances at an ever accelerating pace with both ever higher spatial and temporal resolution. Now physicians have a method to evaluate both coronary atherosclerosis (both non-calcific and calcific plaque) simultaneously with a view of the lumen (estimate per cent stenosis). It is well established that coronary artery calcium (CAC) is a marker of atherosclerosis.
Several large clinical trials found clear, incremental predictive value of CAC over the Framingham risk score when used in asymptomatic patients. Based on multiple observational studies, patients with increased plaque burdens (increased CAC) are approximately ten times more likely to suffer a cardiac event over the next three to five years. Coronary calcium scores have outperformed conventional risk factors, highly sensitive C-reactive protein (CRP) and carotid intima media thickness (IMT) as a predictor of cardiovascular events. This allows anti-atherosclerotic therapies (such as statins, ACE inhibitors and anti-platelet drugs) to be used earlier and more vigorously in those found to have advanced subclinical atherosclerosis.
Many physicians are turning to CT angiography, to visualize both the lumen and plaque burden. Furthermore, the idea that non-calcific ('soft') plaque can be visualized with CT angiography, but not with CAC scanning, has great appeal to physicians. However, there is much more evidence available in the use of CAC scanning especially for the prognosis of subclinical atherosclerosis, at a lower cost and much lower radiation dose. This paper will discuss the available literature and present the potential applications of coronary artery calcium scanning in the age of cardiac CT angiography.
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