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Calcification in atherosclerosis

Nature Reviews Cardiology volume 6, pages 681–688 (2009)Cite this article

Abstract

Coronary calcification has long been known to occur as a part of the atherosclerotic process, although whether it is a marker of plaque stability or instability is still a topic of considerable debate. Coronary calcification is an active process resembling bone formation within the vessel wall and, with the advances in CT technology of the past decade, can be easily quantified and expressed as a coronary artery calcium (CAC) score. The extent of calcium is thought to reflect the total coronary atherosclerotic burden, which has generated interest in using CAC as a marker of risk of cardiovascular events. The current consensus is that large amounts of CAC identify a highly vulnerable patient rather than a vulnerable plaque or vulnerable vessel. Indeed, CAC has incremental prognostic value beyond traditional risk factors in various subsets of the population. Furthermore, whereas the presence of CAC is associated with increased risk, a zero CAC score predicts excellent short-term to mid-term prognosis, even in high-risk patients. The advent of CT angiography has perhaps clouded the importance of CAC as a long-term marker of risk, as opposed to the presence of luminal stenoses that are associated with a more immediate risk of events.

Key Points

  • Calcification of the coronary arteries occurs via an active process that resembles bone formation and is under the control of complex enzymatic and cellular pathways

  • Coronary artery calcium screening is easily performed with multidetector CT; the total coronary calcium score is an index of the total coronary atherosclerotic burden

  • Coronary artery calcium is a better predictor of cardiovascular events than the Framingham risk score and can help to reclassify asymptomatic individuals into high-risk or low-risk categories

  • The best available data on the usefulness of coronary calcium measurement for refinement of cardiovascular risk prediction is in intermediate-risk individuals by use of current risk-prediction algorithms

  • In symptomatic patients, the presence of coronary artery calcium may help to distinguish those with obstructive coronary artery disease from those with no significant disease

  • Rapid coronary calcium progression is associated with poor prognosis; however, data is insufficient at this time to recommend serial calcium score measurements in the general population

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Figure 1: Sequential cranio-caudal axial images of the heart demonstrating calcium deposition in all coronary arteries.

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Article 16 August 2019

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Acknowledgements

Dr. N. Alexopoulos was supported by a scholarship from the Hellenic Cardiological Society.

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    Nikolaos Alexopoulos & Paolo Raggi

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Alexopoulos, N., Raggi, P. Calcification in atherosclerosis. Nat Rev Cardiol 6, 681–688 (2009). https://doi.org/10.1038/nrcardio.2009.165

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