Open Access

Coronary calcium in patients with and without diabetes: first manifestation of acute or chronic coronary events is characterized by different calcification patterns

  • Joseph Shemesh1, 2,
  • Alexander Tenenbaum1, 2, 3,
  • Enrique Z Fisman2, 3Email author,
  • Nira Koren-Morag2 and
  • Ehud Grossman1, 2
Contributed equally
Cardiovascular Diabetology201312:161

https://doi.org/10.1186/1475-2840-12-161

Received: 12 September 2013

Accepted: 1 November 2013

Published: 5 November 2013

Abstract

Background

Coronary artery calcification (CAC) is closely related to coronary atherosclerosis. However, less is known about the clinical significance of extensive CAC (ECAC) in regard to types of first coronary events (acute vs. chronic). Diabetes mellitus (DM) represents a strong risk factor for CAD although its association with CAC is controversial. Aiming to elucidate these controversies we investigated the long-term outcome of coronary artery disease (CAD) in relation to degree of CAC in patients with and without DM from our annual cheek-up outpatient clinic.

Methods

Coronary artery computed tomography (CT) was performed in 667 patients who were yearly evaluated during a mean follow-up period of 6.3 ±3.4 year. The following 4 CAC categories were established: calcium absence; total calcium score (TCS): 1–100 AU; TCS: 101–600 AU and ECAC: TCS above 600 AU. Acute event was defined as first acute myocardial infarction (MI) or a new unstable angina. First chronic event was defined as a positive stress test with a consequent elective percutaneous coronary intervention or coronary artery bypass grafting.

Results

628 subjects (94%) were free from any cardiac events, 39 (6%) experienced first cardiac event: 18 of them suffered acute and 21 chronic events. There were 67 patients with and 600 patients without DM: 78% of patients with DM presented CAC vs. 50% of patients without DM (p < 0.001).The mean TCS was 17 times higher in the chronic than in the acute events group: 914 vs. 55 AU, p < 0.001. In 95% of the patients with chronic events more than one calcified vessel was found, compared to 67% of the patients with acute events and only 30% of those without events (p < 0.001). Incidence of CAD events (all types pooled together) rose consequently from 2% in subjects without CAC to 34% in subjects with ECAC (p < 0.001). However, among the 32 subjects with ECAC, 11 (34%) developed chronic event while none of them had acute event. In contrast, none of subjects with TCS =0 or TCS 1–100 AU presented with chronic events. Subjects with TCS 101–600 AU presented 10 (9%) chronic and 5 (4.5%) acute events (p < 0.001).

Conclusions

Asymptomatic subjects with ECAC are not firstly manifested as acute coronary events but presented a high level of chronic CAD-related events during the 6.3 ±3.4 year follow-up. In contrast, first acute CAD-related events occurred mostly in subjects with mild and moderate CAC score.

Keywords

Angina pectoris Atherosclerosis Coronary calcification Coronary artery disease Coronary computed tomography Diabetes mellitus Myocardial infarction

Coronary artery calcification (CAC) is a well established surrogate marker of the total burden of coronary atherosclerosis [13]. Large prospective studies consistently demonstrated that higher CAC scores are associated with increased risk for coronary artery disease (CAD) related events [4, 5] and that addition of CAC score to traditional risk factors improves risk stratification [5, 6]. Previously, we [7, 8] and others [9] have suggested that subjects with extensive CAC (ECAC) are at increased risk of stable angina but not of acute coronary syndrome, compared to the those with the lower CAC scores.Diabetes mellitus (DM) represents a strong risk factor for CAD, albeit its association with CAC is controversial. While a number of studies have found significant relationship between high CAC and DM [1013], the Multi-Ethnic Study of Atherosclerosis (MESA) did not confirm this association [9]. In an aim to elucidate these controversies we sought to investigate the long-term CAD outcome (stratified according to chronic or acute events) in relation to degree of CAC in patients with and without DM undergoing our annual cheek-up outpatient clinic.

Material and methods

Patient selection

Seven hundred and forty five consecutive subjects who consented to perform a cardiac computed tomography (CT) for coronary calcium evaluation were recruited from our annual cheek-up clinic between January 2001 and January 2002. The inclusion criteria for screening were men above 40 and women above 50 years free of cardiovascular disease. Those who had at least one year of follow-up were included in the present analysis. Seventy six subjects who never returned to the annual check-up were excluded and two others were excluded since an acute MI was found in their files before the study entry. The remaining 667 subjects comprised our study group. All underwent CT at baseline visit and were then yearly evaluated. The development of events was finally assessed on February 2011. So, the follow-up period was until the first diagnosis of event, death, last annual check –up, or 31 January 2011, providing a maximum follow-up of 10 years, mean 6.3 ±3.4 years.

Events definition

Only first coronary events were analyzed. We defined acute event as first acute MI or hospitalization for a new unstable angina. Chronic event was defined as positive stress test on the routine annual check-up, with or without chest pain, with a consequent elective coronary catheterization resulting in percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Follow-up

Events were recorded from the files of the annual check-up program in our institute and were verified by the available documentation. Data on mortality and cause of death were available for all participants from the registry of the Ministry of Internal Affairs. A written informed consent was obtained from all patients and the entire study protocol was approved by the Sheba Medical Center Helsinki Committee.

Annual check-up

All subjects were clinically evaluated at baseline and then annually, and a detailed medical history and standard physical examination were performed. The following variables were recorded: age, height, weight, concomitant diseases, smoking habits, and laboratory evaluation. Estimated glomerular filtration rate (eGFR) was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation [14].

Coronary CT

All CT scans were performed on a dual-detector spiral CT without ECG gating and without contrast injection. Scanning protocol and CAC measuring were done according to a previously published protocol using the modified Agatston method [15]. Total CAC score was the sum of all the individual calcific lesions identified within the area of the coronary arteries. The reproducibility of calcification scoring by this method is high, with an intra class correlation coefficient of 0.99 and of 0.94 for inter-observer agreement [16]. The following 4 CAC categories were distinguished: absence of CAC; mild-moderate CAC: 1–100 AU; high CAC: 101–600 AU and very high ECAC score: above 600 AU, which corresponds to the 95th percentile in our cohort.

A TCS > 0 was considered positive for the presence of any CAC. The number of coronary vessels with CAC was recorded for each subject and defined as having at least one calcific lesion in one of the 4 regions: main left artery, left anterior descending artery (LAD) and its branches, left circumflex artery (LCX) and its branches and right coronary artery (RCA) and its branches.

Assessment of cardiovascular risk factors

Height and weight were measured with participants wearing light clothing without shoes. The body mass index (BMI) was calculated as weight (Kg) divided by the square of the height. Blood pressure (BP) was measured in the seated position after 3 minutes of rest. Hypertension was defined when BP levels were twice ≥140 mm Hg for systolic BP and/or ≥90 mm Hg for diastolic BP or a history of hypertension was reported or when the subject was on antihypertensive medications. Diabetes mellitus (DM) was defined when fasting plasma glucose was on 2 occasions greater than 126 mg/dL (7.0 mmol/L), a history of DM was reported or when the patient was on insulin or oral hypoglycemic medications. Hypercholesterolemia was defined when measured total cholesterol was > 250 mg/dl, or when the patient reported medication with cholesterol lowering agents. Smoking status was determined according to the questionnaire.

Statistical methods

Data were analyzed with IBM SPSS software version 21.0 and were presented as frequencies and percentages for categorical variables and as mean and standard deviation for continuous variables. Significance levels were set at 0.05. The distributions of continuous variables in the study were examined using the Kolmogorov-Smirnov non-parametric test. To demonstrate the differences between the event groups (no event, chronic event and acute event), Chi-Square tests were analyzed for differences in categorical baseline characteristics and incidence of events between the groups. One-way ANOVA tests were performed for continuous characteristic including TCS values, following by analysis of covariance (ANCOVA) to adjust for age as a potential covariate.

Results

The mean period of follow-up was 6.3 ±3.4 year. During this period 628 subjects (94%) were free from any cardiac events (Group I). Throughout follow up 39 (6%) of patients experienced a cardiac event: 18 of them suffered acute events (13 acute MI and 5 unstable angina pectoris – Group II) and in 21 of them chronic events were documented (Group III). Eight patients died without having any known prior cardiac event (non-cardiac death).

The baseline characteristics of the participants are given in Table 1. Patients with events were older than those without and those with chronic events were older than those with acute. The frequency of hypertension was twice higher among those with chronic than in those with acute event and no events. All the other clinical and laboratory parameters were not statistically different between study groups. There were 67 patients with and 600 patients without diabetes in our study. It should be pointed out that 78% of the patients with DM had CAC (TCS above zero) vs. 50% of patients without DM (p < 0.001).
Table 1

Baseline characteristics of the study population

Characteristics

No event N = 628

Acute event N = 18

Chronic event N = 21

p value

Age

55 ± 7.2

57 ± 8.2

60 ± 7.7

0.007

Male gender

526 (84)

17 (94)

21 (100)

0.073

BMI (kg/m2)

27.0 ± 3.5

27.7 ± 4.0

26.2 ± 2.7

0.395

SBP (mmHg)

126 ± 17

124 ± 15

130 ±13

0.444

DBP (mmHg)

79 ± 9

78 ± 9

79 ± 6

0.906

Hypertension

163 (26)

5 (28)

12 (57)

0.007

Diabetes

60 (10)

3 (17)

4 (19)

0.232

Current smokers

106 (22)

4 (33)

5 (31)

0.454

Chronic renal failure

14 (2)

1 (6)

1 (5)

0.511

CAD family history

162 (26)

3 (18)

7 (35)

0.486

Hyperlipidemia

284 (47)

9 (50)

12 (60)

0.475

Urea (mg/dl)

33 ± 7.7

35 ± 7.7

32 ± 5.7

0.557

Creatinine (mg/dl)

1.07 ± 0.15

1.08 ± 0.17

1.13 ± 0.11

0.179

Glucose (mg/dl)

99 ± 23

96 ± 18

101 ± 21

0.761

Calcium (mg/dl)

9.6 ± 0.45

9.6 ± 0.46

9.6 ± 0.50

0.908

Phosphorus (mg/dl)

3.02 ± 0.50

2.76 ± 0.27

3.0 ± 0.69

0.088

Triglyceride (mg/dl)

143 ± 79

156 ± 63

133 ± 58

0.671

Total cholesterol (mg/dl)

    

HDL-cholesterol (mg/dl)

45 ±12

40 ± 5

45 1 ± 3

0.243

LDL-cholesterol (mg/dl)

127 ± 29

127 ± 37

127 ± 26

0.999

Data are number (%) of patients or mean ± SD.

The CAC characteristics of patients are given in Table 2. Among subjects without events half had CAC (TCS > 0) while all those with chronic and three quarter of the acute events group had CAC. Equally, the mean CAC score was 10 times higher in the chronic events group than in those without events (914 vs. 93 AU) and 17 times higher than the mean TCS of the acute group (914 vs. 55 AU). Ninety five percent of the patients with chronic events had more than one calcified vessel compared to 67% of the patients with acute events and only 30% of those without events (p < 0.001).
Table 2

The CAC characteristics according to outcome during follow-up

Variable

No event N = 628

Acute event N = 18

Chronic event N = 21

p value

TCS mean (SD)

93 ± 276

55 ± 62

914 ± 660

<0.001

TCS >0

311 (50)

13 (72)

21 (100)

<0.001

CV > 1

187 (30)

12 (67)

20 (95)

<0.001

No CV mean (SD)

1.02 ± 1.15

1.72 ± 1.23

3.05 ± 0.74

<0.001

TCS - Total calcium score (AU); CV - calcified vessel >1 - more than one calcified major coronary vessel in one of the 4 regions: main left artery, LAD, LCX and RCA including their branches; No CV – mean number of calcified major coronary vessels.

For TCS >0 and CV > 1 data are number (%) of patients.

The incidence of acute and chronic events by TCS categories is given in Table 3 and Figure 1. During follow-up incidence of the CAD events (all types pooled together) rose consequently from 2% in subjects without CAC to 34% in subjects with the highest CAC category TCS > 600 AU (p < 0.001). However, different pattern in the development of the first acute and chronic coronary events in accordance with the CAC category was observed. Among the 32 subjects with TCS > 600 AU, 11 (34%) developed chronic event while none of them had acute event. In contrast, none of subjects with TCS = 0 or TCS 1–100 AU had chronic events. Subjects with TCS 101–600 AU presented 10 (9%) chronic and 5 (4.5%) acute events (p < 0.001).
Figure 1

Incidence of acute and chronic events by TCS categories. TCS - Total calcium score (AU).

Table 3

Incidence of acute and chronic events by TCS categories

Type of event

TCS = 0

TCS 1–100

TCS 101–600

TCS > 600

p value

N = 315

N = 208

N = 112

N = 32

(age-adjusted)

All types

5 (2)

8 (4)

15 (13.5)

11 (34)

<0.001

Acute

5 (2)

8 (4)

5 (4.5)

0

Chronic

0

0

10 (9)

11 (34)

 

Data are number (%) of patients.

TCS - Total calcium score (AU).

Discussion

The main finding of our study is that asymptomatic subjects with ECAC, both with and without DM did not developed first acute CAD-related events during up to 10 years of follow-up. Our data support the suggestion that ECAC is associated with a stable form of atherosclerosis which is mainly manifested by a chronic rather than acute course of CAD [79].

Previous studies have shown a dramatically increased incidence rate of CAD events (when all types of events pooled together) among those with the highest levels of CAC compared to those with CAC = zero [36]. However, as we demonstrate in the current analysis, a different pattern in development of acute and chronic coronary events in accordance with CAC category can be distinguished. The acute events in our study occurred mostly in subjects with mild and moderate CAC and even in absence of CAC. This might have an important clinical relevance, since minimal or mild CAC should not be categorized into a lower risk category (as suggested by the SHAPE investigators) [17]. These findings are also supported by histopathological studies, intravascular ultrasound and CT observations that consistently demonstrated that acute events rise mainly from soft non-calcified or mildly calcified plaques [1827]. In a series of cases of sudden coronary death, more than 50% of thin-cap fibroatheromas showed a lack of calcification or only speckled calcification on postmortem radiographs of coronary arteries [18]. Several studies demonstrated the destabilizing effect of the lipid core, whereas presence of calcium was a stabilizing force and calcified lesions were more resistant to rupture (similar to fibrous plaque) [19, 20].

Thus, it seems that ECAC represents a long standing chronic stage of slowly growing coronary atherosclerosis and can be regarded as a healing process leading to stabilization and decrease vulnerability of the plaques [28]. On the other hand, ECAC causes negative vessels remodeling resulting in flow restriction and leading to clinical manifestations such as chronic angina or silent ischemia upon a routine stress test [1828].

The prevalence of CAC in our patients with DM was significantly higher than in patients without DM. The clinical value of CAC score in diabetic patients has been recently demonstrated in several studies: CAC score can further stratify diabetic patients according to the presence and extent of CAC into patients with very low or high CV risk [1013, 29].

It should be stated that our population was predominantly masculine, and this may represent a potential limitation since the epicardial adipose tissue volume shows gender disparities, being strongly associated with coronary atherosclerosis in men [30]. Therefore, despite of the strong theoretical background and biological plausibility, caution should be used in interpreting our findings because it was not a randomized controlled trial and we cannot rule out other factors that could have influenced the observed clinical outcomes.

Conclusions

Asymptomatic subjects with ECAC did not develop first acute events, but presented a high level of chronic CAD-related events during a long term follow-up. In contrast, most of the acute CAD-related events firstly occurred in subjects with mild and moderate CAC.

Notes

Abbreviations

AU: 

Agatston units

BP: 

Blood pressure

BMI: 

Body mass index

CABG: 

Coronary artery bypass grafting

CAD: 

Coronary artery disease

CAC: 

Coronary artery calcification

CT: 

Computed tomography

DM: 

Diabetes mellitus

ECAC: 

Extensive coronary artery calcification

LAD: 

Left anterior descending artery

LCX: 

Left circumflex artery

MI: 

Myocardial infarction

PCI: 

Percutaneous coronary intervention

RCA: 

Right coronary artery

TCS: 

Total calcium score.

Declarations

Acknowledgements

This work was supported in part by the Cardiovascular Diabetology Research Foundation (RA 58-040-684-1), Holon, Israel.

Authors’ Affiliations

(1)
Cardiac Rehabilitation Institute, Sheba Medical Center
(2)
Sackler Faculty of Medicine, Tel-Aviv University
(3)
Cardiovascular Diabetology Research Foundation

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© Shemesh et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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