From the Desk of Dr.

Tom Hight:

For over a decade Ive used EBCT coronary calcium scoring (CCS) as a screening tool in my primary
care practice, with over 1,000 patients scanned and between 6,000 and 7,000 patient-years, and have had
6 known CV events in that group (two in the same noncompliant patient). The electron beam
technology offers two benefits: lower radiation and faster image acquisition. Image acquisition time is
important when the object being scanned is in almost constant motion, as the coronaries are.1 Ive seen
patients who paid for coronary calcium screening at other institutions (using a 64-slice Multi-Detector
CT) with indeterminate results for RCA and Left Circumflex arteries.

Radiation exposure from EBCT is usually about 10% of standard CT scanners. EBCT always gives the
same low dose, never varying by patient size. (more on radiation below2)

So how can we use this technology in clinical practice? The place to start is with this horrible statistic:
Sudden cardiac death is the first presentation of CHD in 50% of men and 64% of women.345 Our best
hope of changing this statistic is to screen asymptomatic patients.

For asymptomatic patients, an AHA expert panel6 and a joint ACCF/AHA expert panel7 have reviewed
the literature, showing that there is sufficient evidence to use CCS in intermediate Framingham Risk
Score patients (ie, a 10% to 20% 10-year risk of est. coronary events, based on the Framingham Risk
Calculator). Personally, Ive used CCS in high-risk FRC patients (>20% 10-year risk) who, being told
they were high risk, still would not stop smoking or lose weight or take lipid or BP medications. While
negotiating the value proposition of making those changes, changes patients do not want to make, a
positive CCS score seems to increase the stakes, upping the ante on the consequence of their choice.
Were no longer talking about risk. Were talking about reality. These are your arteries.

What about low risk (<10% 10-year) FRC patients? Although the US Preventive Services Task Force
recommends against screening for coronary calcium in low risk adults,8 there are some categories of
FRC low risk patients who might benefit from CCS because their low risk is due to age and they have
risk factors missed by FRC, such as a dramatic family history, HDL2b deficiencies (w/ normal total
HDL), pre-diabetes, peripheral intra-arterial calcification seen on other X-rays, or being female between
45 and 65.9 Knowing that a patient has a positive CCS makes a difference. Patients with documented
coronary calcium are 3x as likely to receive statins and daily ASA, compared with the general
population.10

How useful is the FRC in your practice? Only you can determine that for yourself, by using it.11

Chest pain patients with negative stress testing can benefit from CCS, which has the ability to shift
patients from low to high risk groups, increasing the pre-test probability of significant CAD.12 Adding
CCS to nuclear stress testing for chest pain patients can help identify significant lesions missed by stress
testing, and it can identify patients who need more aggressive risk reduction even if they dont have
hemodynamically significant CAD.13

How many chest pain patients have you sent to the hospital ER who later came back and said,
Everything is OK with my heart! Im fine, yet you know they need more aggressive risk reduction.
Sometimes patients need to be reminded that most coronary events occur in lesions that are not
hemodynamically significant, lesions missed by traditional CAD detection methods.14
As to the promise of low dose CT screening in asymptomatic smokers, the literature has been confusing.
The National Lung Screening Trial (in progress), with 50,000 randomized high-risk smokers, should
define whether CT screening is effective at reducing lung cancer mortality.

Due to the lower radiation dose compared to conventional CT, EBCT can be used to follow pulmonary
nodules (low dose CT is preferred by the expert panel),15 or to rule out renal stones. The downside here
is that EBCT isnt covered by insurance carriers.

H. Thomas Hight, M.D.

Medical Director
LifeTest Atlanta
3/20/10
1
EBCT, with no moving parts (the electron beam moves), is able to capture coronaries without motion artifact better than
conventional CT.
2 In radiation exposure, compared to the MDCT, the EBCT has the disadvantage that its radiation dose cannot be dialed up
by the technician when obese patients are scanned, and so patients weighing more than 300 pounds cannot be scanned
accurately, and are turned away. Conversely, you could say that patients less than 300 pounds will have a lower risk of over-
exposure in the rare case when the MDCT tech forgets to turn the exposure level down after scanning a heavy patient. In a
study* of radiation doses received by about 2000 patients getting 64-slice CT Angiography (CTA) in 50 international study
sites during 2007, the highest and lowest doses received varied by more than six-fold. Individual models of MDCT scanners
differed two-fold in median doses delivered from lowest to highest. Overall, the median dose of 12 mSv was equivalent to
600 Chest X-rays, or 300 PA/Lat films. (note: CTA by EBCT gives about 1.1 mSv, the equivalent of 55 Chest X-rays. CCS
by EBCT gives about 0.7 mSv**, or about 35 CXRs, or 17.5 PA/Lats.)
*Hausleiter, et al. Estimated Radiation Dose Associated With Cardiac CT Angiography. JAMA. 2009;301(5):500-507.
**Morin, et al. Radiation Dose in Computed Tomography of the Heart:; Circulation 2003;107:917-922.
3
Kaul, et al., Atherosclerosis Imaging: Prognostically Useful or Merely More of What We Know? Circulation:
Cardiovascular Imaging. 2009;2:150-160
4
Murabito, et al., Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the
sexes according to initial coronary disease presentation. Circulation. 1993; 88: 25482555
5
AHA. Heart disease and stroke statistics2008 update. American Heart Association:
http://www.americanheart.org/presenter.jhtml?identifier=3000090Accessed 2/18/09
6
Budoff, et al., Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A Scientific Statement From
the American Heart Association Committee on Cardiovascular Imaging and InterventionCirculationAHA. Published online
10.2.06, 2006;114:000-000
7
ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography
in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain Circulation 2007;115;402-426:
http://circ.ahajournals.org/cgi/reprint/115/3/402
8
USPSTF. Screening for coronary heart disease: recommendation statement. Ann Intern Med. 2004; 140: 569572
9
Patients with risk factors may be classified as "low risk" by FRC. For example, in multivariate analyses, women aged <65
years rarely exceed 20% 10-year risk with any combination of risk factors and only exceed 10% risk if they are smokers with
low HDL levels. Cavanaugh, et al, Abstract 4029: systematic examination of risk factor levels associated with high and
intermediate 10-year risks for coronary heart disease in the ATP-III risk assessment tool. Circulation. 2006; 114: II-868.
10
Taylor, et al, Community-Based Provision of Statin and Aspirin After the Detection of Coronary Artery Calcium Within a
Community-Based Screening Cohort J. Am. Coll. Cardiol. 2008;51;1337-1341
11
http://hp2010.nhlbihin.net/atpiii/CALCULATOR.asp?usertype=prof
Diabetics and heart disease patients already have high risk.
12
Nabi, et al., Coronary Atery Calcium Scoring in the Emergency Department: Identifying Which Patients Can Be Safely
Discharged Home. Ann Emerg Med. Feb 5 2010
13
ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography
in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain Circulation 2007;115;402-426
http://circ.ahajournals.org/cgi/reprint/115/3/402
14
Little, et al, The underlying coronary lesion in myocardial infarction: implications for coronary angiography. Clin Cardiol.
1991 Nov;14(11):868-74.
15
Gould, et al, Evaluation of Patients With Pulmonary Nodules: When Is It Lung Cancer?
ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). CHEST September 2007 vol. 132 no. 3 suppl 108S-130S