SHAPE Society

1. The calcium score is a measure of overall
disease extent in a given person and is a
consequence of a variety of factors related
to:
EBCT vs. Conventional Risk FactorsEBCT vs. Conventional Risk Factors
for Coronary Related Eventsfor Coronary Related Events
Genetics & MetabolismGenetics & Metabolism
HabitsHabits
LifestyleLifestyle
Environment andEnvironment and
Susceptibility to inflammationSusceptibility to inflammation
©John A. Rumberger, MD - 2003

2. 1.1. Cannot be fully exploited without an adequate methodCannot be fully exploited without an adequate method
of separating higher-risk individuals from those atof separating higher-risk individuals from those at
lower risk.lower risk.
2.2. If serious misclassification is present, many higher-riskIf serious misclassification is present, many higher-risk
individuals would not be identified, denying themindividuals would not be identified, denying them
appropriate therapy, and...appropriate therapy, and...
3.3. conversely, many lower-risk individuals would beconversely, many lower-risk individuals would be
subject to over-treatment with expensive drugs havingsubject to over-treatment with expensive drugs having
an uncertain long-term safety.an uncertain long-term safety.
Risk Based Treatment Guidelines forRisk Based Treatment Guidelines for
Primary Prevention of CADPrimary Prevention of CAD
©John A. Rumberger, MD - 2003

3. Prediction of MI/SCD in Asymptomatic Patients:Prediction of MI/SCD in Asymptomatic Patients:
EBTEBT
0
1
2
3
4
5
6
7
0 10 20 30 40 50 60 70 80 90
Percentile Rank for Baseline EBCT Calcium ScorePercentile Rank for Baseline EBCT Calcium Score
LowLow
RiskRisk
IntermediateIntermediate
RiskRisk
HighHigh
RiskRisk
VeryVery
HighHigh
RiskRisk
AnnualAbsoluteRisk(%)AnnualAbsoluteRisk(%)
©John A. Rumberger, MD - 2003
Adapted from data presented inAdapted from data presented in
Raggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199

4. EBT “Heart Age”EBT “Heart Age”
Percentile Ranking of CASPercentile Ranking of CAS Adjustments to Chronological AgeAdjustments to Chronological Age
<25<25thth
Percentile Subtract 10 yearsPercentile Subtract 10 years
>>2525thth
- <75- <75thth
Percentile No adjustmentPercentile No adjustment
>>7575thth
- <90- <90thth
Percentile Add 10 yearsPercentile Add 10 years
© 2003 John A Rumberger, MD
*
* Originally suggested byOriginally suggested by
Grundy: AJC 2001;88:8E-11EGrundy: AJC 2001;88:8E-11E
>>9090thth
Percentile Add 20 yearsPercentile Add 20 years
©

5. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Conventional “Low to Intermediate” Risk PatientConventional “Low to Intermediate” Risk Patient
Age 35 to 65 yearsAge 35 to 65 years
MaleMale
TC = 210 mg/dlTC = 210 mg/dl
HDL = 40 mg/dlHDL = 40 mg/dl
No DiabetesNo Diabetes
No SmokingNo Smoking
Systolic BP = 150 mmHgSystolic BP = 150 mmHg
Use NCEPUse NCEP
ATP-IIIATP-III
and Framinghamand Framingham
point scoring systempoint scoring system
©John A. Rumberger, MD - 2003

6. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
0
5
10
15
20
25
30
35 40 45 50 55 60 65
Framingham Risk
<25th Percentile CAS
>75th Percentile CAS
>90th Percentile CAS
Age (years)
““Low to Intermediate”Low to Intermediate”
ConventionalConventional
Risk MaleRisk Male
CoronaryRiskperDecade
Low Risk
Intermediate Risk
High Risk
© 2003 John A Rumberger, MD

7. Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Conventional “Intermediate to High” Risk PatientConventional “Intermediate to High” Risk Patient
Age 35 to 65 yearsAge 35 to 65 years
MaleMale
TC =240 mg/dlTC =240 mg/dl
HDL = 35 mg/dlHDL = 35 mg/dl
No DiabetesNo Diabetes
No SmokingNo Smoking
Systolic BP = 180 mmHgSystolic BP = 180 mmHg
Use NCEPUse NCEP
ATP-IIIATP-III
and Framinghamand Framingham
point scoring systempoint scoring system
©John A. Rumberger, MD - 2003

8. 0
5
10
15
20
25
30
35 40 45 50 55 60 65
Framingham Risk
<25th Percentile CAS
>75th Percentile CAS
>90th Percentile CAS
Over and Under Estimation of Cardiac Risk:Over and Under Estimation of Cardiac Risk:
Framingham vs. EBT “Heart Age”Framingham vs. EBT “Heart Age”
Age (years)
““Intermediate to High”Intermediate to High”
ConventionalConventional
Risk MaleRisk Male
CoronaryRiskperDecade
Low Risk
High Risk
Intermediate Risk
© 2003 John A Rumberger, MD

9. EBT “Heart Age” and RiskEBT “Heart Age” and Risk
IntermediateIntermediate
ConventionalConventional
RiskRisk
HighHigh
ConventionalConventional
RiskRisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
1/3 or more are actually1/3 or more are actually HIGHHIGH riskrisk
1/3 or more are actually1/3 or more are actually INTERMEDINTERMED riskrisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
©John A. Rumberger, MD - 2003

10. EBT “Heart Age” and RiskEBT “Heart Age” and Risk
IntermediateIntermediate
ConventionalConventional
RiskRisk
HighHigh
ConventionalConventional
RiskRisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
1/3 or more are actually1/3 or more are actually HIGHHIGH riskrisk
1/3 or more are actually1/3 or more are actually INTERMEDINTERMED riskrisk
1/3 or more are actually1/3 or more are actually LOWLOW riskrisk
©John A. Rumberger, MD - 2003