Differences in the association of total versus local coronary artery calcium with acute coronary syndrome and culprit lesions in patients with acute chest pain: The coronary calcium paradox

Atherosclerosis. 2018 Jul;274:251-257. doi: 10.1016/j.atherosclerosis.2018.04.017. Epub 2018 Apr 17.


Background and aims: Total coronary artery calcium (CAC) burden is associated with an increased cardiovascular risk, while local CAC may represent stable plaques. We determined differences in relationship of total CAC with acute coronary syndrome (ACS) and local CAC with culprit lesions in patients with suspected ACS.

Methods: We performed computed tomography (CT) for CAC and CT angiography to assess the presence of significant stenosis and high-risk plaque (positive remodeling, low CT attenuation, napkin-ring sign, spotty calcium) in 37 patients with ACS and 223 controls. Total and segmental Agatston scores were measured. Culprit lesions were assessed in subjects with ACS.

Results: Patients (n = 260) with vs. without ACS had higher total CAC score (median 229, 25th-75th percentile 75-517 vs. 27, 25th-75th percentile 0-99, p<0.001), higher prevalence of significant stenosis (78% vs. 7%, p<0.001) and high-risk plaque (95% vs. 59%, p<0.001). In those with ACS, culprit (n = 41) vs. non-culprit (n = 200) lesions, had similar segmental CAC score (median 22, 25th-75th percentile 4-71 vs. 14, 25th-75th percentile 0-51; p=0.37), but higher prevalence of significant stenosis (81% vs. 11%, p<0.001) and high-risk plaque (76% vs. 51%, p=0.005). Significant stenosis (odds ratio 40.2, 95%CI 15.6-103.9, p<0.001) and high-risk plaque (odds ratio 3.4, 95%CI 1.3-9.1, p=0.02), but not segmental CAC score (odds ratio 1.0, 95%CI 1.0-1.0, p=0.47), were associated with culprit lesions of ACS.

Conclusions: Total CAC burden was associated with ACS but segmental CAC was not associated with culprit lesions. Our findings suggest that total but not local CAC is a marker of ACS risk and support the hypothesis that extensive local CAC is a marker of plaque stability.

Keywords: Acute coronary syndrome; Cardiac computed tomography; Coronary artery calcium; Coronary artery calcium density; Coronary artery calcium score; Culprit lesions; High-risk coronary plaque.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / diagnostic imaging*
  • Acute Coronary Syndrome / epidemiology
  • Aged
  • Angina Pectoris / diagnostic imaging*
  • Angina Pectoris / epidemiology
  • Computed Tomography Angiography*
  • Coronary Angiography / methods*
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Artery Disease / epidemiology
  • Coronary Stenosis / diagnostic imaging*
  • Coronary Stenosis / epidemiology
  • Coronary Vessels / diagnostic imaging*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Multidetector Computed Tomography*
  • Plaque, Atherosclerotic
  • Predictive Value of Tests
  • Prevalence
  • Prognosis
  • Randomized Controlled Trials as Topic
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Rupture, Spontaneous
  • Severity of Illness Index
  • United States / epidemiology
  • Vascular Calcification / diagnostic imaging*
  • Vascular Calcification / epidemiology