JACC
HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK
QUICK SEARCH:   [advanced]


     

J Am Coll Cardiol, 2002; 39:408-412
© 2002 by the American College of Cardiology Foundation
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Budoff, M. J.
Right arrow Articles by Brundage, B. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Budoff, M. J.
Right arrow Articles by Brundage, B. H.

CLINICAL STUDY: CORONARY ARTERY DISEASE

Ethnic differences in coronary atherosclerosis

Matthew J. Budoff, MD*,*, Ted P. Yang, MD*, Robert M. Shavelle, PhD, MBA{dagger}, Daniel H. Lamont, MBA* and Bruce H. Brundage, MD{ddagger}

* Division of Cardiology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
{dagger} Life Expectancy Project, San Francisco, California, USA
{ddagger} Bend Medical Clinic, Bend, Oregon, USA

Manuscript received May 10, 2001; revised manuscript received October 15, 2001, accepted November 1, 2001.

* Reprint requests and correspondence: Dr. Matthew Budoff, Division of Cardiology, Harbor-UCLA Research and Education Institute, 1124 West Carson Street, Bldg. RB-2, Torrance, California 90502-2064, USA.
mbudoff{at}rei.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
OBJECTIVES: The study was done to evaluate whether ethnic differences exist in the prevalence of coronary artery calcification (CAC), and to determine whether differences in calcification correlate with the degree of coronary obstruction.

BACKGROUND: Electron beam tomography (EBT) can be used to quantitate the amount of CAC and assist in prognostication of future cardiac events. It is unclear whether ethnic differences in coronary mortality are related to differences in the prevalence of coronary obstruction and CAC.

METHODS: A total of 782 symptomatic subjects underwent both EBT and angiography. A 50% luminal narrowing defined an angiographic obstruction.

RESULTS: We observed substantial ethnic differences in prevalence of both CAC and angiographic stenosis. In whites (n = 453), prevalence of CAC (score >0) was 84%, and significant obstruction on angiogram was 71%. Compared with whites, blacks (n = 108) had a significantly lower prevalence of CAC (62%, p < 0.001) and angiographic disease (49%, p < 0.01). Hispanics (n = 177) also had a lower prevalence of CAC (71%, p < 0.001) and angiographic obstruction (58%, p < 0.01). Asians (n = 44) were not significantly different in regard to CAC (73%, p = 0.06) or angiographic stenosis (64%, p = 0.30). These ethnic differences remained after simultaneously controlling (by use of multiple logistic regression) for age, gender and cardiac risk factors.

CONCLUSIONS: As compared with whites, blacks and Hispanics had significantly lower prevalence of CAC and obstructive coronary disease. Ethnic differences in risk-factor profiles do not explain these differences. This study demonstrated that whites have a higher atherosclerotic burden than blacks and Hispanics, independent of risk-factor differences among symptomatic patients referred for angiography.

Abbreviations and Acronyms
  ECG
  CAC
  coronary artery calcification
  CAD
  coronary artery disease
  CCS
  coronary calcium score
  CI
  confidence interval
  EBT
  electron beam tomography
  ECG
  electrocardiographic
  Hu
  Hounsfield units
  MI
  myocardial infarction
  OR
  odds ratio

Coronary artery disease (CAD) is a major cause of mortality and morbidity in all ethnic and racial subsets (1,2). Often, the first indication of coronary atherosclerosis is acute myocardial infarction (MI) or sudden coronary heart death. Identification of those subjects with a very high probability of suffering coronary death and/or MI, therefore, is of great interest, particularly because coronary disease is an increasingly treatable pathologic entity in both its early and later stages. Both electron beam tomography (EBT) and measurement of coronary artery calcification (CAC) have been found useful as sensitive markers of atherosclerosis (3,4) and are currently used as methods for early detection of coronary disease.

However, prevalence of coronary disease varies among different ethnicities (5–7). This variability may be due in part to ethnic differences in the prevalence of coronary atherosclerosis and its risk factors (8). We studied 782 symptomatic patients using angiography and EBT to examine whether a difference in the prevalence of CAC exists among different ethnicities.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Patient population.   The study sample consisted of 782 patients undergoing coronary angiography for clinical indications, the vast majority of whom were suspected to have CAD (angina). Patients underwent EBT scanning within three months of angiography to evaluate for CACs as part of the research protocol to compare atherosclerosis in patients undergoing angiography. Patients were excluded from the study when EBT scans were performed more than three months after the angiogram (n = 4). All subjects signed a written consent form approved by the Institutional Review Board at Harbor-UCLA Medical Center prior to entry into the study or performing any part of the study protocol.

Angiographic protocol.   The coronary angiograms were analyzed by an experienced reader without knowledge of the EBT results. Each coronary vessel (left main, left anterior descending, circumflex and right coronary artery) was assessed and the visual estimation of the percent luminal reduction for each lesion was reported. Multiple projections were acquired to discern the maximal coronary artery luminal narrowing. Investigators recorded the maximum stenosis in each vessel in one of five categories: none, luminal irregularities (<50% stenosis), 50% to 75%, 75% to 99% or 100% occlusion. A 50% luminal narrowing in any coronary vessel defined a significant angiographic obstruction. A medical resident reviewed medical records of the visit before angiography for the presence or absence of the following risk factors: age, gender, hypertension, high cholesterol, diabetes, tobacco use or family history of premature CAD.

EBT protocol..   A total of 782 patients at Harbor-UCLA Medical Center underwent EBT using an Imatron C-150XL Ultrafast computed tomographic scanner (Imatron Inc., South San Francisco, California). Coronary artery visualization was obtained without contrast medium injection, and 30 consecutive images were obtained at 3-mm intervals beginning 1 cm below the carina and progressing caudally to include the proximal and midcoronary arteries. Exposure time was 100 ms/image slice, and total skin irradiation dose was <600 mrad/scan. Electrocardiographic (ECG) triggering was used and adjusted such that image acquisition occurred at the same point in the cardiac cycle during diastole, at 80% of the RR interval. Proximal coronary artery visualization was obtained without contrast medium injection, and 30 consecutive images were obtained at 3-mm intervals beginning 1 cm below the carina and progressing caudally to include the proximal coronary arteries.

A computed tomographic threshold of 2 pixels and 130 Hounsfield units (Hu) was utilized for identification of a calcific lesion. Each focus exceeding the minimum criteria was scored using the algorithm developed by Agatston et al. (9) and calculated by multiplying the lesion area by a density factor derived from the maximal Hu within this area. The density factor was assigned in the following manner: 1 for lesions whose maximal densities were 130 to 199 Hu, 2 for lesions 200 to 299 Hu, 3 for lesions 300 to 399 Hu and 4 for lesions >400 Hu. A total coronary calcium score (CCS) was determined by summing individual lesion scores from each of four anatomic sites (left main, left anterior descending, circumflex and right coronary arteries). The EBT scoring was performed by a cardiologist blinded to the clinical, ECG and angiographic information.

Statistical methods.   Categorical data are presented as number (percent), and continuous data as mean value ± SD. Either the Fisher exact test or the chi-square test analysis was used to compare categorical variables. All tests of significance were two-tailed, and significance was defined at the ≤0.05 level. Sensitivity, specificity and predictive values were calculated using standard formulas. Accuracy was defined as the number of true positives plus true negatives divided by total number. Comparisons of continuous variables between two groups were performed using two-tailed t tests. Data were analyzed using SAS for PC (Version 6.12, SAS Institute, Cary, North Carolina). Multiple linear regression and multiple logistic regression analyses were performed. Coronary calcium scores were transformed by taking the natural log of (1 + CCS) for inclusion in a secondary analysis.

Hypertension, tobacco use, diabetes, age, gender, family history of premature heart disease, hypercholesterolemia and the utilization of statin therapy were evaluated as independent variables using one-way analysis of variance. Multivariate logistic regression analysis was used to develop statistical models for measuring the presence of both CAC and obstructive CAD, based upon ethnicity. These analyses were performed to adjust for the possible interaction of any individual risk factor.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
A total of 782 patients were evaluated by EBT and angiography. There were 453 white patients, 108 black patients, 177 Hispanics and 44 Asian-Americans. Of the patients enrolled, 69% were men, 505 (65%) had obstructive coronary disease and 606 (78%) had detectable CAC. Table 1 shows the average age and the distribution of coronary risk factors by race. No significant differences existed in the prevalence of any risk factor for any ethnic group.


View this table:
[in this window]
[in a new window]
  		Table 1 Risk Factors by Ethnicity

 
Substantial ethnic differences in prevalence of both CAC and angiographic stenosis were noted (Table 2). Prevalence of atherosclerosis in whites (n = 453) by CAC was 84% and by obstruction on angiogram was 71%. As compared with whites, black patients (n = 108) had a significantly lower prevalence of CAC (62%, p < 0.001) and angiographic disease (49%, p < 0.01). Hispanics (n = 177) also had a lower prevalence of CAC (71%, p < 0.001) and angiographic obstruction (58%, p < 0.01). Asians had less CAC and angiographic stenosis than whites, but these differences were not statistically significant (73%, p = 0.06 and 64%, p = 0.30, respectively). Controlling for age, gender and risk factors, white patients had a higher risk of angiographic disease (odds ratio [OR], 1.65) than all other races separately or combined (p = 0.004). Compared with whites, blacks had 0.48 times the risk (p = 0.0002), Hispanics 0.68 (p = 0.07) and Asians 0.66 (p = 0.25) (Table 3). The same conclusions are reached if the EBT score is included in the model, if risk factors are excluded or if the model contains only race variables.


View this table:
[in this window]
[in a new window]
  		Table 2 Racial Differences in Prevalence of CAC and Obstruction on Angiography

 

View this table:
[in this window]
[in a new window]
  		Table 3 Coronary Artery Disease Model With Risk Factors, Including 95% CI (as Compared with Whites)

 
Controlling for age, gender and risk factors, whites had a higher average EBT score (using the transformed variable ln[score + 1]) than the other races (p = 0.0001). Blacks, Hispanics and Asians had average scores not significantly different from one another (p > 0.10), but significantly different from whites (p = 0.002, 0.0005 and 0.04, respectively). Ethnic differences were also found in CAC by using multivariate logistic regression, with CAC as the dependent variable, and age, gender and other cardiac risk factors as independent variables (Table 4).


View this table:
[in this window]
[in a new window]
  		Table 4 Analysis of Maximum Likelihood Estimates to Test Coronary Artery Disease Likelihood

 
The sensitivity of EBT-determined CAC, compared with angiography in detecting obstructive coronary disease, ranged from 89% to 98% among the different racial groups (Table 5). Specificity of EBT CAC ranged from 50% to 69%. No significant differences existed in sensitivity or specificity of EBT for detecting obstructive angiographic disease among any of the ethnic groups (Table 5).


View this table:
[in this window]
[in a new window]
  		Table 5 Comparison of Electron Beam Tomography to Coronary Angiography in Detecting Coronary Obstruction

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
In symptomatic subjects, we found significant ethnic differences in the prevalence of CAC. Whites and Asian-Americans had a significantly higher prevalence of CAC when compared with blacks and Hispanics. Because this difference in prevalence may depend on differences in risk factors between different ethnic groups, we used logistic regression to control for differences in cardiac risk factors. These differences persisted even after controlling for standard cardiac risk factors. Whites not only had a higher prevalence of CAC but the mean CCSs were significantly higher than the other races. The higher prevalence and degree of calcification correlated with a higher prevalence of obstruction on angiography.

Racial differences in coronary calcium.   Racial differences in CAC have been found in autopsy studies. On 1,242 necropsies performed in Louisiana in 1963, whites were found to have a higher prevalence of CAC when compared with blacks (10,11). Other studies have demonstrated more severe angiographic disease in whites. In a postmortem study of 169 hearts, a distinctly higher proportion of hearts having three or four vessels with 75% stenotic lesions was observed in white men (70%) compared with white women (34%). In contrast, 58% of the hearts of both black men and black women had three or four vessels with ≥75% stenoses (12). Radiographically, whites have also been found to have a higher prevalence of CAC as detected by fluoroscopy (13). These studies demonstrated black race to be a significant, independent and inverse predictor of the presence of coronary calcium (OR, 0.47; 95% confidence interval [CI], 0.29, 0.75).

We similarly documented a lower prevalence of coronary calcium among black patients (p < 0.001 as compared with whites). However, our study is the first to document this difference in both coronary calcium and angiographic burden. We showed that the lower prevalence of coronary calcium is probably entirely due to a lower prevalence of obstructive disease. After multivariate analysis, blacks had 0.48 times the risk of obstructive disease as compared with whites (p = 0.003).

Many epidemiologic reports also suggest that the risks of cardiovascular disease differ between blacks and whites (14). However, results are controversial and conflicting. Some studies (1) show that blacks are protected against coronary heart disease but have a much greater risk of stroke, whereas others (such as the Atherosclerosis Risk in Communities Study) show that because risk factors such as diabetes and hypertension seem to be more prevalent among blacks than among whites (8), blacks were not at higher risk for coronary disease independent of these risk factors (6).

The Charleston Heart Study, begun in 1960, is the largest epidemiologic study used to identify differences in cardiovascular disease in black and white subjects. In 30 years of follow-up, this study showed no significant racial differences in the rate ratios for death from coronary disease (7). However, data from studies in Charleston, South Carolina (7), and Evans County, Georgia, indicated that black men experience lower coronary death rates than white men (15). Furthermore, data from the First National Health and Nutritional Examination Survey (16), and pooled follow-up data from both the first and second survey (17), showed that total incidence of coronary disease and coronary death were lower in black men as compared with white men. Furthermore, the Multiple Risk Factor Intervention Trial also demonstrated adjusted relative risk of coronary heart disease death for blacks compared with whites to be 0.71 (95% CI, 0.53 to 0.95) (18). Thus, increased CAC in whites may translate into increased cardiovascular mortality. Contrary to this observation of increased coronary heart disease incidence and mortality in whites, sudden death due to arrhythmia has been shown to be a more important factor in blacks than in whites (19). Recent large studies demonstrated excess risk of cardiac arrest and sudden cardiac death in blacks compared with whites (19–21).

One other study (22) of coronary calcium and ethnicity has been reported, demonstrating a lower prevalence of coronary calcium in blacks, yet a similar or higher coronary event rate. The investigators postulated that differences in the pathobiology of atherosclerosis and calcium metabolism between blacks and whites were responsible for this finding. However, there was no angiography performed or other measure of disease in that trial (22), and the numbers of black subjects were excessively small.

Our study, by use of angiography, suggests that the lower calcium prevalence is due to the lower prevalence of coronary atherosclerosis in blacks. We have demonstrated that white patients were more likely to have significant CAD than black patients. The finding in our study is similar to other studies of angiographic disease prevalence rates between the races (23), and it supports the hypothesis that the lower CCSs parallel the lower angiographic prevalence of disease in blacks. Increased myocardial mass, left ventricular hypertrophy and more severe hypertension without atherosclerosis most likely explains the higher black mortality in a study performed by Doherty et al. (22). This high prevalence of left ventricular hypertrophy and severe hypertension most likely explains why the findings of that study diverges significantly from the published literature in regards to cardiac event rates and calcium scores (3,24–27). Larger prospective studies of the natural history and progression of subclinical atherosclerosis in different ethnic groups (such as the Multi-Ethnic Study of Atherosclerosis) will provide more definitive answers to some of these questions.

Coronary events and race.   Census results (28) indicate that Hispanics have lower mortality rates from coronary disease when compared with whites, and Asian-Americans have been found to have similar cardiac mortality rates as whites (29). These findings correlated well with our findings of less angiographic disease and CAC in Hispanics, and similar angiographic disease in Asian-Americans, when compared with whites.

The sensitivity of EBT in detecting significant angiographic stenosis was 89% to 98% and did not differ among the different racial groups. Specificity of EBT for obstructive disease ranged from 50% to 69% (Table 5). These values are similar to previous studies on the sensitivity and specificity of EBT in detecting significant angiographic stenosis (30). Detection of CAC in symptomatic subjects is a sensitive marker for atherosclerotic coronary disease (31). Our study showed that whites and Asian-Americans have a significantly higher prevalence of CAC and angiographic disease than blacks or Hispanics.

Study limitations.   Our study, like other studies of symptomatic persons who had their CAD status verified using coronary angiography, is subject to verification bias. This verification bias is a consequence of the preferential referral of positive test responders to angiography and of negative test responders away from angiography, resulting in an overestimation of sensitivity and an underestimation of specificity (32). Also, this was a study of symptomatic individuals; thus, any extrapolation to the asymptomatic population cannot be made. We purposely performed a single-center study to minimize selection bias as much as possible. Our facility has a single group of cardiologists referring for angiography; thus, our study was not biased by socioeconomic status differences as our hospital is a county facility that generally serves a low socioeconomic class. Other study limitations could include: possible bias due to exclusion of cases; missing data or measurement error; possible confounding by variables not controlled (as this was an observational study); possible chance findings due to multiple comparisons and wide confidence intervals within some strata; and limitations of generalizability to asymptomatic cohorts.

Conclusions.   In a symptomatic population, whites and Asian-Americans have a higher burden of atherosclerosis, both angiographically and by EBT, when compared with blacks and Hispanics. The sensitivity and specificity of EBT in detecting significant angiographic obstruction did not differ among different ethnic groups despite a different prevalence in CAC. The EBT-detected CAC correlated well with extent and prevalence of angiographic CAD across all ethnicities, demonstrating a considerable similarity in calcifying stenotic lesions.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Keil JE, Loadholt CB, Weinrich MC, et al. Incidence of coronary heart disease in blacks in Charleston, South Carolina. Am Heart J. 1984;108:779–786[CrossRef][Medline]
  2. American Heart Association. 1993 Heart and Stroke Facts Statistics. Dallas, TX: American Heart Association; 1993. p. 8
  3. Arad Y, Spadaro LA, Goodman K, et al. Predictive value of electron beam computed tomography of the coronary arteries. Circulation. 1996;93:1951–1953[Abstract/Free Full Text]
  4. Budoff M, Georgiou D, Brody A, et al. Ultrafast computed tomography as a diagnostic modality in detection of coronary artery disease: a multi-center study. Circulation. 1996;93:898–904[Abstract/Free Full Text]
  5. Lee MH, Borhani NO, Kuller LH. Validation of reported myocardial infarction mortality in blacks and whites. A report from Community Cardiovascular Surveillance Program. Ann Epidemiol. 1990;1:1–12[Medline]
  6. Kuller LH. Cardiovascular disease and stroke in African-Americans and other racial minorities in the United States: a statement for health professionals: introduction. Circulation. 1991;83:1463–1465[Medline]
  7. Keil JE, Sutherland SE, Knapp RG, et al. Mortality rates and risk factors for coronary disease in blacks as compared with white men and women. N Engl J Med. 1993;329:73–78[Abstract/Free Full Text]
  8. Hutchinson RG, Romm F, Watson RL, et al. Racial differences in risk factors for atherosclerosis. Angiology. 1997;48:279–290[Medline]
  9. Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–832[Abstract]
  10. Strong JP, McGill HC. The natural history of aortic atherosclerosis: relationship to race, sex, and coronary lesions in New Orleans. Exp Mol Pathol. 1963;(Suppl I):15–27
  11. Strong JP, Oalmann MC, Newman WP, et al. Coronary heart disease in young black and white males in New Orleans: community pathology study. Am Heart J. 1984;108:747–759[CrossRef][Medline]
  12. Perper JA, Kuller LH, Cooper M. Arteriosclerosis of coronary arteries in sudden, unexpected deaths. Circulation. 1975;52(Suppl 3):27
  13. Tang W, Detrano RC, Brezden OS, et al. Racial differences in coronary calcium prevalence among high-risk adults. Am J Cardiol. 1995;75:1088–1091[CrossRef][Medline]
  14. Gillum RF. Coronary heart disease in black populations: mortality and morbidity. Am Heart J. 1992;4:839–851
  15. Keil JE, Sutherland SE, Hames CG, et al. Coronary disease mortality and risk factors in black and white men: results from the combined Charleston, SC, and Evans County, Georgia, Heart Studies. Arch Intern Med. 1995;155:1521–1527[Abstract]
  16. Gillum RF, Mussolino ME, Madans JH. Coronary heart disease incidence and survival in African-American women and men. The NHANES I Epidemiologic Follow-up Study. Ann Intern Med. 1997;127:111–118[Abstract/Free Full Text]
  17. Liao Y, McGee DL, Cooper RS. Prediction of coronary heart disease mortality in blacks and whites: pooled data from two national cohorts. Am J Cardiol. 1999;84:31–36[CrossRef][Medline]
  18. Vaccaro O, Stamler J, Neaton JD. Sixteen-year coronary mortality in black and white men with diabetes screened for the Multiple Risk Factor Intervention Trial (MRFIT). Int J Epidemiol. 1998;27:636–641[Abstract/Free Full Text]
  19. Liao Y, Cooper RS, McGee DL, et al. The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults. JAMA. 1995;54:1592–1597
  20. Thomas J, Thomas DJ, Pearson T, et al. Cardiovascular disease in African American and white physicians: the Meharry cohort and Meharry-Hopkins cohort studies. J Health Care Poor Underserved. 1997;8:270–284[Medline]
  21. Becker LB, Han BH, Mayer PM, et al. Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med. 1993;329:600–606[Abstract/Free Full Text]
  22. Doherty TM, Tang W, Detrano RC. Racial differences in the significance of coronary calcium in asymptomatic black and white subjects with coronary risk factors. J Am Coll Cardiol. 1999;34:787–794[Abstract/Free Full Text]
  23. Peniston RL, Lu DY, Papdemetriou V, et al. Severity of coronary artery disease in black and white male veterans and likelihood of revascularization. Am Heart J. 2000;139:840–847[Medline]
  24. Raggi P, Callister TQ, Cooil B, et al. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography. Circulation. 2000;101:850–855[Abstract/Free Full Text]
  25. Wong ND, Hsu JC, Detrano RC, et al. Coronary artery calcium evaluation by electron beam computed tomography and its relation to new cardiovascular events. Am J Cardiol. 2000;86:495–498[CrossRef][Medline]
  26. Arad Y, Sparado LA, Goodman K, et al. Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol. 2000;36:1253–1260[Abstract/Free Full Text]
  27. Detrano R, Tzung H, Wang S, et al. Prognostic value of coronary calcification and angiographic stenoses in patients undergoing coronary angiography. J Am Coll Cardiol. 1996;27:285–290[Abstract]
  28. Mortality from coronary heart disease and cardiovascular disease among adult U.S. Hispanics: findings from the National Health Interview Survey. Atherosclerosis. 1997;30:1200–1204
  29. Marmot MG, Syme SL, Kagan A. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: prevalence of coronary and hypertensive heart disease and associated risk factors. Am J Epidemiol 102;6:514–25
  30. Wexler L, Brundage BH, Crouse J, et al. Coronary artery calcification: pathophysiology, epidemiology, imaging methods and clinical implications. A Scientific Statement from the American Heart Association. Circulation. 1996;94:1175–1192[Free Full Text]
  31. O’Rourke RA, Brundage BH, Froelicher VF, et al. American College of Cardiology/American Heart Association expert consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation. 2000;102:126–140[Free Full Text]
  32. Diamond GA. What price perfection? Calibration and discrimination of clinical prediction models. J Clin Epidemiol. 1992;45:85–89[CrossRef][Medline]



This article has been cited by other articles:


Home page
 ANGIOLOGYHome page
S.-s. Jiang, L. Lv, C. P. Juergens, S.-l. Chen, D.-j. Xu, and Z.-y. Huang
Racial Differences in Coronary Artery Lesions: A Comparison of Coronary Artery Lesions Between Mainland Chinese and Australian Patients
Angiology, August 1, 2008; 59(4): 442 - 447.
[Abstract] [PDF]

Home page
 CirculationHome page
L. J. Shaw, R. E. Shaw, C. N. B. Merz, R. G. Brindis, L. W. Klein, B. Nallamothu, P. S. Douglas, R. J. Krone, C. R. McKay, P. C. Block, et al.
Impact of Ethnicity and Gender Differences on Angiographic Coronary Artery Disease Prevalence and In-Hospital Mortality in the American College of Cardiology-National Cardiovascular Data Registry
Circulation, April 8, 2008; 117(14): 1787 - 1801.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
K. Nasir, L. J. Shaw, S. T. Liu, S. R. Weinstein, T. R. Mosler, P. R. Flores, F. R. Flores, P. Raggi, D. S. Berman, R. S. Blumenthal, et al.
Ethnic Differences in the Prognostic Value of Coronary Artery Calcification for All-Cause Mortality
J. Am. Coll. Cardiol., September 4, 2007; 50(10): 953 - 960.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
C. M. Loria, K. Liu, C. E. Lewis, S. B. Hulley, S. Sidney, P. J. Schreiner, O. D. Williams, D. E. Bild, and R. Detrano
Early Adult Risk Factor Levels and Subsequent Coronary Artery Calcification: The CARDIA Study
J. Am. Coll. Cardiol., May 22, 2007; 49(20): 2013 - 2020.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
P. Greenland, R. O. Bonow, B. H. Brundage, M. J. Budoff, M. J. Eisenberg, S. M. Grundy, M. S. Lauer, W. S. Post, P. Raggi, R. F. Redberg, et al.
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: A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) Developed in Collaboration With the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography
J. Am. Coll. Cardiol., January 23, 2007; 49(3): 378 - 402.
[Full Text] [PDF]

Home page
 J. Lipid Res.Home page
J. R. Crouse III
Thematic review series: Patient-Oriented Research. Imaging atherosclerosis: state of the art
J. Lipid Res., August 1, 2006; 47(8): 1677 - 1699.
[Abstract] [Full Text] [PDF]

Home page
 Psychosom. Med.Home page
T. T. Lewis, S. A. Everson-Rose, L. H. Powell, K. A. Matthews, C. Brown, K. Karavolos, K. Sutton-Tyrrell, E. Jacobs, and D. Wesley
Chronic Exposure to Everyday Discrimination and Coronary Artery Calcification in African-American Women: The SWAN Heart Study
Psychosom Med, May 1, 2006; 68(3): 362 - 368.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
D. Zindrou, K. M. Taylor, and J. P. Bagger
Coronary artery size and disease in UK South Asian and Caucasian men.
Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 492 - 495.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
C. Iribarren, I. Tolstykh, C. P. Somkin, L. M. Ackerson, T. T. Brown, R. Scheffler, L. Syme, and I. Kawachi
Sex and Racial/Ethnic Disparities in Outcomes After Acute Myocardial Infarction: A Cohort Study Among Members of a Large Integrated Health Care Delivery System in Northern California
Arch Intern Med, October 10, 2005; 165(18): 2105 - 2113.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
A. V. Diez Roux, R. Detrano, S. Jackson, D. R. Jacobs Jr, P. J. Schreiner, S. Shea, and M. Szklo
Acculturation and Socioeconomic Position as Predictors of Coronary Calcification in a Multiethnic Sample
Circulation, September 13, 2005; 112(11): 1557 - 1565.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
Y. Arad, K. J. Goodman, M. Roth, D. Newstein, and A. D. Guerci
Coronary Calcification, Coronary Disease Risk Factors, C-Reactive Protein, and Atherosclerotic Cardiovascular Disease Events: The St. Francis Heart Study
J. Am. Coll. Cardiol., July 5, 2005; 46(1): 158 - 165.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
L. J. Shaw, R. C. Hendel, M. Cerquiera, J. H. Mieres, N. Alazraki, E. Krawczynska, S. Borges-Neto, J. Maddahi, and C. N. Bairey Merz
Ethnic Differences in the Prognostic Value of Stress Technetium-99m Tetrofosmin Gated Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging
J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1494 - 1504.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
D. E. Bild, R. Detrano, D. Peterson, A. Guerci, K. Liu, E. Shahar, P. Ouyang, S. Jackson, and M. F. Saad
Ethnic Differences in Coronary Calcification: The Multi-Ethnic Study of Atherosclerosis (MESA)
Circulation, March 15, 2005; 111(10): 1313 - 1320.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
T. Jain, R. Peshock, D. K. McGuire, D. Willett, Z. Yu, G. L. Vega, R. Guerra, H. H. Hobbs, S. M. Grundy, and the Dallas Heart Study Investigators
African Americans and Caucasians have a similar prevalence of coronary calcium in the Dallas Heart Study
J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1011 - 1017.
[Abstract] [Full Text] [PDF]

Home page
 Diabetes CareHome page
P. D. Reaven and J. Sacks
Reduced Coronary Artery and Abdominal Aortic Calcification in Hispanics With Type 2 Diabetes
Diabetes Care, May 1, 2004; 27(5): 1115 - 1120.
[Abstract] [Full Text] [PDF]

Home page
 Arterioscler. Thromb. Vasc. Bio.Home page
M. P. Reilly, M. L. Wolfe, A. R. Localio, and D. J. Rader
C-Reactive Protein and Coronary Artery Calcification: The Study of Inherited Risk of Coronary Atherosclerosis (SIRCA)
Arterioscler. Thromb. Vasc. Biol., October 1, 2003; 23(10): 1851 - 1856.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
A. P. Burke, R. Virmani, Z. Galis, C. C. Haudenschild, and J. E. Muller
Task force #2--what is the pathologic basis for new atherosclerosis imaging techniques?
J. Am. Coll. Cardiol., June 4, 2003; 41(11): 1874 - 1886.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Budoff, M. J.
Right arrow Articles by Brundage, B. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Budoff, M. J.
Right arrow Articles by Brundage, B. H.

HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK