CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Joanne D. Schuijf, PhD,
Maureen M. Henneman, MD and
Jeroen J. Bax, PhD, MD*
* Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden, Zuid-Holland 2333 ZA, the Netherlands (Email: JJBaxACC{at}lumc.nl).
We thank Drs. Akram and Voros for their interest in our article on plaque characteristics on multislice computed tomography coronary angiography (MSCTA) versus coronary calcium score in patients presenting with suspected acute coronary syndrome (ACS) (1). In 13 (33%) patients, no coronary calcium was observed, whereas in 11 (85%), atherosclerotic plaques were detected on MSCTA. Moreover, in 5 (13%) patients, obstructive coronary artery disease (CAD) was identified despite the absence of any detectable calcium. Accordingly, we concluded that in patients presenting with ACS, noncalcified plaques are highly prevalent, and the absence of coronary calcium may not reliably exclude the presence of (significant) atherosclerosis.
Drs. Akram and Voros correctly point out that the relation between calcium and obstructive CAD may also be greatly influenced by age in addition to clinical presentation. Indeed, their observations are in line with our own experience. In daily practice, patients in whom significant stenosis is identified on MSCTA in the absence of any calcium tend to be younger, regardless of presentation.
In our current study, the average age of the 5 patients presenting with obstructive CAD and no coronary calcium was 45 ± 6 years. The range was 40 to 54 years, with 3 patients being younger than 45 years old. In contrast, patients in whom a calcium score of zero accurately ruled out obstructive CAD tended to be older. Their average age was 51 ± 6 years (ranging from 46 to 64 years).
Accordingly, our findings in patients presenting with suspected ACS appear to be in agreement with the observations of Drs. Akram and Voros. Whereas the absence of calcium may reliably rule out obstructive CAD in older patients, caution is indicated in younger patients. However, the precise age that can be used as a safe threshold for this purpose remains to be elucidated. Whereas Drs. Akram and Voros suggest 45 years, our own current findings indicate that a slightly higher criterion may be more prudent. Possibly other factors such as gender and symptomatic status should be taken into account as well.
Importantly, our study was not designed to derive information on the effect of age on the predictive value of calcium. The current observations, therefore, should be interpreted with caution. Nevertheless, we fully agree with the point made by Drs. Akram and Voros: age may indeed be an important factor in the relation between calcium scores and obstructive CAD that merits further investigation.
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References
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1. Henneman MM, Schuijf JD, Pundziute G, et al. Noninvasive evaluation with multislice computed tomography in suspected acute coronary syndrome: plaque morphology on multislice computed tomography versus coronary calcium score J Am Coll Cardiol 2008;52:216-222.[Abstract/Free Full Text]
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