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Joseph Shemesh



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    MS10 - Lung Cancer Screening, Opportunistic Evaluation of Findings (ID 73)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      MS10.02 - Coronary Artery Diseases (Now Available) (ID 3493)

      15:45 - 17:15  |  Presenting Author(s): Joseph Shemesh

      • Abstract
      • Presentation
      • Slides

      Abstract

      Coronary artery calcification (CAC) on low dose chest CT for lung screening

      J. Shemesh MD

      Professor emeritus of cardiology

      Sheba Medical Center

      Introduction:

      CT-based Coronary artery calcification (CAC) Agatston score on Lung cancer screening has an unequivocal prognostic contribution to future cardiovascular (CV) events and mortality.

      Aim: To provide the radiologists with helpful information regarding on how to diagnose, quantify and routinely report on CAC while reading low dose chest CT (LDCT) performed for lung cancer screening.

      Current understandings: CAC can be easily detected and its extent can be quantify or semi-quantify while reading the chest CT without extra radiation, efforts or cost. Most of the target subjects for lung screening are at the same time at high risk to develop cardiovascular (CV) events and mortality (1) . Reporting on CAC enhances the lung screening benefit by providing the clinicians with an additive powerful risk stratification tool that can improve the management of primary prevention of CV events particularly the need for statin . Recently the Society of Cardiovascular Computed Tomography (SCCT) and the Society of Thoracic Radiology (STR) have jointly published guidelines for coronary artery calcium scoring derived from non contrast noncardiac chest CT scans (2). The experts of this guideline , recommend reporting on CAC as Class I indication.

      It has been shown that the absence , presence and severity of CAC identify those who are most likely to benefit from statin therapy for primary prevention (3) Comparing those with and without statin exposure, statin therapy was associated with reduced risk of MACE in patients with CAC but not in patients without CAC . They further found that the effect of statin use on MACE was significantly related to the severity of CAC , with the number needed to treat to prevent 1 initial MACE outcome over 10 years ranging from 100 (CAC 1 to 100) to 12 (CAC >100).

      The most recent guidelines recognize the CAC score as disease score that can individualize the CVD risk and recommended its use to refine the risk estimation in order to better allocate asymptomatic subjects to statin treatment,intensification or avoidance, for primary prevention of CVD (4). The Multi-Ethnic Study of Atherosclerosis (MESA) score is a new score that incorporates the Agatston CAC score in addition to traditional risk factors to estimate the 10 years cardiac risk (5)

      In summary: CAC is the most prevalent incidental finding on LDCT. It can be easily detected measured and reported on lung screening CT without extra radiation, efforts or cost. CAC score helps to avoid or recommend life time statin or aspirin treatment .

      10 Take home messages

      Most of the target subjects for lung screening are at the same time at high risk to develop cardiovascular (CV) events and mortality.

      CAC is the most prevalent incidental finding on LDCT

      CAC is the best biologic prognostic marker for the prediction of CV events and mortality.

      The measure of CAC is now accepted as common practice for primary prevention of CV events.

      CAC can and should be measured and reported on chest CT done for lung cancer screening.

      CAC is associated strongly and in a graded fashion with 10-year risk of incident ASCVD as it is for CHD, independent of standard risk factors, and similarly by age, gender, and ethnicity. While those with zero CAC are almost exclusively below 5% 10 years risk (statin is not indicated), those with CAC ≥ 100 were consistently above 7.5% (statin is indicated).

      In a large-scale cohort without baseline ASCVD, the presence and severity of CAC identified patients most likely to benefit from statins for the primary prevention of CVDs:

      There was no benefit of statins in those with no CAC and low or intermediate baseline risk.

      Patients with a CAC >100 had a 64-71% reduction in MACE even with low (<5%) or intermediate risk (5-20%).

      Reporting on CAC enhances the lung screening benefit by providing the clinicians with an additive powerful risk stratification tool that can improve the management of primary prevention of CV events particularly for the initiation / withhold / intensification / avoidance of statin treatment.

      CAC can be estimated as none, mild, moderate or severe but it is recommended to perform the Agatston CAC score.

      CAC score can recategorize up to half of those who underwent chest CT into a higher or lower CV risk category.

      REFERENCES

      Hecht HS, Henschke CI, Yankelevitz D et al. Combined detection of coronary artery disease and lung cancer. Eur Heart J. 2014;35:2792–6

      Harvey S. Hecht, Paul Cronin Michael J. Blaha et al 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. Journal of Cardiovascular Computed Tomography 2017, Volume 11, Issue 1, Pages 74–84

      Mitchell JD, Fergestrm N, Gage BF, et al. Impact of statins cardiovascular outcomes following coronary artery calcium scoring. J Am Coll Cardiol 2018:72:3233-3244

      2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Grundy SM et al. J Am Coll Cardiol. (2018)

      McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study). J Am Coll Cardiol. 2015;66:1643–53

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