冠状动脉钙化研究进展

冠状动脉钙化越来越受到重视,发现钙化即意味着亚临床动脉粥样硬化的存在,而动脉硬化不一定都有钙化。通常钙化越严重,冠脉管腔狭窄程度也就越高。但有时二者却缺乏很好的相关性。现就冠脉钙化的发生机制,冠脉钙化及积分与冠心病及其严重程度的关系,冠脉钙化检测方法及积分,血管重构在严重的冠脉钙化却没有明显的管腔狭窄中的作用等方面做一综述。     

他汀类药物与冠状动脉钙化关系的研究进展

冠状动脉钙化在冠状动脉粥样硬化、糖尿病血管病变和慢性肾脏病等多种疾病中普遍存在,他汀类药物是冠状动脉粥样硬化性心脏病等血脂代谢紊乱患者的常用药物。既往研究显示,他汀类药物可能具有抑制冠状动脉钙化的作用,而新近研究则提出相反意见。鉴于目前他汀类药物与冠状动脉钙化关系存在一定争议,故本文就冠状动脉钙化发生机制,他汀类药物与冠状动脉钙化关系及两者关系矛盾性结论成因作一分析。     

冠状动脉钙化的研究进展

冠状动脉钙化是冠状动脉粥样硬化患者不良预后的危险因素。多种因素与冠状动脉钙化的发生和发展相关,包括性别、年龄、持续的炎症状态、高血压、高脂血症和糖尿病等,近年来人们越来越关注非传统高危因素,以期为冠状动脉钙化的一级预防开辟新的思路。不断发展的影像学技术也为冠状动脉钙化的早期发现和发生机制的研究提供了很好的帮助。文章将重点回顾冠状动脉钙化的高危因素、发生机制、检查手段、临床意义及其治疗的研究进展,旨在提高人们对冠状动脉钙化的进一步认识和重视水平。     

The effect of type 1 diabetes mellitus on the gender difference in coronary artery calcification

OBJECTIVES

To examine whether the gender difference in coronary artery calcification, a measure of atherosclerotic plaque burden, is lost in type 1 diabetic patients, and whether abnormalities in established coronary heart disease risk factors explain this.

BACKGROUND

Type 1 diabetes abolishes the gender difference in coronary heart disease mortality because it is associated with a greater elevation of coronary disease risk in women than men. The pathophysiological basis of this is not understood.

METHODS

Coronary artery calcification and coronary risk factors were compared in 199 type 1 diabetic patients and 201 nondiabetic participants of similar age (30 to 55 years) and gender (50% female) distribution. Only one subject had a history of coronary disease. Calcification was measured with electron beam computed tomography.

RESULTS

In nondiabetic participants there was a large gender difference in calcification prevalence (men 54%, women 21%, odds ratio 4.5, p < 0.001), half of which was explained by established risk factors (odds ratio after ADJUSTMENT = 2.2). Diabetes was associated with a greatly increased prevalence of calcification in women (47%), but not men (52%), so that the gender difference in calcification was lost (p = 0.002 for the greater effect of diabetes on calcification in women than men). On adjustment for risk factors, diabetes remained associated with a threefold higher odds ratio of calcification in women than men (p = 0.02).

CONCLUSIONS

In type 1 diabetes coronary artery calcification is greatly increased in women and the gender difference in calcification is lost. Little of this is explained by known coronary risk factors.     

冠状动脉钙化研究进展

冠状动脉钙化是动脉粥样硬化的一个重要的危险因素,多项研究揭示冠状动脉钙化和粥样硬化斑块负荷有着密切的关系,因此冠状动脉钙化程度的测量在预测未来心血管事件及死亡率中起着重要的作用。现将通过对冠状动脉钙化的危险因素、发病机制、冠状动脉钙化积分评测及方法、钙化与心血管疾病的关系、冠状动脉钙化与肾脏疾病的关系、冠状动脉钙化与全因死亡及钙化的治疗等方面做一综述。     

Coronary calcification score: the coronary-risk impact factor

CONTEXT: Identification of asymptomatic high-risk individuals is integral to current policies for preventing coronary heart disease, but existing methods of estimating risk lack sensitivity. To overcome this limitation increasing use is being made of non-invasive methods to detect subclinical coronary artery disease--eg, computed tomography (CT) to scan for coronary artery calcification. The location and extent of calcification correlate closely with pathological and angiographic abnormalities, but whether such calcification predicts clinical events, especially in younger individuals, is equivocal. Most data on coronary calcification have been obtained with electron-beam CT, but recently multislice CT, which is more versatile, less expensive, and available in most large hospitals, has been increasingly used. STARTING POINT: Leslee Shaw and colleagues (Radiology 2003; 228: 826-33) showed that the coronary calcification score predicted total mortality within subsets of patients classified at low, intermediate, or high risk according to Framingham criteria. In a cohort of over 10000 individuals, 5-year risk-adjusted survival was 95% when the score was over 1000 compared with 99% for scores of 10 or less. These results agree with other recent studies showing strong correlations between coronary calcification and coronary heart disease events. WHERE NEXT? The increasing use of multislice CT scanners should generate more data for comparison with those obtained from electron-beam CT. Radiation dose, which is higher with multislice than with electron-beam procedures, needs to be reduced, and calcification in scans needs to be quantified more accurately than with existing computer-based analyses. Further studies are needed to establish the predictive power of the coronary calcification score for clinical events and the effects of therapeutic intervention on both these outcomes. It would also be worth investigating the relation between coronary calcification and risk factors not quantified in Framingham-based estimates, including familial and racial predisposition to premature coronary heart disease.     

A comparative study on coronary and aortic calcification by x-ray computed tomography

Coronary and aortic calcification were determined by x-ray computed tomography (CT) in 166 patients with angina pectoris, old myocardial infarction, valvular heart disease, hypertrophic cardiomyopathy, and congenital heart disease together with 79 age-matched control subjects. The incidence of coronary calcification was significantly higher (p<0.01) in ischemic heart disease (64 of 82 cases, 78.0%) and low for the other groups (17 of 163 cases, 10.4%). In all groups, coronary calcification occurred more often in the left anterior descending artery (LAD) than in the right coronary artery (RCA) and the left circumflex artery (LCX). The incidence of aortic calcification was also significantly higher (p<0.01) in ischemic heart disease (68 of 82 cases, 82.9%). Calcification occurred more frequently in the aorta than in the coronary arteries. In contrast to coronary calcification, aortic calcification was detected in 31 of 79 cases (39.2%) in the control group. In elderly subjects, the incidence of coronary and aortic calcification increased. Aortic calcification was observed in all patients over 70 years of age. In conclusion, aortic calcification is commonly observed by x-ray CT in patients over middle age. Coronary calcification is more helpful than aortic calcification for identifying ischemic heart disease.     

Involvement of Lipoprotein(a) in calcification of coronary arteries and thoracic aorta as detected by X-ray computed tomography

The authors compared the severity of coronary calcification and thoracic aortic calcification as detected by x-ray computed tomography (X-ray CT) with Lipoprotein(a) [Lp(a)], and investigated whether Lp(a) is more important than total cholesterol (TC) or HDL-cholesterol (HDLC) as a risk factor for arteriosclerosis. Subjects were 64 patients (47 males, mean age 57.1±8.4 years) comprising 43 cases of ischemic heart disease, 9 cases of chest pain syndrome, 7 of valvular heart disease, and 5 of dilated cardiomyopathy. Fasted blood samples were collected early in the morning and values before medication were used. Lp(a) was measured by ELISA. Evaluation of coronary calcification by X-ray CT was performed in accordance with the procedure described in the authors' previous reports. Coronary calcification was assessed in all slices (slice thickness: 1 cm; scoring system: no coronary calcification, 0 points; coronary calcification less than 1 cm in length, 1 point; 1–2 cm, 2 points; over 2 cm, 3 points). The total score was used as coronary calcification score. For the aortic calcification score, the total number of aorta (slice thickness: 1 cm) with calcification from the superior margin of the aortic arch to the inferior cardiac margin was used. Mean scores of coronary and aortic calcification were 6.1±7.9 and 4.5±5.2 points, and Lp(a), TC, and HDLC, 23.7±23.3, 213±37, and 49.9±15.1 mg/dl, respectively. No correlation was seen between the scores of both coronary calcification and aortic calcification and any of the three lipid parameters, but for cases without coronary calcification, Lp(a) (10.6±8.5 mg/dl) was significantly lower (p<0.1) than that for cases with coronary calcification (1 vessel, 29.4±24.4; 2 vessels, 26.5±16.7; 3 vessels, 32.6±31.0 mg/dl).No significant difference was observed, however, for TC and HDLC between patients with and without coronary calcification/aortic calcification. It is suggested that Lp(a) may be a risk factor for coronary calcification. There is no correlation, however, between Lp(a) and the severity of coronary calcification. Aortic calcification is not related to the serum Lp(a) level.Presented at the 35th Annual Congress of the International College of Angiology in Copenhagen, Denmark, July 1993     

冠状动脉钙化患者的血浆BMP-2水平及其临床意义

目的:研究冠状动脉钙化患者血浆骨形态发生蛋白-2(BMP-2)的水平及临床意义。方法:根据冠状动脉造影(CAG)结果将171例患者分3组:正常对照组、冠状动脉狭窄无钙化组,冠状动脉狭窄伴钙化组,比较3组患者BMP-2水平的差异。结果:CAG发现有冠状动脉钙化的患者组BMP-2水平高于正常组及冠状动脉狭窄而无钙化组。结论:BMP-2水平升高可能是动脉钙化标志之一。     

Clinical significance of coronary calcifications in electron beam tomography

Electron-beam computed tomography (EBCT) permits high-resolution imaging of the beating heart and the coronary arteries and visualization of coronary calcification. For clinical purposes, coronary calcification represents the formation of atherosclerotic plaques. EBCT provides for accurate quantification of calcification, which is itself related to the extent of coronary atherosclerosis in a linear fashion. Accordingly, EBCT has been shown to measure the extent of coronary atherosclerosis. Importantly, an EBCT scan negative for calcification has a high negative predictive value indicating the absence of obstructive coronary artery disease and an excellent short- to midterm prognosis. It appears that, in general, the amounts of calcification detected by EBCT can be used for prospective risk stratification in symptomatic and asymptomatic adults. However, data derived from unbiased populations are not available at present, and the role of calcification in predicting acute coronary syndromes remains debated. Longitudinal EBCT examinations have emerged as another area of substantial clinical interest. The clinical value of this method remains to be defined, in particular, in comparison with competing, established modalities.     

The association between coronary calcification assessed by electron beam computed tomography and measures of extracoronary atherosclerosis: the Rotterdam Coronary Calcification Study

OBJECTIVES: The present study was designed to examine the associations of coronary calcification assessed by electron beam computed tomography (CT) with measures of extracoronary atherosclerosis. BACKGROUND: Although measures of extracoronary atherosclerosis have been used to predict coronary events, it is not yet known to what extent those measures reflect coronary atherosclerosis. METHODS: The Rotterdam Coronary Calcification Study is a population-based study in subjects age 55 years and over. Participants of the study underwent an electron beam CT scan. Coronary calcification was quantified according to the Agatston calcium score. Measures of extracoronary atherosclerosis included common carotid intima media thickness (IMT), carotid plaques, ankle-arm index (AAI) and aortic calcification. We used the first 2,013 participants for the present analyses. Age-adjusted geometric mean calcium scores were computed for categories of extracoronary measures using analyses of variance. RESULTS: Graded associations with coronary calcification were found for the carotid and aortic measures. Associations were strongest for carotid plaques and aortic calcification; coronary calcification increased from the lowest category (no plaques) to the highest category 9-fold and 11-fold in men and 10-fold and 20-fold in women, respectively. A nonlinear association was found for AAI with an increase in coronary calcification only at lower levels of AAI. CONCLUSIONS: In this population-based study, graded associations were found between coronary calcification and common carotid IMT, carotid plaques and aortic calcification. A nonlinear association was found between coronary calcification and the AAI.     

Calcification in culprit lesions of coronary artery disease

Coronary calcification, a type of coronary atherosclerosis, has recently been closely examined in clinical cardiology because its presence may influence the selection of interventional therapy. In addition, plaque instability is one of the most important factors in the mechanism of acute coronary syndrome, and calcium deposit is frequently detected in advanced lesions. However, little is known about the clinical significance of coronary calcification. The incidence of calcium deposits was investigated in the culprit lesions (culprit coronary calcification) of patients with serious coronary artery disease to discover any cardioprotective effect. Initial coronary angiography was performed in 179 consecutive patients with acute myocardial infarction with Q wave on electrocardiography (AMI group; male 139, female 40, mean age 60.2 +/- 10 yr) and in 119 consecutive patients with stable effort angina pectoris (SAP group; male 78, female 41, mean age 63.8 +/- 8 yr) for which balloon plasty or bypass surgery was necessary from 1990 to 1997. Culprit coronary calcification was defined positive if the calcification deposit was present cinefluoroscopically within 5 mm from the culprit point. The culprit point was defined as the narrowest point after successful intracoronary thrombolytic therapy or the latest point to be dilated during a balloon inflation in direct or rescue percutaneous transluminal coronary angioplasty in the AMI group, and the narrowest point of the culprit lesion in the SAP group. There was no statistical difference in clinical background between the 2 groups other than male dominance in the AMI group and high incidence of family history of ischemic heart disease in the SAP group (p < 0.05). Culprit coronary calcification in patients over 50 years old was less frequently positive in the AMI group than the SAP group (26% vs 66%, p < 0.005, respectively). In younger patients under 50 years old, the incidence of culprit coronary calcification was low (14-15%) in both groups. Culprit coronary calcification was frequently positive in the right or the left anterior descending coronary artery in the SAP group (p < 0.005). There was no incidental sex difference of culprit coronary calcification. This comparison suggests that if a plaque contains cinefluoroscopically visible calcification, it may be regarded as less vulnerable or having a history of chronic process of atherosclerosis which results in protecting plaque rupture.     

富含Gla蛋白参与冠状动脉钙化机制的研究进展

冠状动脉钙化在冠状动脉粥样硬化性心脏病患者中较为常见,目前对其发生、发展及形成机制尚不清楚。富含Gla蛋白(GRP)是新近发现的维生素K依赖性蛋白,研究表明GRP通过与矿物质结合发挥抑制钙化晶体的形成及成熟、参与基质Gla蛋白-胎球蛋白A钙化的抑制途径、阻断钙化诱导剂的信号通路及抗炎作用,起到抑制血管钙化的作用。本文就GRP参与冠状动脉钙化机制的研究进展进行综述,为冠状动脉钙化的预防、治疗提供新的方向。     

The association between coronary artery calcification and mean platelet volume in the general population

Patients with coronary artery calcification have an increased risk of coronary vascular events and mortality. Coronary artery calcification can be quantified using the coronary calcium score (CCS) from multi-detected row computed tomography (MDCT), and the score is proportionally related to the severity of atherosclerotic disease. Mean platelet volume (MPV) is gaining interest as a new independent cardiovascular risk factor. Accordingly, the aim of our study was to evaluate the relationship between CCS and MPV in the general population. A total of 2116 individuals were enrolled from a health promotion center between July 2007 and June 2010. Among them, 259 subjects were included in the final analysis. MDCT was used to measure CCS and CCS?>?1 was defined as the presence of coronary calcification. The MPV value was significantly higher in the coronary artery calcification group than in the control group. Multivariate analyses showed that MPV was positively associated with coronary calcification (OR, 1.61; 95% CI 1.02–2.55). In summary, there was a significant association between coronary artery calcification and MPV in the general population. Therefore, the detection of elevated MPV should alert clinicians to the coexistence of multiple underlying CVD risk factors warranting early evaluation and treatment.     

The association between coronary artery calcification and mean platelet volume in the general population

Patients with coronary artery calcification have an increased risk of coronary vascular events and mortality. Coronary artery calcification can be quantified using the coronary calcium score (CCS) from multi-detected row computed tomography (MDCT), and the score is proportionally related to the severity of atherosclerotic disease. Mean platelet volume (MPV) is gaining interest as a new independent cardiovascular risk factor. Accordingly, the aim of our study was to evaluate the relationship between CCS and MPV in the general population. A total of 2116 individuals were enrolled from a health promotion center between July 2007 and June 2010. Among them, 259 subjects were included in the final analysis. MDCT was used to measure CCS and CCS?>?1 was defined as the presence of coronary calcification. The MPV value was significantly higher in the coronary artery calcification group than in the control group. Multivariate analyses showed that MPV was positively associated with coronary calcification (OR, 1.61; 95% CI 1.02-2.55). In summary, there was a significant association between coronary artery calcification and MPV in the general population. Therefore, the detection of elevated MPV should alert clinicians to the coexistence of multiple underlying CVD risk factors warranting early evaluation and treatment.     

Clinical importance of coronary calcification detected by CT

Coronary calcifications appear in advanced atheromatous lesions therefore fluoroscopy is useful for the detection of the atherosclerotic coronary artery disease (Aldrich et al., 1979). However, the detection of coronary calcification by fluoroscopy is difficult in the case of obesity or thick chest wall and also impaired by the background structures including bone and other intrathoracic calcifications. X-ray CT is more advantageous than fluoroscopy in the detection of coronary calcification. It can eliminate the interference from background structures and clearly demonstrates calcified sites of the coronary artery. Therefore, we investigated the clinical usefulness in the detection of coronary calcification with X-ray CT.     

Assessment of coronary calcification by computed tomography inclusive of 3DCT

Coronary artheroclerosis in diabetes patients can be divided into 2 phases, one is seen in the early phase of diabetes or insulin resistance syndrome as unstable plaque with lipid-rich core, thinner fibrous caps and small dose or a lack of calcification and the other in the late or advanced stage of diabetes is hard and stable plaque with much fibrous protein and calcification which extends from truncal to peripheral areas. In diabetic patients in the late stage, coronary accidents occur as the chronic multiple vessel diseases with a lot of calcification, while in the early stage of diabetes vasospastic angina and acute coronary syndrome with less calcification tends to occur. We can find out the coronary calcification by EBCT or 3DCT easily which is characteristic in patients of diabetes complicated with coronary artery disease and in the early stage the stenosis of left truncal artery or large vessels of LAD can be detectable by 3DCT.     

Possibilities of electron beam tomography in noninvasive diagnosis of coronary artery disease: A comparison between quantity of coronary calcification and angiographic findings

This study evaluated the diagnostic value of electron beam tomography (EBT) for detection of coronary artery disease and compared different quantitative parameters of coronary calcification to angiographic findings. Coronary calcification is a sensitive marker of coronary atherosclerosis and is of value in predicting coronary artery disease. One hundred twenty patients (mean age 55 years) underwent EBT and coronary angiography. Coronary calcification was quantified by calcified area, number, and CT density of calcified lesions and a calcium score defined by the product of calcified area, number, and CT density of calcified lesions. The quantity of calcification was related to the number of coronary vessels with significant stenosis and to the maximal degree of stenosis in angiography. The positive predictive value of EBT was 94%; negative predictive value was higher in older than in younger subjects (56% vs 94%). Quantity of calcification increased corresponding to the extend of coronary artery disease. Mean calcified area increased in significant one-vessel disease (9.3-fold), two-vessel disease (24-fold), and three-vessel disease (34.7-fold) compared with values in subjects without coronary artery disease. Calcified area in women with coronary artery disease was lower than in men, however, this difference decreases with age from 6.3-fold (age <50 years) to 1.8-fold (age >60 years). Detection of coronary calcification, helped in this study to distinguish, with high significance, between the presence or absence of coronary artery disease. The quantity of coronary calcium increased with the angiographic degree of coronary artery disease but due to the variation of calcification within a disease category the differentiation between disease category was not absolutely certain.Presented at the 37th Annual World Congress, International College of Angiology, Helsinki, Finland, July 1995     

伴或不伴血管钙化的新型冠状病毒肺炎危重症患者临床特征及转归的回顾性分析

目的分析伴或不伴血管钙化的新型冠状病毒肺炎(COVID-19)危重症患者临床特征及转归的差异。方法对2020年2月入住华中科技大学同济医学院附属同济医院重症监护室的COVID-19危重症患者进行回顾性分析。根据胸部CT表现,将患者分为血管钙化组和非血管钙化组,其中血管钙化组又分为主动脉钙化组、冠状动脉钙化组和同时钙化组(主动脉、冠状动脉均有钙化)。比较不同组别患者的临床特征及转归。结果与非血管钙化组相比,血管钙化组患者年龄偏大,合并高血压与冠心病比例更高,表现为更高的白细胞计数、中性粒细胞计数、C反应蛋白、球蛋白、乳酸脱氢酶、国际标准化比值、D-二聚体、肌酐、肌酸激酶同工酶、高敏肌钙蛋白、肌红蛋白、N末端B型脑钠肽原,较低的淋巴细胞计数、血小板计数、白蛋白、估算的肾小球滤过率,且死亡风险更高。与主动脉钙化组比较,冠状动脉钙化组和同时钙化组的转归更差。结论血管钙化特别是冠状动脉钙化可能是C OVID-19危重症患者预后不良的危险因素。     

冠状动脉CT造影评估冠状动脉钙化进展及临床意义

冠状动脉粥样硬化是冠心病的病理学基础,而冠状动脉钙化是粥样硬化病变的重要标志。检测和评估冠状动脉钙化不仅对预测心血管事件有重要意义,还有助于了解疾病进展,从而更好地指导临床诊治。冠状动脉CT造影(CCTA)是对冠状动脉钙化斑块进行精确量化评估的无创检查手段,其对于定量冠状动脉钙化以及预后评估具有重要的临床价值。本文对冠状动脉钙化CCTA检测方法及其临床应用等进行综述。