Medical Policy: 06.01.06
Original Effective Date: September 2000
Reviewed: July 2016
Revised: July 2016
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This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
Coronary artery calcium (CAC) scoring is a noninvasive test that has been reported to detect the presence of coronary artery disease (CAD) by measuring the location and extent of calcium in the coronary arteries. Tests to determine CAC scoring include:
ECBT and spiral CT or helical CT may be used as an alternative to conventional CT scanning due to their faster throughput. Their speed of image acquisition gives them unique value for imaging of the moving heart. The rapid image acquisition time virtually eliminates motion artifact related to cardiac contraction, permitting visualization of the calcium in the epicardial coronary arteries. Software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting CAD, both as a diagnostic technique in symptomatic patients to rule out an atherosclerotic etiology of symptoms or, in asymptomatic patients, as an adjunctive method for risk stratification for CAD.
ECBT and spiral CT or helical CT (multi-detector CT) for CAC measurement generally takes 10 to 15 minutes and requires only a few seconds of scanning time.
Coronary calcium levels can be expressed in many ways. The most widely used is the Agatston score, which is a weighted summed total of calcified coronary artery area observed on computed tomography. This value can be expressed as an absolute number, commonly ranging from 0 to 400. These values can be translated into age and sex-specific percentile values.
The rationale for measuring calcium in coronary arteries is that it measures coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not be causing ischemia or symptoms. Such a measure may be correlated with the presence of critical coronary stenosis or serve as a measure of the patient’s tendency toward atherosclerosis and future coronary disease. Therefore, it could serve as a variable to be used in risk assessment calculation purposes of determining appropriate preventative treatment in asymptomatic patients. Alternatively, in other clinical scenarios, it might help determine whether there is atherosclerotic etiology or component to the presenting clinical problem in symptomatic patients, thus helping to direct further workup for the clinical problem. Most clinical studies have examined the use of coronary calcium for its potential use in estimating the risk of future coronary heart disease (CAD) events.
Despite the potential benefits of coronary artery calcium screening, it is also subject to a number of limitations and therefore, there is disagreement on its value:
There is extensive evidence on the predictive value of coronary artery calcium (CAC) score for cardiovascular disease among asymptomatic patients, and this evidence demonstrates that scanning has incremental predictive accuracy above traditional risk factor measurement. However, evidence from high-quality studies that demonstrate that the use of CAC score measurement in clinical practice leads to changes in patient management or in individual risk behaviors that improve cardiac outcomes is lacking. At least 1 randomized controlled trial suggests that the use of CAC score measurement in clinical practice may be associated with improved cardiac risk profiles, but an association between CAC score measurement with improved outcomes has not yet been demonstrated in other studies.
CAC scoring has a potential role as a diagnostic test to rule out coronary artery disease (CAD) in patients presenting with symptoms or as a “gatekeeper” test before invasive imaging is performed. Evidence from retrospective studies suggests that negative results on CAC scoring rules out CAD with good reliability. However, further prospective trials would be needed to demonstrate that such a strategy is effective in practice and is at least as effective as alternate strategies for ruling out CAD. To demonstrate that use of calcium scores improves the efficiency or accuracy of the diagnostics work up of symptomatic patients, rigorous studies that define exactly how calcium scores are used in combination with other tests in the triage of patients would be necessary. Retrospective and prospective studies have been mixed in their findings about whether CAC scores add incremental predictive value to cardiac computed tomography angiography findings in predicting outcomes for symptomatic patients with possible CAD.
Because of the lack of high-quality evidence demonstrating improved outcomes from the use of CAC score either as a screening test to risk stratify patients or as a diagnostic test in symptomatic patients, the use of CAC scoring is considered investigational.
Practice Guidelines and Position Statements
In 2009 the U.S. Preventative Services Task Force issued a recommendation regarding using non-traditional risk factors in coronary heart disease risk assessment, current evidence is insufficient to assess the balance of benefits and harms of using the non-traditional risk factors discussed in this statement to screen asymptomatic men and women with no history of CHD to prevent CHD events.
The non-traditional risk factors included in this recommendation are high sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness (carotid IMT), coronary artery calcification (CAC) score on electron beam computed tomography (EBCT), homocysteine level, and lipoprotein(a) level.
American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA):
2010 practice guideline by American College of Cardiology Foundation and the American Heart Association, for assessment of cardiovascular risk in asymptomatic adults: Computed Tomography for Coronary Calcium Scoring:
In 2012, the American College of Cardiology (ACC)/ American Heart Association (AHA) released guidelines for the diagnosis and management of patients with stable ischemic heart disease that include some recommendations related to CAC scoring.
In 2014, ACC/AHA issued focused update to the 2012 guideline on the diagnosis and management of patients with stable ischemic heart disease with no additional recommendations related to CAC scoring.
In 2013, the American College of Cardiology (ACA)/American Heart Association (AHA) released guidelines for the assessment of cardiovascular risk:
Coronary artery calcium scoring, either by electron beam computed tomography or multislice computed tomography (EBCT) or Helical CT or multi-slice spiral computed tomography scanner is considered investigational.
Based on the peer reviewed medical literature because of the lack of high-quality evidence demonstrating improved clinical outcomes or impact to treatment management from the use of coronary artery calcium (CAC) score either as a screening tests to risk stratify patients or as a diagnostic test in symptomatic patients, the use of coronary artery calcium scoring is considered investigational.
U.S. Preventative Services Task ForceExternal Site October 2009. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment, Recommendation Statement.
2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. CirculationExternal Site 2010; 122:e636.
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Journal of the American CardiologyExternal Site j.jacc.2015.11.005.
UpToDateExternal Site Screening for Coronary Heart Disease. Frank G. Yanowitz, M.D.. Topic last updated October 22, 2012.
UpToDateExternal Site Diagnostic and Prognostic Implications of Coronary Artery Calcification Detected by Computed Tomography. Thomas C. Garber, M.D., PhD, FACC, FAHA, Christopher M. Kramer, M.D., FACC, FAHA. Topic last updated November 25, 2014.
Nishant R. Shah, M.D., Stephanie A. Coulter, M.D., An Evidence Based Guideline for Coronary Calcium Scoring in Asymptomatic Patients Without Coronary Heart Disease, Vol 39, Number 2, 2012.
Raimund Erbel, et al. Progression of Coronary Artery Calcification Seems to be Inevitable, but Predictable – Results of The Heinze Nixdorf Recall (HNR) Study. European Heart Journal. doi:10.1093/curheartj/ehu288
UpdateExternal Site Screening for Coronary Heart Disease in Patients with Diabetes Mellitus. Jeroen J Bax, M.D., PhD, Frans J TH Wackers, M.D., PhD, Victoria Delgado M.D., PhD. Topic last updated April 29, 2016.
Budoff MJ, Mohlenkamp S, McClelland R, et al. A comparison of outcomes with coronary artery calcium scanning in unselected populations: the Multi-Ethnic Study of Atherosclerosis (MESA) and Heinz Nixdorf RECALL study (HNR). J Cardiovasc Comput Tomogr. May-Jun 2013;7(3):182-191. PMID 23849491
Martin SS, Blaha MJ, Blankstein R, et al. Dyslipidemia, coronary artery calcium, and incident atherosclerotic cardiovascular disease: implications for statin therapy from the multi-ethnic study of atherosclerosis. Circulation. Jan 7 2014;129(1):77-86. PMID 24141324
Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. May 2014;7(3):453-460. PMID 24803472
Silverman MG, Blaha MJ, Krumholz HM, et al. Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: the Multi-Ethnic Study of Atherosclerosis. Eur Heart J. Sep 1 2014;35(33):2232-2241. PMID 24366919
Gibson AO, Blaha MJ, Arnan MK, et al. Coronary artery calcium and incident cerebrovascular events in an asymptomatic cohort. The MESA Study. JACC Cardiovasc Imaging. Nov 2014;7(11):1108-1115. PMID 25459592
Chang SM, Nabi F, Xu J, et al. Value of CACS compared with ETT and myocardial perfusion imaging for predicting long-term cardiac outcome in asymptomatic and symptomatic patients at low risk for coronary disease: clinical implications in a multimodality imaging world. JACC Cardiovasc Imaging. Feb 2015;8(2):134-144. PMID 25677886
Hou ZH, Lu B, Gao Y, et al. Prognostic value of coronary CT angiography and calcium score for major adverse cardiac events in outpatients. JACC Cardiovasc Imaging. Oct 2012;5(10):990-999. PMID 23058065
Meyer M, Henzler T, Fink C, et al. Impact of coronary calcium score on the prevalence of coronary artery stenosis on dual source CT coronary angiography in Caucasian patients with an intermediate risk. Acad Radiol. Nov 2012;19(11):1316-1323. PMID 22897947
Petretta M, Daniele S, Acampa W, et al. Prognostic value of coronary artery calcium score and coronary CT angiography in patients with intermediate risk of coronary artery disease. Int J Cardiovasc Imaging. Aug 2012;28(6):1547-1556. PMID 21922205
Whelton SP, Nasir K, Blaha MJ, et al. Coronary artery calcium and primary prevention risk assessment: what is the evidence? An updated meta-analysis on patient and physician behavior. Circ Cardiovasc Qual Outcomes. Jul 1 2012;5(4):601-607. PMID 22811506
Mamudu HM, Paul TK, Veeranki SP, et al. The effects of coronary artery calcium screening on behavioral modification, risk perception, and medication adherence among asymptomatic adults: a systematic review. Atherosclerosis. Oct 2014;236(2):338-350. PMID 25128971
Johnson JE, Gulanick M, Penckofer S, et al. Does Knowledge of Coronary Artery Calcium Affect Cardiovascular Risk Perception, Likelihood of Taking Action, and Health-Promoting Behavior Change? J Cardiovasc Nurs. Jan 14 2014. PMID 24434820
Shreibati JB, Baker LC, McConnell MV, et al. Outcomes after coronary artery calcium and other cardiovascular biomarker testing among asymptomatic medicare beneficiaries. Circ Cardiovasc Imaging. Jul 2014;7(4):655-662. PMID 24777939
Yerramasu A, Lahiri A, Venuraju S, et al. Diagnostic role of coronary calcium scoring in the rapid access chest pain clinic: prospective evaluation of NICE guidance. Eur Heart J Cardiovasc Imaging. Feb 9 2014. PMID 24513880
Pursnani A, Chou ET, Zakroysky P, et al. Use of coronary artery calcium scanning beyond coronary computed tomographic angiography in the emergency department evaluation for acute chest pain: the ROMICAT II trial. Circ Cardiovasc Imaging. Mar 2015;8(3). PMID 25710925
Hulten E, Bittencourt MS, Ghoshhajra B, et al. Incremental prognostic value of coronary artery calcium score versus CT angiography among symptomatic patients without known coronary artery disease. Atherosclerosis. Mar 2014;233(1):190-195. PMID 24529143
Chaikriangkrai K, Velankar P, Schutt R, et al. Additive prognostic value of coronary artery calcium score over coronary computed tomographic angiography stenosis assessment in symptomatic patients without known coronary artery disease. Am J Cardiol. Mar 15 2015;115(6):738-744. PMID 25604930
Fihn S, Blankenship J, Alexander K, et al. ACC/AHA/AATS/PCNA/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2014;64(18):1929-1949.
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