Non-invasive screening for coronary artery disease: calcium scoring

Despite the decrease in overall mortality from coronary artery disease, the number of out-of-hospital deaths from myocardial infarction is in the range of 60% of all infarct related case fatalities.1 In patients with known risk of sudden cardiac death (SCD), such as survived resuscitation, left ventricular aneurysm or low left ventricular ejection fraction, the incidence of SCD is in the region of 30% per year. In the general population, it is only 0.5% per year.2 However, the absolute number in this group is 10 times higher than in the patient population with known SCD risk, reaching more than 300 000 case fatalities per year in the USA.2 Even renowned cardiologists such as Ronald W Campbell^w1 and Jeffry M Isner^w2, who were experts on the topic of arrhythmias and myocardial infarction, suffered SCD. The MONICA (Monitoring trends and determinants in Cardiovascular disease) study reported that of all coronary heart disease (CHD) patients who die within 28 days after onset of chest pain, two thirds die before reaching the hospital.^w3 Accordingly, the main task has been to strengthen primary and secondary prevention.^w3 This strategy brings about a major challenge: how can we define who is at risk?

In 1978, Mason Sones, the father of coronary angiography, asked for “a way of recognizing these people before they drop dead”. He noted, “We are still living in a world, where almost one third of the patients die before we are aware that these people were ill or that their lives were in jeopardy”.^w4

For identifying people at risk the Framingham risk score,3 the Prospective Cardiovascular Münster (PROCAM) Score,4 the Systemic Coronary Risk Evaluation (SCORE) of the European Society of Cardiology,5 as well as other more specific scores like the Reynold’s Risk Score for …