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Rahimi, O.; Lee, K.; , . Coronary Artery Calcium Score and COVID-19 Prognosis. Encyclopedia. Available online: https://encyclopedia.pub/entry/21666 (accessed on 18 November 2024).
Rahimi O, Lee K,  . Coronary Artery Calcium Score and COVID-19 Prognosis. Encyclopedia. Available at: https://encyclopedia.pub/entry/21666. Accessed November 18, 2024.
Rahimi, Osman, Kevin Lee,  . "Coronary Artery Calcium Score and COVID-19 Prognosis" Encyclopedia, https://encyclopedia.pub/entry/21666 (accessed November 18, 2024).
Rahimi, O., Lee, K., & , . (2022, April 12). Coronary Artery Calcium Score and COVID-19 Prognosis. In Encyclopedia. https://encyclopedia.pub/entry/21666
Rahimi, Osman, et al. "Coronary Artery Calcium Score and COVID-19 Prognosis." Encyclopedia. Web. 12 April, 2022.
Coronary Artery Calcium Score and COVID-19 Prognosis
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This entry is adapted from the peer-reviewed paper 10.3390/medsci10010005

Coronary artery calcium score can aid in stratifying patients, thus allowing earlier interventions in rapidly developing illnesses.

atherosclerosis coronary artery disease COVID-19

1. Introduction

The association between coronary artery calcification (CAC) and atherosclerotic disease is well known. The CAC score was created to help guide physicians to better calculate atherosclerotic risk in non-invasive nature to stratify risk for major adverse cardiac events. Currently, Agatston scores >100 generally delineate at least a moderate disease [1]; however, ordinal calcium scoring may also be applied to examine the extent of coronary calcifications. Multiple studies have investigated the effects of CAC scores in hospitalized patients with COVID-19 as a potential prognostic marker. There has been some evidence of correlations in increased risk of mortality, mechanical ventilation, and intensive care unit (ICU) admissions. These studies echo that early CAC assessment can aide physicians to better triage high-risk patients.

2. Coronary Artery Calcium Score and COVID-19 Prognosis

CAC scoring can be defined by multiple methods [1]: Agatston scoring, volume score, mass score, and visualization score (V-CACS). The clinical application of CAC scoring allows delineation and risk stratification of patients with increased atherosclerotic risk [1][2]. CAC score can be obtained by a non-contrast computed tomography of the chest, which may be obtained at the time of COVID-19 diagnosis [3]. Although standardized cutoff values for CAC have previously been studied [1][2], the actual utilized scoring and cutoffs for coronary studies seem user- and institution-dependent. Given the variability in the study methods, this analysis aimed to establish a systematic approach to comparison of CAC scores to synthesize and aggregate data. Few studies utilized V-CACS to separate the patients into absent, mild, moderate, and severe categories [4][5]. Other studies reported scores in Agatston format [6][7][8][9][10]. One study reported as “high CAC” and “low CAC” groups [11]. These two parameters were used to assess risk of three clinical outcomes: death, mechanical ventilation, and ICU admission.

A history of coronary atherosclerotic disease (CAD) is known to be associated with a 10% increased mortality risk in hospitalized patients with COVID-19 [12]. Other studies have reported similar findings. Additionally, COVID-19 has been associated with various cardiovascular complications [13][14]. Hyperinflammation, cytokine storm, lymphohistiocytosis, coronary microvascular thrombosis, and endotheliitis have been proposed to be possible mechanisms of acute myocardial injury in COVID-19 [15]. Slipczuk et al. (2021) measured the epicardial adipose tissue (EAT) and deemed it to be an independent risk factor for mortality in patients with COVID-19. Given the increased oxygen demand as well as cardiovascular strain and stress, patients with a history of CAD are at increased risk for worse clinical outcomes compared with their healthy counterparts. A single-center cohort study showed that there was a lower prevalence of myocardial injury if CAC was absent in patients with COVID-19 [16]. Absence of CAC had a high negative predictive value for major adverse cardiac events in patients hospitalized with COVID-19 even in the presence of other cardiac risk factors [17]. Based on the analysis, the presence of CAC alone increased the mortality rate for hospitalized patients with COVID-19 (Figure 2B). It may be safe to presume that patients with no known history of CAD may benefit from CAC scoring as a prognostic indicator for death during hospitalization.

COVID-19 is a primary respiratory disorder that can lead to acute respiratory distress syndrome (ARDS), which for many patients may require mechanical ventilation [18]. ARDS is defined by noncardiogenic pulmonary edema that can lead to life threatening hypoxia from a lack of proper oxygen exchange within the lung parenchyma [19]. The therapy for ARDS in COVID-19 is multidisciplinary, but the mainstay for critically ill patients is low tidal volume mechanical ventilation [19]. The risk of being mechanically ventilated is based on a multitude of factors such as age, obesity, cardiovascular disease, and socioeconomic background [20]. In a single-center cohort study of 5279 patients, the strongest risk factor for development to severe illness and possible intubation, in addition to age, was heart failure, with an odds ratio of 1.9 [20]. This analysis looked to assess whether CAC was a possible risk factor for intubation and mechanical ventilation. Luo et al. (2021) noted an increased risk for mechanical ventilation with high CAC scores; however, the aggregate data were not consistent with this finding. There is a lack of significant elevation in risk for mechanical ventilation related to CAC levels. These data suggest that CAC presence and severity is not an independent risk factor for mechanical ventilation in hospitalized patients with COVID-19.

Hospitalized patients with COVID-19 are at increased risk for multi-organ systemic disease. A study of 138 patients who developed critical illness found the median time from admission to critical care service to be 2.5 days after onset of symptoms [21]. This rapid deterioration can be attributed to the severe pulmonary insult from the infection, but many of these patients have other non-pulmonary complications that lead to ICU admission. The complications most notably found during these admissions include acute kidney injury, encephalopathy, thrombosis, and cardiac injury [20]. Cardiac complications have ranged from cardiomyopathy and arrythmia to myocardial infarction and cardiac arrest [22][23]. One single-center cohort found a 33 percent occurrence of cardiomyopathy in critically ill patients with COVID-19 [24]. This cardiomyopathy is primarily thought to be either related to the hypercoagulable state from increased inflammation leading to coronary thrombosis and ischemic heart disease or direct cardiac myocyte injury from the viral pathogen [25]. However, the contribution of each of these complications to major adverse cardiovascular outcomes has not been fully determined. In a study examining 700 critically ill patients with COVID-19 with arrhythmias, nine patients developed cardiac arrest, all of whom were in the ICU. The development of cardiac arrest was associated with acute in-hospital mortality [26]. With a short median time from admission to an ICU transfer, as well as the known cardiovascular complications that follow, early prognosis via CAC scoring may benefit to risk-stratify patients. There was no significant difference noted between high and low CAC scores for ICU admission risk. There was also no significant difference noted in ICU admission risk whether any CAC was found. Given these findings, the risk of being admitted to an ICU for hospitalized patients with COVID-19 appears to be multifactorial in nature but independent of CAC scoring.

3. Conclusions

CAC was associated with mortality increase by approximately 2 folds. However, the exact mechanism of why CAC increases mortality rate is uncertain. It may be due to myocarditis, type 1 myocardial infarction, type 2 myocardial infarction, or other causes such as increased risk of cardiac arrest. Coronary atherosclerosis is known to be a significant risk factor for poor outcomes in COVID-19 hospitalizations. Patients with no known history of CAD can be non-invasively assessed for possible coronary atherosclerosis via CAC scoring. CAC scoring may not correlate directly with risk of mechanical ventilation or ICU admission in this patient population. Given these findings, CAC scoring can aid in stratifying patients, thus allowing earlier interventions in rapidly developing illnesses.

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Subjects: Cardiac & Cardiovascular Systems
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