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Cardiac calcifications carry different diagnostic and prognostic significance depending on their location. They can involve the coronary arteries, cardiac valves, myocardium, and pericardium. They are commonly observed on image modalities performed for various reasons. To avoid the morbidity and mortality associated with cardiac calcifications (whether in the coronary arteries, cardiac valves, or myocardium/pericardium), they must be promptly diagnosed and treated. This activity reviews the evaluation and treatment of cardiac calcifications in various locations and highlights the interprofessional team's role in evaluating and treating patients with these calcifications. Objectives: Identify the etiology of cardiac calcifications. Outline the appropriate evaluation of cardiac calcifications and their diagnostic and prognostic importance. Review the management options available for cardiac calcifications. Describe interprofessional team strategies for improving care coordination and communication to advance cardiac calcifications and improve outcomes. Access free multiple choice questions on this topic.

Cardiac calcification is a broad term that refers to calcium deposits in the heart valves, coronary arteries, myocardium, and pericardium. Each cardiac area has a unique significance of these calcifications.[1] While coronary artery calcifications can help risk-stratify intermediate-risk patients into low or high risk for atherosclerotic cardiovascular disease (ASCVD), valve calcifications can lead to valve narrowing, causing stenosis and flow abnormalities, and hence symptoms from valve narrowing. Pericardial calcifications may indicate constrictive pericarditis, while myocardial calcification can be a result of previous global myocardial injury (or infarction). When dense and heavy, calcifications can be detected by chest x-rays. However, a more dedicated study, eg, computed tomography (CT) for myocardial and pericardial calcifications, cardiac computed tomography angiography (CCTA) for coronary artery calcifications (CAC), and echocardiography for valvular calcifications, is more specific.[2]

Coronary Artery Calcifications Vascular calcifications, medial calcification, and intimal calcification have 2 distinct forms. Medial calcifications (involving tunica media) are seen in patients with disturbance of calcium and phosphate homeostasis. These are patients with hypercalcemia, hyperparathyroidism, hyperphosphatemia, and end-stage renal disease, which is the most common cause of medial calcification, and the duration of dialysis correlates with the degree of calcification. Intimal calcifications (involving the tunica intima) represent atherosclerotic coronary artery disease (CAD) and are related to advanced age. Other traditional risk factors include hypertension, smoking, diabetes, hyperlipidemia, metabolic syndrome, and chronic kidney disease.[3] Valvular Calcifications Age-related degeneration is the most common cause of valve calcification. However, patients with disturbances in calcium and phosphate hemodynamics (hypercalcemia, hyperphosphatemia, and hyperparathyroidism) and end-stage renal disease) are more prone to develop valvular calcifications.[4] Pericardial and Myocardial Calcifications Any previous infection (tuberculosis) or previous radiation exposure that leads to constrictive pericarditis is marked by calcium deposits in the pericardium. Myocardial calcifications are related to previous global myocardial injuries (sepsis, myocardial infarction, radiation-induced myocardial injury, and previous myocarditis). However, any disturbance in calcium and phosphate metabolism can accelerate the myocardial and pericardial calcifications.[5]

The presence of cardiac calcifications is age-dependent. Around 90% of men and 67% of women older than the age of 70 years have such calcifications (particularly the coronary artery calcifications). According to one study, the prevalence of coronary calcification in Whites, African Americans, Hispanics, and Chinese males is 70.4%, 52.1%, 56.5%, and 59.2%, respectively, and in females is 44.6%, 36.5%, 34.9%, and 41.9%, respectively.[6]

Two distinct pathological mechanisms for calcification anywhere in the body are dystrophic calcification (calcification of dead and dying tissues) and metastatic calcification (calcification of normal living tissue). Metastatic calcification is usually related to disturbances in calcium homeostasis. While dystrophic calcification is not related to any disturbance in calcium metabolism, it can occur despite normal blood calcium and phosphorus levels.[7]

Patients with coronary artery calcifications are usually asymptomatic or may complain of exertional symptoms of chest pain and dyspnea. Past history should focus on the presence of ASCVD risk factors like hyperlipidemia, diabetes, hypertension, and smoking. Patients with valvular calcifications may present with exertional chest pain, dyspnea, or syncope/near syncope, depending on the severity of valve calcification and stenosis. Physical examination may reveal a murmur depending on the valve involved. Patients with pericardial calcifications may present with symptoms of right-sided heart failure, including ascites and pedal edema. They usually have a previous history of infection or radiation exposure. The examination is significant for a raised jugular venous pulse and positive Kussmaul's sign, fluid shift, and dullness to percussion in the abdomen. In patients with myocardial calcification, a history of preceding global or focal myocardial injury is usually present. A previous history of severe sepsis or septic shock may also be present in such patients.

Coronary Artery Calcifications A cardiac CT angiogram (CTA) is better at demonstrating and quantifying the CAC. This is particularly important in asymptomatic patients with an intermediate (10% to 20%) 10-year risk of ASCVD based on the Framingham risk score, as well as in asymptomatic individuals 40 years and older with diabetes mellitus for coronary artery calcium scanning.[8] Currently, the American College of Cardiology/American Heart Association provides a class IIa indication for asymptomatic patients with an intermediate 10-year risk of ASCVD (10% to 20%) based on the Framingham risk score, as well as for asymptomatic individuals 40 years and older with diabetes mellitus. CAC measurement is generally not recommended for patients at low (less than 10%) or high (greater than 20%) 10-year risk of cardiac events based on the Framingham risk score.[9] Quantification of CAC is based on the Agatston score, calculated using CTA of the coronary arteries, as follows; No identifiable disease: 0 Mild disease: 1 to 99 Moderate disease: 100 to 399 Severe disease: greater than 400 In general, the extent of CAC correlates with coronary artery disease burden and does not exactly tell us about the degree of stenosis for which a coronary angiogram or other intravascular imaging modalities are needed. Valvular Calcifications Aortic valve stenosis is the most common valve pathology in older adults. This condition is usually diagnosed with an echocardiogram, which measures the valvular area and valvular gradients. Severe aortic valve stenosis is usually diagnosed by a valve area of <1 cm2, peak velocity of >4 m/sec, and mean gradient of > 40 mm Hg. Accurate diagnosis of severe aortic valve stenosis relies on normal heart contractile function. In cases of left ventricular failure, severity may be misdiagnosed on an echocardiogram. Aortic valve calcium scoring (not readily available) is a quantitative, flow-independent method of assessing aortic valve stenosis severity (recommended thresholds of 2000 in men and 1250 in women). Similarly, for other calcified valves, an echocardiogram can also predict the severity of stenosis.[10] Pericardial and Myocardial Calcifications

Aortic valve stenosis is the most common valve pathology in older adults. This condition is usually diagnosed with an echocardiogram, which measures the valvular area and valvular gradients. Severe aortic valve stenosis is usually diagnosed by a valve area of <1 cm2, peak velocity of >4 m/sec, and mean gradient of > 40 mm Hg. Accurate diagnosis of severe aortic valve stenosis relies on normal heart contractile function. In cases of left ventricular failure, severity may be misdiagnosed on an echocardiogram. Aortic valve calcium scoring (not readily available) is a quantitative, flow-independent method of assessing aortic valve stenosis severity (recommended thresholds of 2000 in men and 1250 in women). Similarly, for other calcified valves, an echocardiogram can also predict the severity of stenosis.[10] Pericardial and Myocardial Calcifications For pericardial calcifications seen on chest x-ray or CT scan in patients with signs and symptoms of right heart failure, a thorough evaluation of right heart function should be performed, including right heart catheterization and echocardiogram. Pericardial calcification is usually diagnosed as a rim of calcification or spotty calcification involving the pericardium.[11] Myocardial calcifications are usually diagnosed as incidental findings on chest imaging or autopsy of patients. A predisposing global cardiac injury, like ischemia or sepsis, is usually present in these patients.

Coronary Artery Calcifications Coronary artery calcifications have no known treatment. As mentioned above, a certain threshold of the CAC risk score predicts which patients would benefit from statins and should therefore be prescribed per the guidelines. In addition, other modifiable risk factors for ASCVD, including hypertension, diabetes, and cigarette smoking, should be addressed.[12][13] Valvular Calcifications For valvular calcifications and stenosis that fulfill the criteria for valvular replacement, either a transcatheter or surgical valve replacement procedure should be performed. This should take into account the patient's frailty as well as the surgical risks, calculated using the STS score (Society of Thoracic Surgeons). While surgery is preferred in young patients, a transcatheter aortic valve replacement (TAVR) may be more desirable in patients with higher surgical risks.[14] Pericardial and Myocardial Calcifications In addition to medical management of heart failure with diuretics and other guideline-directed medical treatment (GDMT), a pericardiectomy may be necessary in refractory constrictive pericarditis. Pericardiectomy is a procedure with high morbidity and mortality rates. The treatment of myocardial calcifications is not well elucidated in the literature.

The most important differential diagnosis of coronary artery calcifications is coronary artery disease. On chest imaging, including CT scans, it may be difficult to distinguish calcifications in the coronary arteries, valves, annulus, pericardium, great vessels, cardiac lumen, and myocardium. However, advanced imaging, eg, echocardiography, cardiac MRI, and cardiac CTA, can help determine the precise locations of these calcifications. The morphology of calcifications on chest imaging can provide clues to their source in difficult cases. Coronary artery calcifications follow an expected anatomic course and usually are linear. Pericardial calcifications are usually dense but oriented in a linear configuration and usually spare the apex. Calcifications of the mitral annulus are arranged in dense ring-like clumps, whereas valvular and great vessel calcifications are thin and curvilinear and located in an expected anatomic location. Myocardial calcifications are diffuse and frequently involve the septum.

The CAC score is prognostic. A score of 400 or more indicates an increased risk of ASCVD events, while a lower score predicts a lower risk. This score can be used in combination with other ASCVD risk prediction models. In patients with intermediate risk of ASCVD using the Framingham score, a CAC of 0 will indicate lower risk when these two scores are combined. Similarly, in patients with an intermediate ASCVD score, a high CAC will predict a high risk of future ASCVD events when combined with the original score.[15] The severity of valvular stenosis is calculated from echocardiographic measurements based on visual and hemodynamic estimates. Severe aortic valve stenosis carries a poor prognosis, especially with symptoms present.[16] The signs and symptoms of heart failure can predict the prognosis of pericardial calcification. If the symptoms are refractory to medical management, they indicate a poor prognosis. In these cases, surgical management is required. The prognostic value of myocardial calcification remains unclear. For now, it is merely recognized as an incidental finding on various imaging modalities or autopsy.

If not addressed, coronary artery calcifications can lead to worse cardiovascular outcomes. Aggressive lifestyle modification and high-dose statin in asymptomatic patients with high coronary artery calcium scores are required to reduce the risk of future events. Pericardial calcifications can lead to worsening constrictive pericarditis and symptoms of refractory heart failure. In the long run, myocardial calcifications can lead to impaired diastolic filling.[16]

With the widespread use of imaging modalities, health care providers are now more likely to encounter patients with cardiac calcifications. The cardiologist usually pursues cardiac computed tomography angiography (CCTA), which is helpful for diagnosing, managing, and prognosing patients at intermediate risk or with ASCVD. Moreover, the CAC score can be combined with other traditional risk scores to improve the prediction of ASCVD events in patients. This can help control risk factors aggressively and guide statin prescribing. Valvular calcification is an age-related mechanism that is potentiated by the disturbance in calcium homeostasis. It ultimately results in valvular stenosis. For severe or symptomatic valvular stenosis, valve replacement is offered. It can be either percutaneous or surgical, and is based on a patient’s age, comorbidities, frailty, and the presence of other surgical risk factors. Pericardial calcifications on chest imaging suggest a diagnosis of constrictive pericarditis when supported by signs and symptoms and other definitive tests. Myocardial calcifications are diffuse and have unclear treatment or prognostic value.

Cardiac calcifications have a unique diagnostic, therapeutic, and prognostic significance. When present in the coronary arteries, calcifications predict risk for future adverse cardiovascular events. The use of cardiac CT angiogram to quantify these calcifications can help risk-stratify asymptomatic patients with intermediate risk of ASCVD into high or low risk. This is important because the treatment strategy differs between these 2 groups: high-risk groups require intensive lifestyle modifications and treatment of underlying risk factors, while the low-risk group needs reassurance and appropriate follow-up. Myocardial calcifications have been less well studied. They usually follow a global myocardial injury likely in the setting of sepsis, coronary artery disease, or myocarditis. Their role, other than serving as an incidental finding on chest imaging, is unclear. However, these patients should be closely followed to monitor the symptoms of cardiomyopathy since these calcifications can theoretically restrict the filling of the heart, leading to diastolic failure. Pericardial calcifications are usually present in constrictive pericarditis. In patients with refractory heart failure symptoms, a pericardiectomy may be needed to relieve the symptoms of heart failure. In general, the outcomes of cardiac calcifications depend on their cause and location. However, to improve the outcomes, prompt consultation with an interprofessional group of physicians, including primary care physicians, cardiologists, cardiac surgeons, and pulmonologists, is recommended.