Visually assessed coronary and cardiac calcium outperforms perfusion data during scintigraphy in the prediction of adverse outcomes Nicola Gaibazzi a, ⁎, Sergio Suma a , Silvia Garibaldi a , Carmine Siniscalchi a , Daniele Sartorio a , Gregg Pressman b , Valentina Lorenzoni c a Parma University Hospital, Parma, Italy b Einstein Medical Center, Philadelphia, PA, United States of America c Istituto Sant'anna, Pisa, Italy abstract article info Article history: Received 22 October 2019 Received in revised form 6 March 2020 Accepted 11 March 2020 Available online xxxx Objectives: To determine whether calcifications of the coronary arteries (coronary artery calcium 0 to 4 score), or extending the assessment also to cardiac valves and thoracic aorta (overall calcium 0 to 8 score), as seen on com- puted tomography for attenuation correction during stress-scintigraphy (SPECT-CT), are associated with total mortality and non-fatal myocardial infarction. We aimed to assess whether these calcifications added to the prognostic value of SPECT imaging. Background: The presence/amount of calcium in the coronary arteries, but also in the heart valves and aorta, has been associated with cardiovascular (CV) and all-cause mortality. This information can be obtained during SPECT-CT examinations, where low resolution CT images are co-registered for attenuation correction of myocar- dial perfusion, but then discarded. Methods: Clinical data were collected on 353 consecutive patients submitted to stress SPECT-CT between Sept 2010 and Oct 2012, for suspected coronary artery disease (CAD). Follow-up data on outcomes were collected ret- rospectively. Results: Mean age was 72 and 58% were male. Mean follow-up was 6.4 years, during which 48 subjects died (15 from CV causes) and 10 had non-fatal myocardial infarction (MI). Reversible perfusion defects were detected in 55 patients (15.6%), 39 of whom (11%) had Nmild defects. The presence of a calcium score N 1 in the attenuation correction images was the strongest univariate predictor of all-cause death or MI (hazard ratio 7.21, p b .001). On multivariate analysis, controlling for age, gender and myocardial perfusion defects an overall calcium score N 2 remained a predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p b .001). Conclusions: Visual assessment of coronary or overall coronary, cardiac and aortic calcium in the CT images used for attenuation correction during SPECT-CT is feasible and reproducible. It was strongly associated with all-cause death and MI, even after controlling for clinical variables and myocardial perfusion data. This simple visual cal- cium assessment does not add additional costs or radiation, and may significantly improve risk-assessment of pa- tients with suspected CAD undergoing SPECT-CT. Condensed abstract: Calcium in the coronary arteries, heart valves and aorta has been associated with worse prog- nosis. We sought to determine whether assessment of such calcifications on computed tomography images (co- registered for myocardial perfusion attenuation correction and then discarded) are independently associated with long-term outcome on top of available data. We enrolled 353 consecutive patients, referred for suspected coronary artery disease. An overall calcium score N 1 in the attenuation correction images was the strongest univariate (hazard ratio 7.21, p b .001) and multivariate predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p b .001), even after controlling for clinical vari- ables and myocardial perfusion data. © 2020 Elsevier B.V. All rights reserved. Keywords: Perfusion scintigraphy Coronary calcium Computed tomography Outcome Mortality International Journal of Cardiology xxx (xxxx) xxx Abbreviations: CAD, coronary artery disease; MI, myocardial infarction; SPECT, single photon emission computed tomography; SPECT-CT, hybrid single photon emission computed tomography.; CT, computed tomography.; CAC, coronary artery calcium; CC, cardiac valve and extra-cardiac calcium in the thoracic aorta; SDS, summed difference score; LAD, left anterior descending coronary artery; RCA, right coronary artery; Cx, circumflex coronary artery; CV, cardiovascular; MPD, myocardial perfusion defect; BMI, body mass index. ⁎ Corresponding author at: Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy. E-mail address: ngaibazzi@ao.pr.it (N. Gaibazzi). IJCA-28434; No of Pages 6 https://doi.org/10.1016/j.ijcard.2020.03.032 0167-5273/© 2020 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: N. Gaibazzi, S. Suma, S. Garibaldi, et al., Visually assessed coronary and cardiac calcium outperforms perfusion data during scintigraphy in the..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2020.03.032