Coronary Artery Disease: Raggi P

Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Möhlenkamp S, McCollough CH, Vliegenthart R, Shaw LJ, Stanford W, Taylor AJ, van Ooijen PM, Wexler L, Raggi P, Anonymous00008, Anonymous00009. · Department of Radiology, Groningen University Hospital, Hanzeplein 1, 9700 RB, Groningen, The Netherlands. · Eur Radiol. · Pubmed #18651153 No free full text.

Abstract: Current guidelines and literature on screening for coronary artery calcium for cardiac risk assessment are reviewed for both general and special populations. It is shown that for both general and special populations a zero score excludes most clinically relevant coronary artery disease. The importance of standardization of coronary artery calcium measurements by multidetector CT is discussed.

Taylor AJ, Raggi J, Raggi P. · No affiliation provided · J Cardiovasc Comput Tomogr. · Pubmed #19083901 No free full text.

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Shaw LJ, Blumenthal RS, Raggi P. · No affiliation provided · J Nucl Cardiol. · Pubmed #15295406 No free full text.

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Raggi P, Khan A, Arepali C, Stillman AE. · Emory University School of Medicine, 1365 Clifton Road, NE, AT-504, Atlanta, GA 30322, USA. · Curr Atheroscler Rep. · Pubmed #18706286 No free full text.

Abstract: It has become commonplace to try to gear the intensity of preventive measures to the degree of risk. It is, however, problematic to merely use traditional risk factors to gauge risk in the individual patient because the tools currently in use are based on population estimates and they may not directly apply to the individual being assessed. Indeed, it is not unusual for patients at low to intermediate risk to suffer unexpected events, whereas some high-risk patients appear unusually healthy. Imaging for atherosclerosis may offer an alternative to this approach. Often, there is a large discrepancy between the burden of atherosclerosis estimated with coronary artery calcium or intima-media thickness and the risk of future cardiovascular events estimated with the Framingham risk score. This may justify some of the clinical discrepancy. Here, we review the current evidence surrounding the use of coronary artery calcium for risk prediction.

Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Möhlenkamp S, McCollough CH, Vliegenthart R, Shaw LJ, Stanford W, Taylor AJ, van Ooijen PM, Wexler L, Raggi P. · Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. · Int J Cardiovasc Imaging. · Pubmed #18504647 links to  free full text

Abstract: Current guidelines and literature on screening for coronary artery calcium for cardiac risk assessment are reviewed for both general and special populations. It is shown that for both general and special populations a zero score excludes most clinically relevant coronary artery disease. The importance of standardization of coronary artery calcium measurements by multi-detector CT is discussed.

Raggi P, Shaw LJ. · Division of Cardiology, Emory University School of Medicine, 1365 Clifton Road NE, AT-504, Atlanta, GA 30322, USA. · Curr Cardiol Rep. · Pubmed #18417003 No free full text.

Abstract: The importance of screening for subclinical coronary artery disease is reinforced by the detection gap existing between the currently used risk stratification tools and the persistently elevated rates of cardiovascular disease in Western countries. Medicare data clearly indicate the extremely high cost of caring for patients with end-stage diseases, and early detection may curb some of these expenses. Coronary artery calcium screening has become a widely used tool to estimate risk in a variety of categories in the general population and is discussed in this review.

Bellasi A, Raggi P, Merz CN, Shaw LJ. · Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA 30306, USA. · Cleve Clin J Med. · Pubmed #17708130 links to  free full text

Abstract: Coronary artery disease is different in women than in men in its pathogenesis, symptoms, and prognosis. Needed is a strategy for detecting and assessing coronary disease specifically in women. This review highlights recent evidence on sex differences in coronary artery disease.

Bellasi A, Raggi P. · Department of Nephrology, Ospedale San Paolo, University of Milan, Milan, Italy. · Semin Dial. · Pubmed #17374086 No free full text.

Abstract: Cardiovascular calcification (CV) is highly prevalent in chronic kidney disease stage V and has been associated with an increased risk for all-cause as well as cardiovascular mortality. A number of noninvasive imaging techniques are available to screen for the presence of CV-plain x-rays of the abdomen and extremities to identify macroscopic calcifications of aorta and peripheral arteries; echocardiography for assessment of valvular calcification; two-dimensional ultrasound for calcification of carotid arteries, femoral arteries and aorta, and computed tomography technologies that constitute the gold standard for quantification of coronary artery and aorta calcification. Some of these modalities are also useful to monitor calcification progression and to assess the effect of different therapeutic strategies directed at modifying calcification progression. In this article we review the strengths and limitations of the most common noninvasive techniques employed for the imaging of vascular calcification.

Raggi P, Thomas GS. · Emory University School of Medicine, Atlanta, GA, USA. · J Nucl Cardiol. · Pubmed #16580951 No free full text.

This publication has no abstract.

Shaw LJ, Taylor A, Raggi P, Berman DS. · Cedars-Sinai Medical Center and David Geffen School of Medicine at UCLA, Los Angeles, Calif 90048, USA. · J Nucl Cardiol. · Pubmed #16580949 No free full text.

This publication has no abstract.

Raggi P, Taylor A, Fayad Z, O'Leary D, Nissen S, Rader D, Shaw LJ. · Section of Cardiology, Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA. · Arch Intern Med. · Pubmed #16287763 links to  free full text

Abstract: Coronary artery disease imaging has traditionally been based on luminal angiography, but it has become evident that this tool, although extremely useful in diagnosing obstructive disease, is insufficient to define the presence and extent of atherosclerotic disease in the vessel wall. Progression of coronary artery disease was also initially evaluated using quantitative coronary angiography, and evidence soon accumulated that minor regression or nonprogression of luminal disease was associated with a favorable cardiovascular outcome. In recent years, however, several other techniques have been developed to image atherosclerosis and are emerging as useful tools in preventive cardiovascular medicine. These techniques provide new methods to assess the burden of atherosclerosis, gauge the risk of cardiovascular events, and offer a means to test the efficacy of therapeutic approaches to atherosclerosis. Furthermore, noninvasive coronary angiography can be performed with some of the new imaging modalities, potentially reducing the number of unnecessary invasive tests. This review focuses on techniques such as cardiac computed tomography, carotid artery intima-media thickness, cardiovascular magnetic resonance imaging, and intravascular ultrasonography as emerging tools in cardiovascular disease prevention.

Raggi P, Bellasi A, Ratti C. · Section of Cardiology, Tulane University School of Medicine, Tulane University, New Orleans, LA 70112, USA. · Diabetes Care. · Pubmed #16249559 links to  free full text

Abstract: Cardiovascular disease is the most frequent cause of death and disability in diabetes, and the morbidity and mortality for coronary artery disease (CAD) in this population is two to four times higher than in nondiabetic subjects. Traditional risk factors do not fully explain the level of cardiovascular risk, and coronary disease events are often silent in diabetic patients. Thus, research has recently focused on improving the risk assessment of an individual patient with new tools in an effort to better identify subjects at highest risk and in need of aggressive management. Cardiovascular imaging has proven very helpful in this regard. Traditional methods to assess CAD are based on detection of obstructive luminal disease responsible for myocardial ischemia. However, acute coronary syndromes often occur in the absence of luminal stenoses. Hence, the utilization of imaging methodologies to visualize atherosclerosis in its presymptomatic stages has received mounting attention in recent years. In this article, we review the current literature on the utility of traditional imaging modalities for obstructive CAD (nuclear and echocardiographic stress testing) as well as atherosclerosis plaque imaging with carotid intima-media thickness and coronary artery calcium for risk stratification of diabetic patients.

Raggi P, Bellasi A. · Section of Cardiology, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, SL48, New Orleans, LA 70112-2699, USA. · Ital Heart J Suppl. · Pubmed #16161502 No free full text.

Abstract: Cardiovascular disease is the first cause of morbidity and mortality for both men and women in developed countries. Tracking the progression of the atherosclerotic plaque appears to be an effective way to predict modification of risk in individual patients. Quantitative coronary angiography was initially proposed as a method of choice to assess coronary disease progression. With this methodology it was possible to demonstrate a strong association of plaque regression with reduction in adverse cardiovascular outcomes. More recently, the focus of research has turned to the development of noninvasive modalities to image the atherosclerotic plaque in its preclinical stages and to evaluate the effectiveness of preventive therapies with sequential imaging. The ease of performance of these tests enabled their use as intermediate endpoints in clinical trials to test new strategies to treat atherosclerosis. If proven successful, these imaging tools may allow a reduction in size and duration of clinical trials with a substantial cost benefit for society.

Bellasi A, Raggi P. · Cardiology Section, Tulane University School of Medicine, New Orleans, Louisiana 70112-2699, USA. · Curr Opin Cardiol. · Pubmed #16093755 No free full text.

Abstract: PURPOSE OF REVIEW: Algorithms and equations to calculate risk of cardiovascular events, though very useful as an in-office tool to conduct a preliminary assessment demonstrate a limited ability to predict risk in the individual patient. This has favored the development of several imaging modalities for subclinical atherosclerosis such as imaging of coronary calcium by computed tomography. RECENT FINDINGS: Arterial wall calcification is intimately associated with atherosclerosis development and is therefore an optimal marker of the presence of disease. The paradigm underlying the use of imaging technologies to identify subclinical disease is that the quantification of plaque burden may provide a better risk stratification approach for the individual patient than the currently available tools. SUMMARY: The most recent evidence supports this approach as will be discussed in the current review.

Nasir K, Raggi P, Rumberger JA, Budoff MJ, Blumenthal RS. · The Ciccarone Preventive Cardiology Center, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA. · Cardiol Rev. · Pubmed #15949051 No free full text.

Abstract: Cardiovascular disease (CVD) is the leading cause of mortality in women and a major cause of morbidity. Coronary artery disease (CAD) accounts for nearly half of all CVD deaths. Traditional risk factors are very helpful in predicting the development of CAD in women; however, many women suffer events in the absence of established risk factors for atherosclerosis. To meet the challenge of CAD, several tools have been developed to identify atherosclerotic disease in its preclinical stages, with the hope of modifying its natural history. In this article, we review the current literature on utilization of electron beam tomography (EBT) for detection of CAD as a tool to conduct risk stratification in the general asymptomatic female population as well as among asymptomatic women. In conclusion, EBT can be used to estimate the overall coronary atherosclerotic plaque burden in women. It can also be used to diagnose its presence and determine its extent; furthermore, information from the coronary artery calcium scores can be used to assess the likelihood of obstructive disease and to provide prognostic information. Finally, EBT has the potential to determine the consequences of therapeutic interventions regarding progression, stabilization, or regression of coronary atherosclerotic disease.

Taylor A, Shaw LJ, Fayad Z, O'Leary D, Brown BG, Nissen S, Rader D, Raggi P. · Walter Reed Army Medical Center, Atlanta, GA, USA. · Atherosclerosis. · Pubmed #15823269 No free full text.

Abstract: Progression of coronary artery disease was initially evaluated using quantitative coronary angiography with ensuing evidence indicating a strong relationship to adverse cardiovascular outcomes. Since then, several other atherosclerosis imaging techniques have emerged as new tools in cardiovascular medicine to evaluate the effectiveness of preventive therapies through serial monitoring of changes in atherosclerosis burden. Conducting large randomized trials to test new approaches for the medical management of atherosclerosis, with the goal of showing a reduction in event rates, may often be impractical in an era of cost containment and reduced societal resources. Recent evidence has unfolded that investigates alternative ways of assessing therapeutic results such as the attainment of surrogate goals with substantial outcome relevance. Atherosclerosis imaging modalities such as coronary computed tomography, carotid ultrasound, cardiovascular magnetic resonance imaging, and intravascular ultrasound each possess specific imaging abilities and inter-test characteristics that enable their serial use as intermediate endpoints in clinical trials and, increasingly, in individual patient management. The current review focuses on the application of these modalities as emerging tools in cardiovascular prevention.

Raggi P, Berman DS. · Tulane University School of Medicine, New Orleans, LA 70112-2699, USA. · J Nucl Cardiol. · Pubmed #15682370 No free full text.

Abstract: Cardiac computed tomography (CT) has seen an exponential increase in interest as applications expanded from identification of coronary artery calcification to noninvasive coronary angiography and, more recently, identification of soft and noncalcified plaques. The interest arises from the well-known fact that cardiovascular disease remains the most prevalent cause of death in the Western hemisphere and the fact that in a large proportion of patients the initial event is either sudden death or a disabling myocardial infarction or stroke. Although traditional risk factors are extremely helpful in determining risk in a population, the prognostic ability of risk factors alone in the individual patient is limited. Hence, researchers have turned their attention to noninvasive modalities to image the atherosclerotic plaque in its preclinical stages, hoping to better address this ailment at its inception and change the natural history of the disease. Measurements of coronary artery calcium (CAC) serve as a quantitative reflection of the severity of coronary artery atherosclerosis, and greater calcium burdens correlate with more advanced disease. Indeed, CAC has been shown to add prognostic value to traditional risk factors in patients at intermediate risk, and in this group of patients, it is most cost-effective. Furthermore, CAC measurements providing an assessment of coronary atherosclerotic plaque burden appear to be complementary to myocardial perfusion single photon emission computed tomography that offers information regarding inducible ischemia. In this manner, a better assessment of risk in a patient suspected of harboring preclinical or early coronary artery disease can be achieved. In this article we review the most relevant literature regarding the utilization of CAC testing as a tool to refine risk assessment and use several case studies to exemplify the combination of CT imaging and functional myocardial perfusion studies, which may provide a better identification of patients in need of aggressive medical therapy and those needing invasive assessment for possible coronary revascularization.

Ratti C, Ferramosca E, Bellasi A, Chiurlia E, Modena MG, Raggi P. · Cardiology Section, Tulane University School of Medicine, New Orleans, LA 70112, USA. · Ital Heart J Suppl. · Pubmed #15615348 No free full text.

Abstract: The use of noninvasive imaging techniques like electron beam and multislice computed tomography, to measure coronary artery calcium, is becoming increasingly accepted for risk stratification in both symptomatic and asymptomatic populations. The National Cholesterol Education Panel guidelines indicate that measurement of coronary calcium is an option for advanced risk assessment in appropriately selected persons. Because of the recognized high risk for cardiovascular events in patients with diabetes, they belong to the same high-risk category previously reserved for patients with known coronary heart disease. Diabetic patients might benefit from risk stratification with these noninvasive techniques. Indeed, absence of coronary calcium might indicate a low risk for events, while the presence of moderate to high calcium scores may help physicians to better gauge the intensity of medical therapy provided to their patients.

Raggi P, James G. · Section of Cardiology, Tulane University School of Medicine, 1430 Tulane Avenue, SL48, New Orleans, LA 70112-2699, USA. · Curr Atheroscler Rep. · Pubmed #15023294 No free full text.

Abstract: Current vital statistics clearly indicate a continuing epidemic of cardiovascular disease in the Western hemisphere and strongly suggest that the most desirable approach to this ailment is prevention rather than delayed treatment. Over 7 million people in the United States suffer from coronary artery disease and more than 500,000 die from its complications annually. In the majority of cases, the event announcing the presence of atherosclerosis is either sudden death or a disabling myocardial infarction or stroke. Though recent trials indicate a need for treatment of very large segments of the population, a review of current clinical practices indicates that the preventive attitude of the majority of physicians is not sufficiently developed and remains limited in most training programs. Additionally, although traditional risk factors are very helpful in predicting the development of cardiovascular disease, many individuals suffer events in the absence of established risk factors for atherosclerosis. To meet the challenge of coronary artery disease, several tools have been developed to identify atherosclerotic disease in its preclinical stages, with the hope of modifying its natural history. In this article, we review the current literature on utilization of electron beam tomography for detection of coronary artery calcification as a tool to conduct risk stratification for coronary artery disease events in the general population.

Raggi P. · Section of Cardiology, Tulane University School of Medicine, New Orleans, LA 70112-2699, USA. · Prev Cardiol. · Pubmed #14605515 No free full text.

Abstract: Over 7 million people in this country have coronary artery disease, and more than 500,000 die from its complications annually. Over 1 million Americans have an acute myocardial infarction each year, and in the majority of cases the event announcing the presence of coronary atherosclerosis is either sudden death or a disabling myocardial infarction. Therefore, the most desirable approach to such an epidemic is prevention rather than delayed treatment. Yet, statistics from primary care and subspecialty practices indicate that the preventive attitude of the majority of physicians is not sufficiently developed and remains limited in most training programs. Though traditional risk factors are very helpful in predicting the development of cardiovascular disease, many individuals suffer events in the absence of established risk factors for atherosclerosis. To meet the challenge of coronary artery disease, several tools have been developed to identify atherosclerotic disease in its preclinical stages in the hope of modifying its natural history. This review deals with the utilization of electron beam tomography for detection of coronary artery calcification as an additional tool available for use by preventive cardiologists and internists.

Naghavi M, Libby P, Falk E, Casscells SW, Litovsky S, Rumberger J, Badimon JJ, Stefanadis C, Moreno P, Pasterkamp G, Fayad Z, Stone PH, Waxman S, Raggi P, Madjid M, Zarrabi A, Burke A, Yuan C, Fitzgerald PJ, Siscovick DS, de Korte CL, Aikawa M, Airaksinen KE, Assmann G, Becker CR, Chesebro JH, Farb A, Galis ZS, Jackson C, Jang IK, Koenig W, Lodder RA, March K, Demirovic J, Navab M, Priori SG, Rekhter MD, Bahr R, Grundy SM, Mehran R, Colombo A, Boerwinkle E, Ballantyne C, Insull W, Schwartz RS, Vogel R, Serruys PW, Hansson GK, Faxon DP, Kaul S, Drexler H, Greenland P, Muller JE, Virmani R, Ridker PM, Zipes DP, Shah PK, Willerson JT. · The Center for Vulnerable Plaque Research, University of Texas-Houston, The Texas Heart Institute, and President Bush Center for Cardiovascular Health, Memorial Hermann Hospital, Houston, USA. · Circulation. · Pubmed #14557340 links to  free full text

Abstract: Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document will focus on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.

Raggi P. · Tulane University School of Medicine, 1430 Tulane Ave, SL48 New Orelans, LA 70112, USA. · Ital Heart J Suppl. · Pubmed #12611208 No free full text.

Abstract: Coronary artery disease is very prevalent in western countries and it represents the most frequent cause of death for both men and women. In the United States over 7 million people suffer from this ailment and about 500,000 die each year from its complications. Often the presenting event is an acute myocardial infarction or sudden death and the cost for society both financial and in terms of human lives lost is excessive. Despite the emphasis on prevention of atherosclerosis, unheralded events continue to occur in the general population in the absence of established risk factors. Indeed, risk factors justify only 60-70% of the risk of events for an individual patient. The focus of research has therefore turned to the application of non-invasive modalities for the imaging of the atherosclerotic plaque in its pre-clinical stages. The aim is to apply this information to guide a physician in choosing the patient in need of more aggressive preventive measures. One such imaging modality, electron beam tomography, is employed to visualize the calcified component of the atherosclerotic plaque. Calcium deposition in the wall of the coronary arteries is a highly sensitive and specific marker of atherosclerotic disease. This article summarizes the extensive amount of research published during the past 15 years on the use of calcium imaging as a tool to predict events.

Raggi P. · Section of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA. · J La State Med Soc. · Pubmed #12517028 No free full text.

Abstract: Coronary artery disease is very prevalent in the United States where over 7 million people suffer from it, and more than 500,000 die from its complications annually. For the majority of individuals suffering an acute myocardial infarction, the event represents the first indication of the presence of underlying coronary atherosclerosis. Furthermore, due to the outward remodeling of arteries that slowly accumulate atheroma in their imtima (Glagov effect), sudden death or acute myocardial infarction may occur in the absence of obstructive luminal atherosclerotic plaque. Therefore, it might seem highly desirable to detect atherosclerosis in its early stages to implement effective preventive measures rather than apply delayed treatment. Yet, statistics from primary care and sub-specialty practices indicate that the preventive attitude of the majority of physicians is not sufficiently developed, and most training programs still struggle to implement strong educational curricula in this field. To these limitations, one may add that traditional risk factors help predict only about 60% to 65% of the risk, while many individuals continue to suffer events in the absence of established risk factors for atherosclerosis. In light of this knowledge, several tools have been developed to identify atherosclerotic disease in its pre-clinical stages in the hope of modifying its natural history. This review deals with the utilization of electron beam tomography for detection of coronary arterial calcium as an additional tool to risk stratify asymptomatic individuals.

Salazar HP, Raggi P. · Tulane University School of Medicine, New Orleans, Louisiana, USA. · Am J Cardiol. · Pubmed #11879663 No free full text.

Abstract: The field of atherosclerosis imaging has expanded rapidly in the last decade, and technologies such as electron-beam computed tomography (EBCT), have contributed significantly to our understanding of the prevalence of silent coronary artery disease and its consequences. Nonetheless, proper use of technology is necessary to conduct effective and cost-beneficial screening programs. Because most adverse events related to atherosclerosis occur in individuals at an intermediate risk level, it seems appropriate to concentrate screening efforts on this group of patients. This article reviews the current understanding of the value of coronary artery calcium screening in asymptomatic individuals and in symptomatic patients at low-to-intermediate risk and the use of EBCT as a tool for assessing the efficacy of therapy for atherosclerosis.

Budoff MJ, Raggi P. · Division of Cardiology, Saint John's Cardiovascular Research Center, Los Angeles County Harbor-University of California-Los Angeles Medical Center Research and Education Institute, Torrance, California 90502, USA. · Am J Cardiol. · Pubmed #11473747 No free full text.

Abstract: The ability to observe changes in atherosclerotic plaque burden over time should provide an accurate measure of efficacy for different cardiovascular therapies. Electron-beam computed tomography (EBCT), by quantification of coronary artery calcification, is a noninvasive measure of atherosclerosis burden. This article summarizes data from abstracts and publications related to coronary artery calcium measurement and its use in progression studies. The issues related to interscan variability and reproducibility of this measure are detailed. The limitations of multidetector spiral computed tomography (high radiation dose and poor reproducibility) are also addressed. Several studies of progression using 2 scans, administered > or =1 year apart, demonstrate significant annual progression (22% to 52% per year). All studies demonstrate that therapy with cholesterol-lowering agents slows the atherosclerotic process, and that it may lead to regression of coronary calcium over time. There are 2 small prognostic studies that demonstrate that coronary events predominantly occur in those patients who exhibit significant progression of coronary artery calcium. Large multicenter trials are underway to evaluate the prognostic significance of coronary artery calcium progression. The progression of coronary artery atherosclerosis can be observed noninvasively by monitoring the progression of coronary calcification with EBCT. With annual progression rates of 22% to 52% and a median interscan variability of only 5% to 8%, this technology provides an opportunity to noninvasively monitor patients to assess the clinical efficacy of medical therapies in studies as short as 1 year.