UH Harrington Heart & Vascular Institute No-Cost Calcium Score at the Forefront for Diagnostic Evaluation of Coronary Artery Disease

Innovations in Cardiovascular Medicine & Surgery | Winter 2023

Nonobstructive plaque has, for the first time, been included in The American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guideline for the Evaluation and Diagnosis of Chest Pain’s1 definition of coronary artery disease (CAD). Along with highlighting the increased risk of atherosclerotic events associated with nonobstructive plaque, the 2021 guideline speaks to the importance of preventive measures in improving patient outcomes.

Sanjay Rajagopalan,MD

Preventive medical treatments begin with an understanding of risk for future calamitous events. Coronary artery calcium (CAC) scoring is recognized as a safe and robust prognosticator of atherosclerosis and vascular age. Over the past decade, University Hospitals Harrington Heart & Vascular Institute’s trailblazing commitment to offer low- or no-cost CAC scoring has reclassified the 10-year CAD risk profile, based on traditional risk factor approaches, in at least one in every five individuals.

“Calcium scoring is the best test available for patients who want to know and address their risk for heart disease,” says Sanjay Rajagopalan, MD, Chief of Cardiovascular Medicine and Chief Academic and Scientific Officer at University Hospitals Harrington Heart & Vascular Institute, and the Herman K. Hellerstein MD Professor of Medicine and Radiology at Case Western Reserve University School of Medicine.

After initially offering low-cost CAC in 2014, Daniel Simon, MD, former President of UH Harrington Heart & Vascular Institute, now President of Academic & External Affairs and Chief Scientific Officer for University Hospitals Health System, Dr. Rajagopalan and fellow leaders within the UH Harrington Heart & Vascular Institute and Radiology had the foresight and pragmatism to eliminate cost barriers. Since 2017, any provider throughout University Hospitals can order CAC screening at no charge to individuals who meet broad eligibility criteria.

• Men aged 45 or older and women aged 55 or older with no previous history of cardiovascular disease and one or more risk factors for heart disease
• Men and women aged 40 or older with a chronic inflammatory condition

“We are the only health system in the Americas to offer this test for free,” says Dr. Rajagopalan. “There was an immediate impact on utilization when cost burdens were removed.” In the first several months after implementation of no-charge CAC (NC-CAC), demand for screening rose 546 percent.

“At a time when almost all health systems charge for the test, we took the transformative step of providing this information for free to allow patients to take charge of their health,” says Dr. Rajagopalan. “Our work is guideline-changing and has pushed the world toward a shift to the mindset that prevention may ultimately be the quintessential example of ‘value-based’ healthcare. Effectively identifying individuals at risk and thereby facilitating the initiation of risk-reducing treatments or, conversely, removing patients from medications that they may not need because they are at very low risk may be the ultimate form of cost avoidance.”

Today, over 100,000 people have taken advantage of University Hospitals’ unprecedented screening program. “It is a massive systemwide undertaking that would not happen without the collaboration of a team of individuals, including our radiology colleagues,” says Dr. Rajagopalan. CAC scoring data is captured from patients’ electronic medical records (EMRs) and maintained in CLARIFY, a prospective registry that enables further research into the prevention and treatment of CAD.

Here, Dr. Rajagopalan highlights some early findings from the registry.

• Improved Healthcare Equity. NC-CAC has been associated with increased interest in testing among women, minorities and people living in lower-income ZIP codes. “Hopefully, we will continue to attrition this treatment gap and provide appropriate therapies for underserved populations,” says Dr. Rajagopalan.
• Informed Care Management. Reclassification of risk categories has helped providers up- or downgrade statin eligibility with greater precision. Learning their NC-CAC results has also sparked patients’ motivation to adhere to healthy lifestyle modifications and pharmacotherapy. “We continue to grow in understanding the resources and support individuals need to take ownership over their health,” says Dr. Rajagopalan.
• Precision Medicine. Using AI and machine learning applications, researchers can extract information from a CT scan and combine it with macro elements from EMRs to generate a granular medical portrait prior to clinical examination. Additional genomic, social, demographic, environmental and other personal biometric assessments can further enhance precision initiatives. “We are also conducting several pragmatic clinical studies to convert this data into digital tools that facilitate patients’ understanding of their health status,” says Dr. Rajagopalan. “If you present people with infographics that make information digestible, they are much more engaged. Integrating these precision approaches with conventional measures is the future of medicine.”
• Augmenting NC-CAC with AI approaches in Imaging, Including HeartFlow®. Noninvasive HeartFlow analysis combines CT imaging with AI to quantify blood flow diminished by arterial blockage. “A derivation of fractional flow reserve, HeartFlow can tell us the flow drop beyond a blockage,” says Dr. Rajagopalan. “The technique is becoming increasingly popular because it can obviate the need for invasive angiogram in appropriately selected patients. Our calcium scoring program has resulted in better use and integration of this approach in higher-risk individuals to better inform the patient and physician and facilitate more judicious use of the cardiac catheterization laboratory.”

For more information, email Dr. Rajagopalan at Sanjay.Rajagopalan@UHhospitals.org.

Contributing Expert:
Sanjay Rajagopalan, MD
Chief, Division of Cardiovascular Medicine
University Hospitals Harrington Heart & Vascular Institute
Herman K. Hellerstein MD Professor of Medicine and Radiology 
Director, Cardiovascular Research Institute 
Case Western Reserve University School of Medicine

1 Cardoso, R., Shaw, L. J., Blumenthal, R. S., Nasir, K., Ferraro, R., Maron, D. J., Blaha, M. J., Gulati, M., Bhatt, D. L., & Blankstein, R. (2022). Preventive cardiology advances in the 2021 AHA/ACC chest pain guideline. American journal of preventive cardiology, 11, 100365. https://doi.org/10.1016/j.ajpc.2022.100365

2 No-Charge Coronary Artery Calcium Screening for Cardiovascular Risk Assessment. Al-Kindi SG, Costa M, Tashtish N, Duriuex J, Zidar D, Rashid I, Sullivan C, Gilkeson R, Simon D, Rajagopalan S. J Am Coll Cardiol. 2020 Sep 8;76(10):1259-1262. doi: 10.1016/j.jacc.2020.06.077. PMID: 32883418.

3 Effect of No-Charge Coronary Artery Calcium Scoring on Cardiovascular Prevention. Al-Kindi S, Tashtish N, Rashid I, Gupta A, AnsariGilani K, Gilkeson R, Cainzos-Achirica M, Nasir K, Pronovost P, Simon DI, Rajagopalan S. Am J Cardiol. 2022 Jul 1;174:40-47. doi: 10.1016/j.amjcard.2022.03.019. Epub 2022 Apr 27. PMID: 35487777.

4 Deep learning segmentation and quantification method for assessing epicardial adipose tissue in CT calcium score scans. Hoori A, Hu T, Lee J, Al-Kindi S, Rajagopalan S, Wilson DL. Sci Rep. 2022 Feb 10;12(1):2276. doi: 10.1038/s41598-022-06351-z. PMID: 35145186.

5 Impact of low/no-charge coronary artery calcium scoring on statin eligibility and outcomes in women: The CLARIFY study.Al-Kindi S, Tashtish N, Rashid I, Sullivan C, Neeland IJ, Robinson M, Gross EM, Shaw L, Cainzos-Achirica M, Nasir K, Kreatsoulas C, Gilkeson R, Simon DI, Rajagopalan S. Am J Prev Cardiol. 2022 Sep 11;12:100392.

6 Machine learning derived ECG risk score improves cardiovascular risk assessment in conjunction with coronary artery calcium scoring.Siva Kumar S, Al-Kindi S, Tashtish N, Rajagopalan V, Fu P, Rajagopalan S, Madabhushi A. Front Cardiovasc Med. 2022 Oct 5;9:976769. doi: 10.3389/fcvm.2022.976769. eCollection 2022. PMID: 36277775

7 Prevalence of thoracic aortic aneurysm in patients referred for no/low-charge coronary artery calcium scoring: Insights from the CLARIFY registry. Khawaja T, Janus SE, Tashtish N, Janko M, Baeza C, Gilkeson R, Al-Kindi SG, Rajagopalan S. Am J Prev Cardiol. 2022 Aug 30;12:100378. doi: 10.1016/j.ajpc.2022.100378. eCollection 2022 Dec. PMID: 36106308.