The Role of Coronary Artery Calcium Score as a Systemic Marker of Atherosclerosis: A Cross-Sectional Imaging Study
Keywords:
Coronary Artery Calcium Score, Peripheral Artery Disease, Plaque Morphology, Ankle-Brachial Index, Atherosclerosis
Abstract
Background. Coronary Artery Calcium Score (CACS) is widely used to assess coronary atherosclerosis. However, its utility in reflecting systemic atherosclerosis burden remains limited. Notably, no prior study has investigated the relationship between CACS and plaque morphology in the lower extremities. This study aimed to address this gap by examining the association between CACS, ankle-brachial index (ABI), and peripheral arterial plaque morphology as assessed by duplex ultrasonography.
Methods. This single-center, cross-sectional study enrolled 100 consecutive patients who underwent coronary CT angiography and lower extremity Doppler ultrasound between November 2024 and May 2025. CACS was calculated using Agatston method. ABI and Doppler-based plaque morphology were evaluated to determine the presence, severity, and complexity of peripheral artery disease (PAD).
Results. A moderate inverse correlation was found between CACS and ABI (r = -0.628, p < 0.001), while a moderate positive correlation was observed between CACS and plaque morphology (r = 0.619, p <0.001). CACS showed good discriminatory power for detecting peripheral plaque (AUC = 0.765), and excellent performance in identifying advanced plaque types (III-IV) at a threshold of 478.5 HU (AUC = 0.852; sensitivity 68%; apecificity 91.7%).
Conclusion. This is the first study to demonstrated a direct association between coronary calcium burden and plaque morphology in the lower extremities. These findings highlight the potential role of CACS as a surrogate marker for systemic atherosclerosis and a valuable tool for identifying asymptomatic individuals who may benefit from peripheral arterial evaluation.
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30. Bethel M, Annex BH. Peripheral Arterial Disease: A Small and Large Vessel Problem. Am Hear J Plus Cardiol Res Pract. 2023;28:100291.
2. Fioretti V, Gerardi D, Giugliano G, Di Fazio A, Stabile E. Focus on Prevention: Peripheral Arterial Disease and the Central Role of the Cardiologist. J Clin Med. 2023;12:4338.
3. Li B, Syed MH, Qadura M. Increasing Awareness for Peripheral Artery Disease through the Identification of Novel Biomarkers. Biomolecules. 2023;13:1189.
4. Song P, Rudan D, Zhu Y, Fowkes FJI, Rahimi K, Fowkes FGR, Rudan I. Global, Regional, and National Prevalence and Risk Factors for Peripheral Artery Disease in 2015: An Updated Systematic Review and Analysis. Lancet Glob Heal. 2019;7:e1020-e1030.
5. Malik A, Malik MI. Fecal Microbiota Transplantation in Human Immunodeficiency Virus-Infected Patient Population: A Systematic Review and Meta-Analysis. Gastroenterol Res. 2023;16:209-216.
6. Muharram FR, Multazam CECZ, Mustofa A, Socha W, Andrianto, Martini S, Aminde L, Yi-Li C. The 30 Years of Shifting in The Indonesian Cardiovascular Burden—Analysis of The Global Burden of Disease Study. J Epidemiol Glob Health. 2024;14:193-212.
7. Bakhshi H, Bagchi P, Meyghani Z, Tehrani B, Qian X, Garg PK, Ambale-Venkatesh B, Bhatia HS, Ohyama Y, Wu CO, Budoff M, Allison M, Criqui MH, Bluemke DA, Lima JAC, DeFilippi CR. Association of Coronary Artery Calcification and Thoracic Aortic Calcification with Incident Peripheral Arterial Disease in the Multi-Ethnic Study of Atherosclerosis (MESA). Wahl D, ed. Eur Hear J Open. 2021;1:1-8.
8. Said A, Novianti AD, Fety Y. Deteksi Dini Peripheral Artery Disease melalui Pemeriksaan Ankle Brachial Index pada Kelompok Prolanis di Puskesmas Poasia. Heal Inf J Penelit. 2021;13:11-18.
9. AbuRahma AF, Adams E, AbuRahma J, Mata LA, Dean LS, Caron C, Sloan J. Critical Analysis and Limitations of Resting Ankle-Brachial Index in the Diagnosis of Symptomatic Peripheral Arterial Disease Patients and the Role of Diabetes Mellitus and Chronic Kidney Disease. J Vasc Surg. 2020;71:937-945.
10. Ugwu E, Anyanwu A, Olamoyegun M. Ankle Brachial Index as a Surrogate to Vascular Imaging in Evaluation of Peripheral Artery Disease in Patients with Type 2 Diabetes. BMC Cardiovasc Disord. 2021;21:10.
11. Huang HL, Chang CH, Lo MT, Lin C. Diagnostic Potential of Combined Photoplethysmography and Ankle-Brachial Index in Peripheral Arterial Disease: A Duplex Ultrasonography-Based Comparative Study. J Am Heart Assoc. 2024;13:e034625.
12. Çelik Aİ, Bezgin T, Karaaslan MB, Coşkun R, Çağdaş M. The Relationship between Coronary Artery Calcium Score and Monocyte to High-Density Lipoprotein Cholesterol Ratio in Patients with Stable Angina Pectoris. Turk Kardiyol Dern Ars. 2022;50:583-589.
13. Dell’Aversana F, Tuccillo R, Monfregola A, De Angelis L, Ferrandino G, Tedeschi C, Cacciapuoti F, Tamburro F, Liguori C. Epicardial Adipose Tissue Volume Assessment in the General Population and CAD-RADS 2.0 Score Correlation Using Dual Source Cardiac CT. Diagnostics. 2025;15:681.
14. Shabbir A, Virk ST, Malik J, Kausar S, Nazir TB, Javed A. Coronary Artery Calcium Score: Assessment of SYNTAX Score and Prediction of Coronary Artery Disease. Cureus. 2021;13:11-17.
15. Rezaie-Kalamtari K, Norouzi Z, Salmanipour A, Mehrali H. Updates on CAD Risk Assessment: Using the Coronary Artery Calcium Score in Combination with Traditional Risk Factors. Egypt Hear J. 2025;77:14.
16. Lee JW, Kim JY, Han K, Im DJ, Lee KH, Kim TH, Park CH, Hur J. Coronary CT Angiography CAD-RADS versus Coronary Artery Calcium Score in Patients with Acute Chest Pain. Radiology. 2021;301:81-90.
17. Obisesan OH, Osei AD, Uddin SMI, Dzaye O, Blaha MJ. An Update on Coronary Artery Calcium Interpretation at Chest and Cardiac CT. Radiol Cardiothorac Imaging. 2021;3:e200484.
18. Jeremias Z, Rat N, Benedek I, Rapolti E, Ratiu M, Muresan A, Benedek T. High Iliac Calcium Score is Associated with Increased Severity and Complexity of Peripheral Arterial Disease and Predicts Global Atherosclerotic Burden. Vasa. 2018;47:377-386.
19. Williams MC, Wereski R, Tuck C, Adamson PD, Shah ASV, van Beek EJR, Roditi G, Berry C, Boon N, Flather M, Lewis S, Norrie J, Timmis AD, Mills NL, Dweck MR, Newby DE. Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT-HEART randomised controlled trial in Scotland. Lancet. 2025;405:329-337.
20. Maahs E, Schwartz A, Berezowitz A, Davis S, Guzman RJ. An Ultrasound-based Femoral Artery Calcification Score. J Vasc Surg Cases, Innov Tech. 2024;10:101381.
21. Aboyans V, Ricco J-B, Bartelink M-LEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763-816.
22. Sztajzel R. Ultrasonographic Assessment of the Morphological Characteristics of the Carotid Plaque. Swiss Med Wkly. 2005;135:635-643.
23. Murphy SJ, Lim ST, Kinsella JA, Tierney S, Egan B, Feeley TM, et al. Simultaneous assessment of plaque morphology, cerebral micro-embolic signal status and platelet biomarkers in patients with recently symptomatic and asymptomatic carotid stenosis. J Cereb Blood Flow Metab. 2020;40:2201-2214.
24. Mohseni P, Khalili D, Djalalinia S, Mohseni H, Farzadfar F, Shafiee A, Izadi N. The Synergistic Effect of Obesity and Dyslipidemia on Hypertension: Results from the STEPS Survey. Diabetol Metab Syndr. 2024;16:81.
25. Wen J, Huang Y, Lu Y, Yuan H. Associations of Non-High-Density Lipoprotein Cholesterol, Triglycerides And the Total Cholesterol/HDL-C Ratio with Arterial Stiffness Independent of Low-Density Lipoprotein Cholesterol in a Chinese Population. Hypertens Res. 2019;42:1223-1230.
26. McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al. 2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension. Eur Heart J. 2024;45:3912-4018.
27. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A, Schlaich M, Stergiou GS, Tomaszewski M, Wainford RD, Williams B, Schutte AE. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75:1334-1357.
28. Yadav V, Khanduri S, Yadav P, Pandey S, Tyagi E, Yadav H, Krishnam A, Hamza M. Diagnostic Accuracy of Color Doppler and Calcium Scoring versus Dual-Energy Computed Tomography Angiography in the Assessment of Peripheral Arterial Diseases of Lower Limb. J Clin Imaging Sci. 2020;10:45.
29. Shahbad R, Pipinos M, Jadidi M, Desyatova A, Gamache J, MacTaggart J, Kamenskiy A. Structural and Mechanical Properties of Human Superficial Femoral and Popliteal Arteries. Ann Biomed Eng. 2024;52:794-815.
30. Bethel M, Annex BH. Peripheral Arterial Disease: A Small and Large Vessel Problem. Am Hear J Plus Cardiol Res Pract. 2023;28:100291.
Published
2025-12-16
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How to Cite
Aulia, M., Kusumawardhani, N., Hidayat, S., & Pranata, R. (2025). The Role of Coronary Artery Calcium Score as a Systemic Marker of Atherosclerosis: A Cross-Sectional Imaging Study. Indonesian Journal of Cardiology, 46(4), 158-170. https://doi.org/10.30701/ijc.1866
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Clinical Research
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