# The Impact of Coronary Calcium Scores on the Development of Myocardial Ischemia: An Analysis of Associated Risk Factors

## TL;DR

This study shows that higher coronary calcium scores are strongly linked to myocardial ischemia, helping predict heart disease risk.

## Contribution

The study identifies specific CAC score cutoffs for predicting myocardial ischemia and evaluates associated risk factors.

## Key findings

- Patients with myocardial ischemia had significantly higher CAC scores than non-ischemic patients.
- Decision tree analysis identified critical CAC score thresholds for predicting ischemia in specific coronary arteries.
- Hypertension, diabetes, and smoking were associated with higher CAC scores in ischemic patients.

## Abstract

Background: Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally, with myocardial ischemia (MI) being one of the most critical manifestations of coronary artery disease (CAD). Myocardial ischemia occurs when there is an insufficient supply of oxygen-rich blood to the heart muscle, typically caused by blockages or narrowing in the coronary arteries due to atherosclerosis. The coronary artery calcium (CAC) score, which quantifies calcium deposits in the coronary arteries, has emerged as a valuable tool in predicting cardiovascular events, including myocardial ischemia. Understanding the relationship between CAC scores and myocardial ischemia, along with other risk factors, could improve patient management and help predict adverse cardiovascular outcomes.

Objective: This study aims to evaluate the relationship between CAC scores and the development of myocardial ischemia, as detected through diagnostic imaging methods such as CT angiography and stress echocardiography, and to analyze associated risk factors, including traditional and emerging clinical factors.

Methodology: A prospective, cross-sectional observational study was conducted in the Departments of Cardiology and Radiology at Mardan Medical Complex between February 2023 and June 2025. Diagnostic methods such as CT angiography and stress echocardiography were used to assess the presence of myocardial ischemia. Demographic data, clinical characteristics, comorbidities, and CAC scores were collected. Statistical analyses, including two-way analysis of variance (ANOVA), Mann-Whitney U tests, and decision tree modeling, were used to explore the relationship between CAC scores and myocardial ischemia, along with various risk factors such as age, gender, BMI, smoking history, and comorbidities.

Results: The study included 129 patients, with 74 (57.36%) diagnosed with myocardial ischemia. A strong correlation was observed between elevated CAC scores and ischemia, with ischemic patients displaying significantly higher CAC scores (671.92 ± 185.82) compared to nonischemic patients (246.36 ± 98.51). The overall CAC scores for individual coronary arteries were 73.57 ± 39.24 for the left main artery (LMA), 196.19 ± 104.63 for the left anterior descending artery (LAD), 122.62 ± 65.40 for the left circumflex artery (LCX), and 98.10 ± 52.32 for the right coronary artery (RCA), while the total CAC score averaged 490.48 ± 261.58. Decision tree analysis identified critical cutoff values for predicting ischemia, including 403.0 for total CAC, 161.2 for LAD, 100.75 for LCX, 80.6 for RCA, and 60.45 for LMA. Additionally, risk factors such as hypertension, diabetes, and smoking were associated with higher CAC scores, particularly among ischemic patients.

Conclusion: CAC scoring is an essential tool for evaluating the risk of myocardial ischemia and cardiovascular events, complementing traditional risk factors to improve stratification and enable more focused interventions for patients.