What is Cardiac Calcifications?
Cardiac calcification refers to the buildup of calcium, a mineral, in various parts of the heart such as the heart valves, the arteries that supply blood to the heart (coronary arteries), the heart muscle (myocardium), and the outer lining of the heart (pericardium). Each of these calcium deposits can have different impacts on the heart.
For example, calcium deposits in the coronary arteries may help in categorizing patients who are at moderate risk into either low or high risk for developing heart and blood vessel disease. Meanwhile, calcium deposits in the heart valves can lead to a narrowing of the valve, disrupting the normal flow of blood and causing symptoms. This condition is known as stenosis.
Deposits in the pericardium might signal a condition known as constrictive pericarditis- a type of inflammation that can make the heart stiff. Calcium deposits in the heart muscle, on the other hand, can occur as a result of severe, widespread heart muscle damage.
Dense and heavy calcium deposits in the heart can often be spotted in chest x-rays. However, other more specialized tests may be needed for an accurate diagnosis. A computed tomogram (CT), a type of scan, may be used to see the deposits in myocardium and pericardium. To see deposits in the coronary arteries, a cardiac computed tomogram angiogram (CCTA) might be done, and an echocardiogram might be used to view calcium deposits in the heart valves. These tests are more detailed and provide a clearer picture of calcium deposits in the heart.
What Causes Cardiac Calcifications?
Calcification in the arteries of your heart, or coronary artery calcifications, can occur in two specific ways. First, ‘medial calcifications’ can develop when there’s an imbalance in the body’s calcium and phosphate levels. Conditions like hypercalcemia (too much calcium in the blood), hyperparathyroidism (overactive parathyroid glands), hyperphosphatemia (high phosphate level in the blood), and end-stage renal disease (advanced kidney disease) can trigger this type of calcification. The more a patient is on dialysis (a treatment for kidney disease), the more the calcification develops.
The second form is ‘intimal calcifications’, and this reflects atherosclerotic coronary artery disease, which is a condition where the arteries narrow due to plaque buildup. This type is linked to growing older and other risk factors like high blood pressure, smoking, diabetes, high cholesterol, metabolic syndrome, and chronic kidney disease.
Calcification can also occur in the heart valves. While it’s commonly due to aging, patients with imbalanced calcium and phosphate levels are more prone to it. Those conditions include hypercalcemia, hyperphosphatemia, hyperparathyroidism, and advanced kidney disease.
Calcification can also affect the pericardium (the sac that encloses your heart) and the myocardium (the heart muscle). Past infections such as tuberculosis or exposure to radiation can cause a condition called ‘constrictive pericarditis’, where calcium deposits form in the pericardium. Myocardial calcifications can occur after severe heart injuries from conditions like sepsis (a life-threatening complication of an infection), heart attack, radiation-induced heart injury, or previous inflammation of the heart muscle. Any imbalance in calcium and phosphate metabolism can speed up these calcifications.
Risk Factors and Frequency for Cardiac Calcifications
Cardiac calcifications are deposits of calcium in the heart. The likelihood of having these calcifications increases with age. For instance, about 90% of men and 67% of women over the age of 70 have these calcifications, particularly in the coronary arteries. The occurrence of coronary calcification varies between different racial and ethnic groups. Let’s break down these statistics:
- For men, the rates are:
- White men: 70.4%
- African American men: 52.1%
- Hispanic men: 56.5%
- Chinese men: 59.2%
- For women, the rates are:
- White women: 44.6%
- African American women: 36.5%
- Hispanic women: 34.9%
- Chinese women: 41.9%
Signs and Symptoms of Cardiac Calcifications
People with calcium build-up in their heart arteries often don’t experience any symptoms or might experience chest pain and shortness of breath when they exert themselves. If someone has a history of risk factors such as high cholesterol, diabetes, high blood pressure, and smoking, this could point towards this condition. If the calcium build-up occurs in the heart valves, symptoms might include chest pain when engaging in physical activity, shortness of air, or fainting/near fainting. The severity of these symptoms depends on the extent of valve calcification and narrowing. A physical check might reveal a distinctive heart sound depending on the valve affected.
Calcium build-up in the sac surrounding the heart might manifest with signs of a failing right side of the heart, including fluid build-up in the abdomen and swelling in the feet. These people usually have a past event of infection or exposure to radiation. Examinations might reveal a high neck vein pulse, presence of Kussmaul’s sign (increased neck vein distention with inspiration), fluid shifting within the abdomen, and the abdomen sounding dull when tapped.
In cases where calcium has built up in the heart muscle, there’s usually a history of damage to the entire or part of the heart muscle. These individuals might also have had severe bacterial infection or septic shock in the past.
- Chest pain when exerting oneself
- Shortness of breath when exerting oneself
- History of heart disease risk factors: high cholesterol, diabetes, high blood pressure, and smoking
- Fainting or near fainting during physical activity (for valve calcification)
- Distinctive heart sound during check-up (for valve calcification)
- Fluid build-up in the abdomen
- Swelling in the feet
- High neck vein pulse
- Kussmaul’s sign presence
- Abdomen sounding dull when tapped
- History of heart muscle damage or severe infection
Testing for Cardiac Calcifications
The CT angiogram (CTA), a kind of X-ray test, is effective in showing and measuring coronary artery calcifications (CAC). This observation can be crucial for diagnosing patients who have a medium risk of heart disease in 10 years, commonly patients above 40 with diabetes.
The American College of Cardiology and the American Heart Association recommend this measurement for patients with the same risk profile. However, this measurement is usually not suggested for patients with either a very low or very high risk of heart disease in the next 10 years.
The CAC measurement can be rated on a scale known as the Agatston score.
– 0: No detectable disease
– 1 to 99: Mild disease
– 100 to 399: Moderate disease
– Above 400: Severe disease
This score gives us an idea of the extent of heart disease in the patient but does not get specific about how much the arteries are narrowed. For this, other methods like the coronary angiogram are used.
Now, let’s discuss calcification (hardening) of the heart valves, specifically, the aortic valve, which is a common issue in older adults. It is typically caught using an ultrasound of the heart (echocardiogram), which also provides the measurements of the valve opening and the blood pressure gradients across the valve. We define severe Aortic Stenosis (AS – narrowing of the aortic valve) if the valve opening is less than 1 cm2, if there’s a fast blood flow across the valve (> 4 m/sec), and if there’s high pressure difference (> 40 mmHg). Correct diagnosis is depending on the heart’s capacity to pump blood. If there’s a weakness of heart function, the condition might not be detected correctly with an echocardiogram.
A less commonly used method to assess the severity of AS is the Aortic valve calcium score, which quantitatively measures the calcium build up in the valve. Other valves that are hardened can also be diagnosed with an echocardiogram to determine how narrow they are.
Pericardial calcification is typically seen as a ring or spotty hardening around the sac enclosing the heart in chest X-rays or CT scans of patients showing signs and symptoms of heart failure specifically affecting the right side of the heart. In these cases, a thorough analysis of the right heart’s function should be done, which typically includes a right heart catheterization and an echocardiogram.
Lastly, myocardial calcifications often come up as surprises when taking chest images or during autopsies. They are usually linked to a severe injury to the entire heart, such as insufficient blood supply to the heart (ischemia) or widespread infection (sepsis).
Treatment Options for Cardiac Calcifications
There is currently no known cure for the hardening of the coronary arteries known as coronary artery calcifications. However, a certain level of risk, determined by a CAC risk score, can indicate which patients might benefit from a type of medication called statins. Doctors determine this and prescribe these medications according to certain guidelines. This condition is also associated with other health risks that can be managed, such as high blood pressure, diabetes, and cigarette smoking.
For heart valve hardening and narrowing, a condition known as valvular calcifications and stenosis, if the patient meets certain criteria, they may need a valve replacement procedure. This can be done either with a surgical procedure or a less invasive procedure called a transcatheter valve replacement. Which procedure is best for a patient depends on their overall health condition, and the risk of complications from surgery. While surgery is often the preferred option for younger patients, patients who are at higher risk for complications from surgery might benefit more from a transcatheter aortic valve replacement procedure.
In some cases where there is hardening of the sac surrounding the heart, also known as pericardial calcification, and heart failure, the patient may need a surgery called a pericardiectomy in refractory constrictive pericarditis. This procedure removes part of the pericardium, the protective layer around the heart. It’s worth mentioning that this surgery has a high rate of complications and is typically a challenging procedure for the patient to recover from. Apart from this procedure, usual treatments for heart failure, including water pill (diuretics) and other medications, continue to be administered.
The treatment for hardening of the heart muscle, also known as myocardial calcifications, has not been well-studied or clearly defined in medical literature.
What else can Cardiac Calcifications be?
If a doctor is trying to identify coronary artery calcification – which is when the arteries that supply blood to your heart harden – they also have to consider that it might actually be coronary artery disease. This can get tricky when looking at images of your chest, like CT scans, because it’s hard to tell the difference between calcifications in different parts of your heart and chest like the coronary artery, heart valves, the ring-like structure around your heart (annulus), the protective layer around your heart (pericardium), large blood vessels, and the interior of your heart (cardiac lumen), and the heart muscle itself (myocardium). But there are more sophisticated imaging technologies, like echocardiography (a sort of heart ultrasound), cardiac MRI (which uses magnets to create heart images), and cardiac CTA (which uses x-rays to get a detailed heart picture), that can give doctors a better idea of where the calcifications are.
Even with just regular chest images, doctors can get an idea of where the calcification might be based on what it looks like and where it’s positioned. For example, coronary artery calcification usually follows the anatomy of the blood vessels and tends to be linear. Calcification in the protective layer of the heart is also linear and skip the pointed end of the heart (which we call the apex). Calcification in the ring-like structure around the heart tends to clump together in a ring-like arrangement. Meanwhile, calcification in the heart valves and large blood vessels are thin, curvy, and are generally located where you’d expect them to be based on anatomy. Finally, when the heart muscle itself calcifies, the hardened areas usually spread across the heart and often involve the wall that separates the two sides of the heart, called the septum.
What to expect with Cardiac Calcifications
The CAC score, which stands for Coronary Artery Calcium score, gives us an idea of your heart health. A score of 400 or more suggests that you are at a higher risk of heart and blood vessel disease events, while a lower score suggests that your risk is lower. Doctors often use this score in combination with other heart disease prediction models.
For example, in patients in the middle range for heart risk (using a measure called the Framingham score), a CAC score of 0 means their total risk is lower when both scores are added together. Likewise, if you had an intermediate risk for heart diseases and a high CAC score, it indicates a higher risk of future heart events when considered with the original score.
We evaluate the seriousness of valvular stenosis, a condition where a heart valve is narrower than usual, using an imaging test called an echocardiogram. Severe aortic valve stenosis, in particular, often predicts a poor outcome, especially when symptoms are already present.
For another condition called pericardial calcification, where calcium deposits form in the pericardium (the sac-like structure around your heart), the signs of poor prognosis are typically symptoms of heart failure. In case these symptoms don’t respond to treatment with medicines, it means the prognosis (the likely course of the disease) is poor. In these instances, surgery might be necessary.
Currently, we’re not sure about the prognosis value of myocardial calcification (calcium build-ups in heart muscle). As of now, we simply know it gets discovered by chance during various imaging tests or post-death examinations.
Possible Complications When Diagnosed with Cardiac Calcifications
If coronary artery calcifications, or hardenings in the arteries, aren’t treated, they may result in severe heart-related problems. Major changes in lifestyle and high doses of cholesterol-lowering medications, known as statins, are critical for patients with high coronary artery calcium scores who don’t have symptoms, to prevent future issues. Calcifications in the lining around the heart, or the pericardium, may worsen a condition known as constrictive pericarditis and cause symptoms of a type of hard-to-treat heart failure. Over time, calcifications in the heart muscle can lead to a decreased ability of the heart to fill with blood.
Main Risks:
- Severe heart-related problems from untreated artery hardening
- Increased risk of cardiac events in asymptomatic patients with high coronary artery calcium scores
- Worsening of constrictive pericarditis due to pericardial calcification
- Symptoms of refractory heart failure from pericardial calcification
- Decreased heart function due to long-term myocardial calcification
Preventing Cardiac Calcifications
Medical imaging has become a common tool used by doctors, making it easier for them to detect heart problems such as heart calcifications. Heart calcifications are hardened spots on the heart that show up on scans. One particular type of scan, called a cardiac computed tomography angiography (CCTA), is often used by heart specialists. It helps doctors diagnose, manage, and predict the progression of heart diseases in patients who have an average risk of having a heart and blood vessel disease, also known as ASCVD.
In addition to this, the CAC score, which measures the degree of calcification in the arteries, can be combined with traditional risk scores for more accurate predictions of ASCVD events in patients. This aids doctors in identifying and managing risk factors more effectively, which can include prescribing cholesterol medication, or statins.
Valvular calcification, or the hardening of heart valves, is an issue that often increases with age. It’s caused by upsets in the body’s calcium balance and can eventually lead to valvular stenosis, a condition where the heart valves narrow. If the narrowing of the heart valves is severe or causes symptoms, a valve replacement may be suggested. This could be done either by inserting a new valve through a small incision which is called percutaneous or by open-heart surgery, depending on the patient’s age, overall health, physical condition, and any other factors that could increase surgical risk.
Hardened areas – pericardial calcifications – on the heart wrapping (pericardium) could hint at a diagnosis of constrictive pericarditis, a condition causing the heart to pump less effectively, especially if other symptoms match and additional tests support the diagnosis. And finally, calcifications that spread across the heart muscle, or myocardium, are less clear in terms of the best treatment approach or what this means for a patient’s future health.
