Association between coronary artery calcium score and myocardial ischemia assessed by stress perfusion cardiac magnetic resonance imaging

Q: What are the key findings of this study?

Coronary artery calcium score independently predicted myocardial ischemia on stress CMR (aOR 1.07 per 100 AU, 95% CI 1.03-1.10; p < 0.001), with an overall ischemia prevalence of 26.0%.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Coronary artery calcification undergoing stress perfusion cardiac magnetic resonance imaging (n=215). Intervention: Coronary artery calcium (CAC) score (per 100 Agatston units) vs. Lower CAC scores. Primary outcome: Myocardial ischemia on stress perfusion CMR (adjusted OR 1.07 per 100 AU, 95% CI 1.03-1.10, p=<0.001).

Q: What does this research mean for the field?

Higher coronary artery calcium scores are independently associated with myocardial ischemia on stress perfusion CMR, with ischemia occurring in over 40% of patients with CAC ≥ 1,000 AU and absent in those with CAC < 300 AU. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To assess the prevalence and predictors of myocardial ischemia detected by stress cardiac magnetic resonance in patients with coronary artery calcium, as well as its impact on clinical management.

Yodying Kaolawanich; Methat Meechuen; Issarayus Laohabut; Thanawat Ruengchaisiwawaith; Thananya Boonyasirinant

doi:10.1371/journal.pone.0361659

October 30, 2026PLoS ONEOpen Access

Association between coronary artery calcium score and myocardial ischemia assessed by stress perfusion cardiac magnetic resonance imaging

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Key result

Higher CAC score is linked to ~7% higher odds of myocardial ischemia per 100 AU.

adjusted OR 1.07 per 100 AU
95% CI 1.03-1.10
P<0.001
n=215

Why the study?

Although CAC scoring effectively stratifies cardiovascular risk and stress perfusion CMR accurately detects myocardial ischemia, the prevalence, associated factors, and clinical impact of myocardial ischemia on CMR in patients with CAC needed investigation.

Does a higher coronary artery calcium (CAC) score predict inducible myocardial ischemia on stress perfusion cardiac magnetic resonance (CMR) and influence subsequent clinical management in adults undergoing cardiovascular risk stratification?

Key Points

To assess the prevalence and predictors of myocardial ischemia detected by stress cardiac magnetic resonance in patients with coronary artery calcium, as well as its impact on clinical management.
Analyzed 215 patients aged ≥18 years who underwent coronary artery calcium (CAC) scoring followed by stress perfusion CMR between 2013 and 2026.
Evaluated ischemia prevalence across CAC categories using multivariable logistic regression and receiver operating characteristic (ROC) analysis to identify predictive thresholds.
Myocardial ischemia was detected in 26.0% of patients overall (56/215), including 0.0% with CAC <300 AU (0/32), 17.1% with CAC 300–999 AU (14/82), and 41.6% with CAC ≥1,000 AU (42/101).
CAC score independently predicted myocardial ischemia (adjusted OR 1.07 per 100 AU, 95% CI 1.03–1.10, p < 0.001), with an optimal cutoff of ≥1,093 AU predicting ischemia with an AUC of 0.75 (p < 0.001).
Following stress CMR results, medication regimens changed in 37.2% of patients and 18.1% underwent invasive cardiovascular procedures.

Study Design

Type

Cohort (n=215)

Blinding

Unblinded

Multicenter

No

Structured PICO

Does a higher coronary artery calcium (CAC) score predict inducible myocardial ischemia on stress perfusion cardiac magnetic resonance (CMR) and influence subsequent clinical management in adults undergoing cardiovascular risk stratification?

P

Population

215 adults (mean age 69.3 years, 39.1% female) in Thailand with detectable coronary artery calcium who underwent stress perfusion CMR within 180 days of CT.

E

Exposure

Non-contrast computed tomography (CT) for coronary artery calcium (CAC) scoring (Agatston method) followed by 1.5T or 3.0T adenosine stress perfusion cardiac magnetic resonance (CMR) and late gadolinium enhancement (LGE) imaging

O

Outcome

Prevalence and predictors of inducible myocardial ischemia on stress perfusion CMR (defined as a subendocardial perfusion defect persisting beyond peak myocardial enhancement and for several RR intervals, >2 pixels wide, following ≥1 coronary arteries, without LGE in the corresponding segment)surrogate

Main Result

Odds Ratio: 1.07 (95% CI 1.03–1.1)

p-value: p=<0.001

In patients with detectable coronary artery calcium undergoing downstream stress perfusion CMR, myocardial ischemia was present in 26.0% (occurring exclusively at CAC ≥300 AU and reaching 41.6% at CAC ≥1,000 AU) and prompted medication modifications in 37.2% and invasive coronary procedures in 18.1% of patients.

Limitations

Single-center study with a modest sample size
Cohort consisted entirely of Southeast Asian patients, limiting generalizability to other ethnic populations
Retrospective, referral-based design introducing selection bias
CMR interpreters were not blinded to CAC scores or baseline clinical characteristics
ROC-derived CAC threshold of ≥1,093 AU lacked external validation
Single-center study with a modest sample size, limiting generalizability
Cohort consisted entirely of Southeast Asian patients, whose distinct risk profiles may not apply to other ethnic populations
Retrospective, referral-based design introducing substantial selection bias, as only patients selectively referred for downstream stress perfusion CMR were included
ROC-derived CAC threshold of ≥1,093 AU was identified within a single-center cohort without external validation

Implication

May support CAC-informed ischemia testing selection; leaves open prospective validation before practice change.

Abstract

Background Coronary artery calcium (CAC) scoring effectively stratifies cardiovascular risk, and stress perfusion cardiac magnetic resonance (CMR) accurately detects myocardial ischemia. We aimed to investigate the prevalence and factors associated with myocardial ischemia on CMR in patients with CAC, and to assess the clinical impact of myocardial ischemia following CMR. Methods This study included 215 patients aged ≥18 years who underwent CAC scoring for risk stratification, followed by stress CMR between 2013 and 2026. The prevalence and predictors of myocardial ischemia were investigated. Receiver operating characteristic (ROC) analysis was performed to assess the association between CAC scores and myocardial ischemia. Additionally, subsequent clinical management following CMR was determined. Results The mean age was 69.3 ± 9.1 years (60.9% male). The average 10-year PREVENT risk score was 18.6 ± 8.7%. Overall, myocardial ischemia was present in 26.0% of patients (56/215): 17.1% in the CAC 300–999 Agatston units (AU) group (14/82) and 41.6% in the CAC ≥ 1,000 AU group (42/101). CAC score was the only independent predictor of myocardial ischemia (adjusted OR 1.07, 95%CI 1.03 − 1.10; p < 0.001 per 100 AU). Across clinical risk score categories and diabetes status, CAC score was consistently associated with myocardial ischemia, with no significant interactions observed (all p for interaction >0.05).The number of ischemic segments increased with increasing CAC scores (p < 0.001). ROC analysis demonstrated an optimal cutoff threshold of CAC ≥ 1,093 AU for detecting myocardial ischemia (AUC 0.75, p < 0.001). The clinical impact of stress CMR included medication changes in 37.2% of patients, while 18.1% underwent invasive procedures. Conclusions In patients with CAC scores undergoing stress CMR, the prevalence of myocardial ischemia was approximately one-fourth and was associated with higher CAC scores. Stress CMR may influence clinical management in this population. Larger or prospective studies validating these findings and evaluating prognosis are warranted.

Discussion

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Cite This Study

Kaolawanich et al. (2026) conducted a cohort in Coronary artery calcification undergoing stress perfusion cardiac magnetic resonance imaging (n=215). Coronary artery calcium (CAC) score (per 100 Agatston units) vs. Lower CAC scores was evaluated on Myocardial ischemia on stress perfusion CMR (adjusted OR 1.07 per 100 AU, 95% CI 1.03-1.10, p=<0.001). Coronary artery calcium score independently predicted myocardial ischemia on stress CMR (aOR 1.07 per 100 AU, 95% CI 1.03-1.10; p < 0.001), with an overall ischemia prevalence of 26.0%.

synapsesocial.com/papers/6ae682cae432e7a5c4ef375f https://doi.org/10.1371/journal.pone.0361659

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Association between coronary artery calcium score and myocardial ischemia assessed by stress perfusion cardiac magnetic resonance imaging

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Association between coronary artery calcium score and myocardial ischemia assessed by stress perfusion cardiac magnetic resonance imaging

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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