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Guidelines for Endothelial Testing

Coronary Calcium + Endothelial Function Testing Predict Outcomes Better than each Alone

Atherosclerosis. 2017 Nov 3;267:146-152.

Impact of flow-mediated dilatation and coronary calcification in providing

complementary information on the severity of coronary artery disease.

Arakawa K1, Ohno M2, Horii M2, Ishigami T3, Kimura K4, Tamura K3.

Author information

Department of Cardiology, Fujisawa Shonandai Hospital, Kanagawa, Japan. Electronic address: hiroking@gamma.ocn.ne.jp.
Department of Cardiology, Fujisawa Shonandai Hospital, Kanagawa, Japan.
Department of Medical Science and Cardiorenal Medicine, Yokohama City University, School of Medicine, Kanagawa, Japan.
Division of Cardiology, Yokohama City University Medical Center, Kanagawa, Japan.



Endothelial dysfunction and coronary artery calcification (CAC) may represent two distinct and separate processes in the development of coronary atherosclerosis. However, the interaction between these factors in determining the development of coronary artery disease (CAD) is uncertain.


Brachial artery flow-mediated dilatation (FMD) was measured by high-resolution ultrasound before coronary angiography, in 156 patients undergoing coronary CT angiography on suspicion of CAD (M/F 100/56, age 67 ± 11yrs). CAC score was measured with the Agatston method.


The discriminative performance of FMD and CAC score in predicting the presence of type C lesion, multivessel disease, and high SYNTAX score (>22) was determined by ROC curve analysis. The optimal cutoff values for type C lesion were FMD < 3.70% (AUC 0.663, p = 0.037) and log(CACscore+1) 6.452 (AUC 0.735, p = 0.006). The combination of these cutoff values identified the lesion with the highest predictive accuracy of 82%. In addition, the optimal cutoff values for multivessel disease were FMD <5.40% (AUC 0.689, p = 0.001) and log(CACscore+1) > 5.914 (AUC 0.731, p = 0.001), while those for high SYNTAX score were FMD <4.10% (AUC 0.664, p = 0.020) and log(CACscore+1) < 6.693 (AUC 0.817, p = 0.001). The combined measurement of each cutoff value identified multivessel disease and high SYNTAX score with predictive accuracy of 77% and 83%, respectively, which were significantly higher than each parameter alone, with the exception of the predictive accuracy of log(CACscore+1) for high SYNTAX score (p = 0.083).


Endothelial dysfunction and CAC may provide complementary information in predicting the extent and severity of coronary artery disease.


Coronary artery calcification; Coronary artery disease; Endothelial dysfunction; Flow-mediated dilatation; Multidetector computed tomography


A similar study by Dr. Budoff’s team at Harbor UCLA showed the following, and suggesting that a comprehensive assessment of

vascular health requires all 3 (measuring risk factors, structural assessment e.g. coronary calcium, and functional

assessment e.g. endothelial function).


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Comprehensive Assessment Requires All 3 Assess.png
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