Diabetes is a coronary heart disease risk equivalent. The associated high overall mortality is largely attributable to increased cardiovascular deaths1.     

Most of the morbidity and mortality in this high-risk condition are driven by accelerated atherosclerosis2, characterized by increased amounts of =connective tissue, glycoproteins and calcified plaque in the blood vessels 3. Imaging by computed tomography (CT) reveals that individuals afflicted with diabetes have extensive calcification of their vascular beds 4. 

In 1996 and subsequently in 2000, AHA consensus documents5 have stated that “CAC is a part of development of CAD and occurs exclusively in atherosclerotic CAD and is absent in normal arteries”. CAC plaque documents the presence of CAD in an individual patient as compared with just the presence of risk factors. Detection of asymptomatic CAD has been of great interest since the publication of the Screening for Heart Attack Prevention and Education (SHAPE) 6. Moreover, detection of vulnerable plaque leading to coronary events is of paramount importance. 

Several studies have shown that subclinical atherosclerosis, as measured by coronary artery calcium (CAC), predicts future cardiovascular disease (CVD) events and death, independent of conventional risk factors7, in the general population. Because individuals with diabetes represent a group at high risk for cardiovascular events and death, risk stratification may be particularly useful in this population.

This study examines and compares the extent of CAC in diabetics and non-diabetics by using Agatston Scoring.

The study was conducted in the Department of Radio Diagnosis, Sri Chamundeshwari Medical College Hospital and research institute from September 2024 to June 2026 STUDY GROUP CHARACTERISTICS Age Distribution: In our study, most patients- 21 of 50 (42%) were in the age bracket of 51-60 years. This is similar to the study on 11,490 individuals by Rumberger et al 38 where most patients were in the age distribution of 50-54yrs. Also in an Indian study by Agarwal et al 144, most patients were within 50-59 years. Then mean age in our study was 56.6 years which is lesser than most studies done in non-Indian population. Detrano et al 7 reported a mean age of 62.2 ± 10.2 yrs in a study of 6722 patients. In the non-coronary disease cohort of the study by Budoff et al- MESA study145, the mean age was 62 ± 10 years. The PREDICT study 146 which included patients with type 2 diabetes asymptomatic for coronary artery disease (similar to our study), the mean age was 62.9 years. In a comparative study of the CAC in diabetic and non-diabetic patients 147 (325 patients in each group) the mean age in both groups was 61.1 ± 8.2 years. In a subset of the Diabetes Heart Study where 1,051 diabetics were followed for mortality events based on their CAC then mean age was 61.7 ± 9.1 years. All these studies were mostly in the European or North American population. With a lower mean age in our study compared to these studies it is evident that the occurrence of diabetes and CAC is more and early in Indian population. Gender Distribution: Most patients in this study- 43 of 50 (86%) were males and only 7 of 50 (14%) were females. Among the diabetics and non-diabetics most patients were males- 23 of 25 (92%) and 20 of 25 (80%) respectively. In the study by Detrano et al 7 only 47.2 % of the participants were male. Budoff et al 145 reported a male incidence of 47% and 71% in the non-coronary heart disease and coronary heart disease cohorts respectively. In the diabetic cohort of our study, with 92% of the participants being male, this is significantly more than the previous published major studies. Only 46% (516 of 1123) of the patients were male in the study on diabetic patients and CAC done by Agarwal et al 148. In the PREDICT study 146 where only diabetics were analyzed, 67.68% of the patients were male. This shows that compared to other study populations, the prevalence of type 2 diabetic males was more in our study. GLYCOSYLATED HAEMOGLOBIN (HbA1C): In our study higher mean RBS was recorded in DM group and compared to Non-DM group and the difference between them was found to be statistically significant (p<0.001) and higher mean HbA1C was recorded in DM group compared to Non-DM group and the difference between them was found to be statistically significant (p<0.001). The mean HbA1C in the DM group was 7.83 % ± 1.26 %. In the PREDICT study 146 the mean HbA1C in 495 Type 2 diabetic subjects assessed for coronary calcification was 8.1% ± 1.6%. In the study on 1,123 diabetic patients by Agarwal et al 148 the mean HbA1C was 7.7% ± 1.8%. PATTERN OF VESSEL INVOLVEMENT Number of vessels involved: In Agatston scoring, the calcium score for each vessel is calculated separately and finally added to arrive at the final Agatston score. The number of vessels involved also varies depending on multiple factors. In our study the number of vessels involved in each group was not statistically significant (p value- 0.110). No calcification (hence no vessel involved) was seen in 3 patients (12%) and 6 (24%) patients in the DM and Non-DM group respectively. One vessel involvement was seen in 3 patients (12%) and 8 patients (32%) in the DM and non-DM groups respectively. One vessel involvement was the most common pattern of vessel involvement in the non- DM group. The incidence of two vessel involvement was equal in both groups- 7 patients (28%). Three vessel involvements were seen in 7 patients (28%) in the DM group and 3 patients (12%) in the non-DM group. In the DM group the most common pattern of vessel involvement was two and three vessel involvement- 7 patients each (28%). The maximum vessel involvement- 4 vessels, was seen in 5 patients (20%) in the DM group and only in 1 patient (4%) in the non- DM group. Even though the overall pattern of vessel involvement between the groups is not statistically significant the more extensive level of vessels involvement was more numerically in the DM group. In a study on Indian population by Agarwal et al144 on 105 patients where pattern of vessel involvement was divided as none, single vessel, double vessel and triple vessel , 32 patients has single vessel disease, 28 patients had double vessel disease, 23 patients had triple vessel disease and 22 patients had normal coronary arteries. In those with single vessel disease, 11 patients had DM and 21 patients were non DM. In those with double vessel disease, 16 patients had DM and 12 patients were non DM. In those with triple vessel disease, 17 patients had DM and 6 patients were non DM. In patients who had normal coronary arteries, 4 had DM and 18 patients were non DM. Number of lesions in each vessel: The least common vessel involved in CAC is the LM in both the DM and non DM group with a mean of 0.60 and 0.36 lesions respectively (p value- 0.559). On analyzing the number of lesions in the other vessels, the DM group has a significantly more number of lesions in all three- LAD, LCX and RCA when compared to the non DM group. The mean number of lesions in the LAD was 6.32 ± 8.1 in the DM group and 2.08 ± 2.43 in the non DM group with the number of lesions in the DM group significant (p value- 0.018). In the CX then mean number of lesion in the DM group was 2.40± 2.75 and in the non DM group was 0.84 ± 1.28 (p value- 0.011). In the RCA the mean number of lesions in the DM group was 4.96 ± 7.84 and in the non DM group was 0.64 ± 0.99 (p value- 0.011). On comparing the total number of lesions between two groups then mean number of lesions in the DM group was 14.20 ± 16.09 and in the non DM group was 3.92 ± 3.96 and this difference was significant (p value- 0.004). AGATSTON SCORE On comparing the total Agatston score of the DM group and the non DM group the difference was statistically significant (420.97 ± 713 vs 55.08 ± 97.67, p value- 0.018). On comparing vessel by vessel basis also the difference was statistically significant with higher scores recorded in the DM group than the non DM group except with regard to the LM. The Agatston score in the DM group and non DM group in the LM, LAD, CX and RCA were 21.58 ± 67.19 vs 6.64 ± 32.91 ( p value- 0.323), 246.74 ± 443.57 vs 33.02 ± 81.31 (p value- 0.026), 35.43 ± 46.77 vs 8.99 ± 17.20 (p value- 0.013) and 117.22 ± 247.23 vs 6.42 ± 15.38 ( p value- 0.035) respectively. In the PREDICT study 146 where diabetics were only studied, the mean CAC was 119 (range- 16 to 490). In a study by Sosnowski et al 147the highest median value was observed in type 2 diabetic men (95.5 AU; range, 0–3755). The median CAC in non-diabetic men (24.5, range 0–3036) was as high as in diabetic women (24.5 AU, 0–3755). In the study on diabetics by Agarwal et al 148 the mean CAC was 1,706.1 among all participants and significantly high- 3,182.5, in diabetics who faced mortality. In a study on 30,904 diabetics without coronary artery disease, the mean CAC among diabetic and non-diabetic men were 346 ± 749 and 127 ± 359 (p value- <0.001) respectively. Among the diabetic and non-diabetic women the mean CAC scores were 142 ± 479 and 52 ± 219 (p value- <0.001) respectively. Compared with non-diabetic subjects, men and women with diabetes exhibited higher CAC scores across all ages, with the exception of women 40 to 44 years of age and men and women ≥70 years of age. Within each five-year age group, diabetic men exhibited consistently higher CAC scores than did diabetic women (p <0.001 for all comparisons), except for the youngest age group (subjects <40 years old; p = 0.05)149. In a recent comparative study lead in Cuba by Peix et al 150, the CCS in diabetic patients was 74.1±168.8AU vs 5.2±14.6AU in controls, p<0.01. Furthermore they found that the 13.6% diabetic patients had a CCS greater than 100AU. In our study severity of CAC by Agatston scores were graded as nil when CAC is zero, mild when CAC is 1 to 100, moderate when CAC is 101- 399, severe when CAC is 400- 99 and extensive when CAC is > 1000. On grading final scores of all patients in both groups based on the above criteria the overall severity of CAC in the DM was significantly more than the non DM group ( p value- 0.024). In the DM group and non DM group, 3 patients (12%) and 6 patients (24%) had no CAC. In the non DM group, mild calcification was the most common type of severity of CAC with 16 patients (64%) having a CAC of 1-100. In the DM group, mild and moderate severity of CAC was seen most commonly and equally with 8 patients (32%) in each category. Severe CAC was seen in 3 patients (12%) in the DM group and only 1 patient (4%) in the non DM group. There were no patients with extensive CAC (>1000AU) in the non DM group but 3 patients in the DM group had extensive CAC. In the MESA study by Budoff et al 145 involving 6,814 patients, CAC of 0, 1-100, 101-400 and >400 was noted in 2167, 859, 373 and 202 women respectively and 1249, 935, 554 and 475 men respectively. In the PREDICT study 146 on individuals with Type 2 diabetes asymptomatic for coronary heart disease, 495 patients were stratified based on their severity of CAC (measures by EBCT) in a method almost similar to the stratification in our study. Most patients were in the CAC group of 11-100 and 101-400 with each having >120 patients. In the study by Agarwal et al 148 on diabetics where the CAC stratification was similar to that in our study, CAC <10, 10-99, 100-299, 300-999 and ≥1000 was reported in 14%, 21%, 12%, 17% and 36% of the patients respectively. Most patients in this study were with extensive CAC. In an Indian study by Agarwal et al 144, 105 patients underwent CAC measurement. 72 patients recorded a CAC between 0-250, 15 had a CAC of 250-500 and 20 patients recorded a CAC>500. On comparing the CS in the 0-250 range there were 49 non DM as compared to 23 DM. However when a CAC of >250 was compared, the ratio of DM to non DM patients a marked increase. In the study by Sosnowski et al 147, in a head to head comparison with non-diabetic patients with the same prevalence of traditional risk factors, the proportion of type 2 diabetic patients with a positive CACS reached almost 75% and were higher than in non-diabetics. Moreover, the proportion of diabetic patients with the CACS between 400 and 1000 AU or above 1000 AU was twice higher than that of non-diabetics. Interestingly, the above differences were more pronounced in women, while in men aged 60 years and older, these differences were no longer observed. Budoff et al 145 point out that the best way to assess the test result is to use the absolute value of coronary calcium, using values of 100 and 400 to differentiate between patients at low and very high risk. On comparing our study results with previous studies it is evident that the extent and severity of CAC depends on the type of population studied and direct comparisons are possible only with matched populations. Formulas for calculation of Agatston Score , Volume Score and Density Score . AGATSTON SCORE : CAC = Area x Density factor VOLUME SCORE : Area x Slice thickness DENSITY SCORE : Agatston Score ÷ Volume Score x 1 / Slice thickness

 Coronary artery calcification (CAC) is a well-established marker of the total burden of coronary atherosclerosis.

 In our study of 50 patients ( 25 diabetic and 25 non-diabetic patients ) conducted in Department of Radiodiagnosis Sri Chamundeshwari Medical College Hospital  and research institute from September 2024 to June  2026

most of the patients (42%) belonged to 51-60 years and most of the patients were males (86%).

 Diabetic patients showed more number of calcific plaques in LAD, LCA and RCA than non-diabetics.

 Diabetics have higher total number of lesions and more extensive vessel involvement than non-diabetics.

 In our study the LM is the least common vessel involved in both diabetics and non- diabetics.

 Double and triple vessel involvement is more common in diabetics than non-diabetics.

 Diabetic patients showed significantly higher total Agatston score than non- diabetics.

 Coronary artery calcium scoring by Agatston scoring can be used as a non-invasive diagnostic imaging method to evaluate coronary artery disease, for screening risk of future cardiac events.

SUMMARY

• Cardiovascular disease in Diabetics is more severe, complex and results in higher complication rates than in non-diabetics.
• The objective of this study is to assess the Calcium Scoring by Agatston Scoring in Multi Detector Computed Tomography of the heart in Diabetics and non –diabetics and to compare the severity between them.
• 50 patients (25 diabetic and 25 non-diabetic patients) referred to the Department of Radiodiagnosis, Sri Chamundeshwari Medical College Hospital and research institute from September 2024 to June  2026

were included in this descriptive study.

• In our study, most patients- 21 of 50 (42%) were in the age bracket of 51-60 years.
• Most patients in this study- 43 of 50 (86%) were males and only 7 of 50 (14%) were females.
• In our study higher mean RBS was recorded in DM group compared to non-DM group and the difference between them was found to be statistically significant (p<0.001) and higher mean HbA1C was recorded in DM group compared to non-DM group and the difference between them was found to be  statistically significant ( p<0.001).
• One vessel involvement was the most common pattern of vessel involvement in the non - DM group.
• Double and triple vessel involvement is more common in DM than non – DM group.
• Diabetic patients had more extensive level of vessel involvement than non-diabetic patients.
• Diabetic patients had significantly more number of lesions in LAD, LCX and RCA than non-diabetic patients.
• On comparing the total number of lesions between two groups, the mean number of lesions in the DM group was 14.20 ± 16.09 and in the non -DM group was 3.92 ± 3.96 and this difference was significant (p value- 0.004).
• On comparing the total Agatston score of the DM group and the non- DM group, the difference was statistically significant (420.97 ± 713 vs 55.08 ± 97.67, p value- 0.018).
• Coronary artery calcium scoring by Agatston scoring was significantly higher in Diabetic patients than in non –diabetic patients and hence it can be used as a non invasive diagnostic imaging method to evaluate coronary artery disease, for screening risk of future cardiac events and in the stratification

of diabetic patients into more aggressive risk factor management regimens.

Agatston result : Total Agatston Score (AS): 0  - ZERO CALCIFICATION

Agatston result : Total AS: 72.8 – MILD CALCIFICATION

MPR images showing  few calcific plaques along LAD 

Agatston result :Total AS : 198.6 – MODERATE CALCIFICATION

MPR images  showing few calcific plaques along LAD 

MPR images  showing multiple dense calcific plaques along LAD 

Agatston result : Total AS : 760.9 – SEVERE CALCIFICATION