Calcified coronary artery disease: Mechanisms, risk factors and clinical consequences

doi:10.4331/wjbc.121278

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World Journal of Biological Chemistry

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1949-8454

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Biol Chem. Sep 5, 2026; 17(3): 121278
Published online Sep 5, 2026. doi: 10.4331/wjbc.121278

Calcified coronary artery disease: Mechanisms, risk factors and clinical consequences

Nikolaos Ktenopoulos, Anastasios Apostolos, Theoni Theodoropoulou, Paschalis Karakasis, Panagiotis Iliakis, Nikolaos Tsiamis, Nikias Milaras, Ioannis Skalidis, Kiriaki Evdaimon, Marios Sagris, Maria Drakopoulou, Andreas Synetos, George Latsios, Konstantinos Tsioufis, Konstantinos Toutouzas

Nikolaos Ktenopoulos, Anastasios Apostolos, Theoni Theodoropoulou, Panagiotis Iliakis, Nikolaos Tsiamis, Nikias Milaras, Marios Sagris, Maria Drakopoulou, Andreas Synetos, George Latsios, Konstantinos Tsioufis, Konstantinos Toutouzas, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Athens 11527, Greece

Paschalis Karakasis, Second Department of Cardiology, Medical School, Department of Hygiene, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece

Ioannis Skalidis, Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay Santé, Massy 91300, France

Kiriaki Evdaimon, Rea Gynecological Hospital, Athens 17564, Attikí, Greece

Kiriaki Evdaimon, Vocational High School of Rafina, Rafina 19009, Attikí, Greece

Author contributions: Ktenopoulos N and Apostolos A contributed to the conception and design of the review, literature search, drafting of the manuscript and critical revision of the intellectual content; Theodoropoulou T, Karakasis P, Iliakis P, Tsiamis N, Milaras N, Skalidis I and Evdaimon K contributed to the literature review, data collection, manuscript preparation and editing; Sagris M, Drakopoulou M, Synetos A and Latsios G contributed to critical revision of the manuscript and provided important scientific and clinical input; Tsioufis K and Toutouzas K supervised the work, contributed to the interpretation of the literature and critically revised the manuscript for important intellectual content; all authors reviewed and approved the final version of the manuscript.

AI contribution statement: Portions of this manuscript were edited using ChatGPT, an AI language model developed by OpenAI, solely for language refinement, improvement of clarity and assistance with manuscript formatting and response-to-reviewer preparation. The authors carefully reviewed, verified and approved all AI-assisted outputs. AI tools were not used to generate original scientific data, perform independent scientific analyses, interpret results, or draw scientific conclusions. The authors take full responsibility and accountability for the integrity, accuracy, originality and scientific validity of the manuscript and all submitted materials.

Conflict-of-interest statement: The authors declare that they have no conflict of interest regarding this review.

Corresponding author: Nikolaos Ktenopoulos, MD, FESC, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Vasilissis Sofias 114, Athens 11527, Greece. nikosktenop@gmail.com

Received: March 22, 2026
Revised: May 19, 2026
Accepted: June 16, 2026
Published online: September 5, 2026
Processing time: 167 Days and 5.3 Hours

Abstract

Coronary artery calcification is a common manifestation of advanced atherosclerosis and an important determinant of cardiovascular risk and procedural complexity during percutaneous coronary intervention (PCI). Calcification evolves from microcalcifications within the intima to larger fragmented, sheet-like or nodular deposits. Although extensive calcification often reflects stable plaque, specific patterns such as spotty calcification and eruptive calcified nodules are associated with plaque vulnerability and thrombotic events. In calcified lesions, PCI is technically challenging because calcium impairs balloon expansion, stent delivery and optimal stent deployment, increasing the risk of under-expansion and adverse outcomes. Intracoronary imaging with intravascular ultrasound and optical coherence tomography enables detailed calcium characterization and guides lesion preparation. This review summarizes the mechanisms, prevalence, risk factors, clinical consequences and contemporary management of calcified coronary artery disease.

Keywords: Coronary artery calcification; Atherosclerosis; Intravascular imaging; Calcified nodule; Percutaneous coronary intervention

Core Tip: Coronary artery calcification reflects both atherosclerotic burden and lesion complexity. While extensive sheet-like calcium is often associated with stable plaque, spotty calcification and eruptive calcified nodules may increase thrombotic risk. Intracoronary imaging with intravascular ultrasound and optical coherence tomography enables accurate calcium assessment and guides appropriate lesion preparation. A phenotype-driven approach may improve stent expansion and outcomes in patients undergoing percutaneous coronary intervention for calcified coronary artery disease.