Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000

Alexander C Razavi; Leslee J Shaw; Daniel S Berman; Matthew J Budoff; Nathan D Wong; Viola Vaccarino; Marly van Assen; Carlo N De Cecco; Arshed A Quyyumi; Anurag Mehta; Paul Muntner; Michael D Miedema; Alan Rozanski; John A Rumberger; Khurram Nasir; Roger S Blumenthal; Laurence S Sperling; Martin Bødtker Mortensen; Seamus P Whelton; Michael J Blaha; Omar Dzaye

doi:10.1016/j.jcmg.2023.12.006

Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000

JACC Cardiovasc Imaging. 2024 Feb 12:S1936-878X(24)00026-3. doi: 10.1016/j.jcmg.2023.12.006. Online ahead of print.

Authors

Alexander C Razavi¹, Leslee J Shaw², Daniel S Berman³, Matthew J Budoff⁴, Nathan D Wong⁵, Viola Vaccarino⁶, Marly van Assen⁷, Carlo N De Cecco⁷, Arshed A Quyyumi⁶, Anurag Mehta⁸, Paul Muntner⁹, Michael D Miedema¹⁰, Alan Rozanski¹¹, John A Rumberger¹², Khurram Nasir¹³, Roger S Blumenthal¹⁴, Laurence S Sperling⁶, Martin Bødtker Mortensen¹⁵, Seamus P Whelton¹⁴, Michael J Blaha¹⁴, Omar Dzaye¹⁶

Affiliations

¹ Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
² Icahn School of Medicine at Mount Sinai, Blavatnik Family Women's Health Research Institute, New York, New York, USA.
³ Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA.
⁴ Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA.
⁵ Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA.
⁶ Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA.
⁷ Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
⁸ VCU Health Pauley Heart Center and Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.
⁹ Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹⁰ Nolan Family Center for Cardiovascular Health, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.
¹¹ Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA.
¹² Corazon Imaging, Columbus, Ohio, USA.
¹³ Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
¹⁴ Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
¹⁵ Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
¹⁶ Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address: odzaye@jhmi.edu.

PMID: 38385932
DOI: 10.1016/j.jcmg.2023.12.006

Abstract

Background: Although a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined.

Objectives: Among persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates.

Methods: The authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years).

Results: The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]).

Conclusions: Among asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.

Keywords: LDL cholesterol; atherosclerotic cardiovascular disease; coronary artery calcium; diabetes; very high risk.