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Coronary Artery Calcium and Long-Term, Cause-Specific Mortality in Young Adults
Study Questions:
Is the prevalence of coronary artery calcium (CAC) in adults aged 30-49 years associated with subsequent coronary heart disease (CHD), cardiovascular disease (CVD), and all-cause mortality?
Methods:
The authors conducted a multicenter retrospective cohort study among 22,346 individuals from the CAC Consortium who underwent CAC testing (baseline examination, 1991-2010, with follow-up through June 30, 2014). CAC was quantified using computed tomography for clinical indications and each case was followed up for cause-specific mortality. Participants were free of clinical CVD at baseline. The 10-year risk of atherosclerotic CVD (ASCVD) was calculated according to the Pooled Cohort Equations (PCE) calculator. For individuals aged 30-39 years, the raw PCE was used with removal of the age limitation. Competing risks regression modeling was used to calculate multivariable-adjusted subdistribution hazard ratios for CHD and CVD mortality.
Results:
The sample of 22,346 participants (25.0% women) had a mean age of 43.5 (standard deviation [SD], 4.5) years, with a high prevalence of hyperlipidemia (49.6%) and family history of CHD (49.3%), but a low prevalence of current smoking (11.0%) and diabetes (3.9%). The prevalence of any CAC was 34.4%, with 7.2% having a CAC score of >100; 41% of those with a CAC score >100 had 0 or 1 traditional risk factor. Presence of CAC with score 1-100 was higher in those ages 40-49 years (29.3%) compared to 19% in those 30-39 years. During follow-up, 12.7 (SD, 4.0) years, there were 40 deaths related to CHD, 84 deaths related to CVD, and 298 total deaths. A total of 27 deaths related to CHD (67.5%) occurred among individuals with CAC at baseline. The CHD mortality rate per 1,000 person-years was 10-fold higher among those with a CAC score of >100 (0.69; 95% confidence interval [CI], 0.41-1.16) and fourfold with a score >0 (0.27; 95% CI, 0.19-0.40) compared with those with a CAC score of 0 (0.07; 95% CI, 0.04-0.12). After multivariable adjustment, those with a CAC score of >100 had a significantly increased risk of CHD (subdistribution hazard ratio, 5.6; 95% CI, 2.5-12.7), CVD (subdistribution hazard ratio, 3.3; 95% CI, 1.8-6.2), and all-cause mortality (hazard ratio, 2.6; 95% CI, 1.9-3.6) compared with those with a CAC score of 0.
Conclusions:
In a large sample of young adults undergoing CAC testing for clinical indications, 34.4% had CAC, and those with elevated CAC scores had significantly higher rates of CHD and CVD mortality. CAC may have potential utility for clinical decision making among select young adults at elevated risk of CVD.
Perspective:
The guidelines for primary prevention of ASCVD (particularly CHD and CHD mortality) encourage risk assessment and use of life-time risk for those 20-39 years and 10-year risk for persons 40-79 years. In those ages 40-79 years with intermediate risk (≥7.5-20%) or when risk is 5% to <7.5% with risk enhancers, CAC scoring has been proposed to help determine need for statins, aspirin, and antihypertensive therapy. This study suggests that CAC testing might be extended to younger adults with elevated lifetime risk for ASCVD (e.g., >39%) when there is uncertainty regarding treatment choices.
Clinical Topics: Cardiovascular Care Team, Dyslipidemia, Noninvasive Imaging, Prevention, Nonstatins, Novel Agents, Statins, Smoking
Keywords: Antihypertensive Agents, Aspirin, Atherosclerosis, Coronary Disease, Diabetes Mellitus, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipidemias, Middle Aged, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Smoking, Tomography
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