Prevalence, Vascular Distribution, and Multi-Territorial Extent of Subclinical Atherosclerosis in a Middle-Aged Cohort | Journal Scan

Study Questions:

What is the prevalence, distribution, and extent of subclinical atherosclerosis in middle-aged populations?


The PESA (Progression of Early Subclinical Atherosclerosis) study prospectively enrolled 4,184 asymptomatic bank employees in Madrid, Spain, to evaluate the systemic extent of atherosclerosis in the carotid, abdominal aortic, and ilio-femoral territories by 2-D/3-D ultrasound and coronary artery calcification (CAC) by computed tomography. The extent of subclinical atherosclerosis, defined as presence of plaque or CAC ≥1, was classified as focal (one site affected), intermediate (2-3 sites), or generalized (4-6 sites).


Age ranged from 40-54 years (mean age 45.8 years, 63% male); 42% had dyslipidemia; and 78% had 0-1, 18% had 2, and 5% had >2 coronary risk factors. Subclinical atherosclerosis was present in 63% of participants (71% of men; 48% of women). Intermediate and generalized atherosclerosis was identified in 41%. Plaques were most common in the ilio-femorals (44%), followed by carotids (31%) and aorta (25%), while CAC was present in 18%. Among participants with low Framingham Heart Study (FHS) 10-year risk, subclinical disease was detected in 58%, with intermediate or generalized disease in 36%. When assessing longer-term risk (30-year FHS), 83% of participants at high risk had atherosclerosis, with 66% classified as intermediate or generalized.


Subclinical atherosclerosis was highly prevalent in this middle-aged cohort, with nearly half the participants classified as having intermediate or generalized disease. Most participants at high FHS risk had subclinical disease; nonetheless, extensive atherosclerosis was also present in a substantial number of low-risk individuals, suggesting added value of imaging for diagnosis and prevention.


Like MESA (Multi-Ethnic Study of Atherosclerosis), PESA was conducted in an unselected population. CAC was much less likely in middle-aged women, but the prevalence of aortic atherosclerosis was similar to that of men. Interestingly, of the subjects with CAC = 0, nearly 60% had plaques at other vascular sites. Follow-up of the PESA cohort will allow for the comparison of the value of noncoronary atherosclerosis sites and CAC for predicting cardiovascular events, which may differ by sex.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Computed Tomography, Nuclear Imaging

Keywords: Atherosclerosis, Coronary Artery Disease, Diagnostic Imaging, Dyslipidemias, Follow-Up Studies, Middle Aged, Prevalence, Primary Prevention, Prospective Studies, Risk Factors, Tomography, X-Ray Computed, Vascular Calcification

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