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CAC and Coronary Artery Disease in Young Adults
Study Questions:
Is coronary artery calcium (CAC) associated with coronary heart disease (CHD) in young adults?
Methods:
Data from the CARDIA (Coronary Artery Risk Development in Young Adults) study were used for the present analysis. CARDIA is a prospective community-based study of 5,115 black and white adults between the ages of 18 and 30 years at the time of enrollment (from March 25, 1985, to June 7, 1986). The cohort has been under surveillance for 30 years, with CAC measured 15 (n = 3,043), 20 (n = 3,141), and 25 (n = 3,189) years after recruitment. The mean follow-up period for incident events was 12.5 years, from the year 15 computed tomographic scan through August 31, 2014. The primary outcome of interest was incident CHD, which included fatal or nonfatal myocardial infarction (MI), acute coronary syndrome without MI, coronary revascularization, or CHD-related death. Additional outcomes included incident cardiovascular disease (CVD) (i.e., CHD, stroke, heart failure, and peripheral arterial disease) and all-cause mortality. The probability of developing CAC by age 32-56 years was estimated using clinical risk factors measured 7 years apart between ages 18 and 38 years.
Results:
A total of 3,043 participants (mean age 40.3 years; 1,383 men and 1,660 women) were included in the study at study year 15. Participants who had CAC comprised 10.2% of the cohort (n = 309), with a geometric mean Agatston score of 21.6 (interquartile range, 17.3-26.8). During the 12.5 years of follow-up (after completion of the CAC scoring), 57 incident CHD events and 108 incident CVD events were documented. Participants with any CAC had a fivefold increase in CHD events (hazard ratio [HR], 5.0; 95% confidence interval [CI], 2.8-8.7) and a threefold increase in CVD events (HR, 3.0; 95% CI, 1.9-4.7) with adjustment for demographics, risk factors, and treatments. When CAC scores were stratified, the risk for CHD events was 2.6 (95% CI, 1.0-5.7) for CAC 1-19, 5.8 (95% CI, 2.6-12.1) for CAC 20-99, and 9.8 (95% CI, 4.5-20.5) for CAC score of ≥100. A CAC score of ≥100 had an incidence of 22.4 deaths per 100 participants (HR, 3.7; 95% CI, 1.5-10.0), with most due to CHD. Risk factors for CVD in early adult life identified those above the median risk for developing CAC and, if applied, in a selective CAC screening strategy could reduce the number of people screened for CAC by 50% and the number imaged needed to find one person with CAC from 3.5 to 2.2.
Conclusions:
The authors concluded that the presence of CAC among individuals aged between 32 and 46 years was associated with increased risk of fatal and nonfatal CHD during 12.5 years of follow-up. A CAC score of ≥100 was associated with early death. Adults <50 years with any CAC, even with very low scores, identified on a computed tomographic scan are at elevated risk of clinical CHD, CVD, and death. Selective use of screening for CAC might be considered in individuals with risk factors in early adulthood to inform discussions about primary prevention.
Perspective:
These data suggest that there is benefit to measuring CAC among young adults. However, it remains to be determined if statin initiation in young adults significantly attenuates this risk.
Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Diagnostic Imaging, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Peripheral Arterial Disease, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Stroke, Tomography, X-Ray Computed, Vascular Calcification, Young Adult
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