Ten-Year Association of CAC With ASCVD Events

Study Questions:

What is the contribution of coronary artery calcium (CAC) for atherosclerotic cardiovascular disease (ASCVD) events, and does the association of CAC with events vary by sex, race/ethnicity, or age category?


The investigators utilized MESA (Multi-Ethnic Study of Atherosclerosis), a prospective multi-ethnic cohort study of 6,814 participants (51% women), aged 45–84 years, free of clinical CVD at baseline. They evaluated the relationship between CAC and incident ASCVD using Cox regression models adjusted for age, race/ethnicity, sex, education, income, cigarette smoking status, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, diabetes, lipid-lowering medication, systolic blood pressure, antihypertensive medication, intentional physical exercise, and body mass index. Only the first event for each individual was used in the analysis.


Overall, 500 incident ASCVD (7.4%) events were observed in the total study population over a median of 11.1 years. Hard ASCVD included 217 myocardial infarctions (MI), 188 strokes (not transient ischemic attacks), 13 resuscitated cardiac arrests, and 82 coronary heart disease (CHD) deaths. Event rates in those with CAC = 0 Agatston units ranged from 1.3% to 5.6%, while for those with CAC >300, the 10-year event rates ranged from 13.1% to 25.6% across different age, gender, and racial subgroups. At 10 years of follow-up, all participants with CAC >100 were estimated to have >7.5% risk regardless of demographic subset. Ten-year ASCVD event rates increased steadily across CAC categories regardless of age, sex, or race/ethnicity. For each doubling of CAC, they estimated a 14% relative increment in ASCVD risk, holding all other risk factors constant. This association was not significantly modified by age, sex, race/ethnicity, or baseline lipid-lowering use.


The authors concluded that CAC is associated strongly and in a graded fashion with 10-year risk of incident ASCVD as it is for CHD.


This study reports that CAC is strongly associated with major adverse CV events (i.e., stroke, CV death, or nonfatal MI) regardless of sex, race/ethnicity, or age group. CAC measurement has emerged as a noninvasive test that can risk stratify asymptomatic individuals into low-, intermediate-, and high-risk groups and the 2013 American College of Cardiology/American Heart Association risk estimator suggests that CAC measurement may be appropriate both in patients with 10-year risk <7.5% and when treatment decisions are uncertain in higher-risk patients.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Lipid Metabolism, Nonstatins, Exercise, Smoking

Keywords: Antihypertensive Agents, Atherosclerosis, Blood Pressure, Body Mass Index, Cholesterol, HDL, Cholesterol, LDL, Coronary Disease, Diagnostic Imaging, Diabetes Mellitus, Exercise, Heart Arrest, Myocardial Infarction, Myocardial Ischemia, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Smoking, Stroke

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