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Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future
Michael G Silverman1, James R Harkness1, Ron Blankstein2
1Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.
Insights
Coronary artery calcium (CAC) burden and distribution predict future revascularization needs in asymptomatic individuals. Higher CAC scores and more affected vessels increase the likelihood of needing percutaneous coronary intervention or coronary artery bypass grafting (CABG).
Area of Science:
- Cardiovascular Imaging and Diagnostics
- Preventive Cardiology
- Interventional Cardiology
Background:
- Coronary revascularization decisions are influenced by disease extent and location.
- The relationship between coronary artery calcium (CAC) burden, distribution, and future revascularization type remains unclear.
Purpose of the Study:
- To assess how coronary artery calcium (CAC) burden and its regional distribution predict the need for and type of future coronary revascularization.
- To differentiate between percutaneous coronary intervention and coronary artery bypass graft (CABG) based on CAC characteristics in asymptomatic individuals.
Main Methods:
- Analysis of 6,540 asymptomatic MESA study participants (aged 45-84) with vessel-specific CAC measurements.
- Follow-up for a median of 8.5 years to track revascularization events and types.
- Multivariate analysis of CAC score, number of vessels with CAC, and specific artery involvement predicting revascularization.
Main Results:
- Revascularization occurred in 4.2% of participants, primarily symptom-driven.
- Revascularization rates increased with higher CAC scores and more widespread CAC distribution.
- Three- or four-vessel CAC, higher burden, and left main involvement independently predicted CABG over percutaneous coronary intervention.
Conclusions:
- Baseline coronary artery calcium (CAC) burden and distribution are strong predictors of future coronary revascularization in asymptomatic individuals.
- CAC measures independently forecast the need for percutaneous coronary intervention versus CABG over 8.5 years.
Objectives:
The aim of this study was to evaluate the impact of coronary artery calcium (CAC) burden and regional distribution on the need for and type of future coronary revascularization-percutaneous versus surgical (coronary artery bypass graft [CABG])-among asymptomatic subjects.
Background:
The need for coronary revascularization and the chosen mode of revascularization are thought to be functions of disease burden and anatomic distribution. The association between the baseline burden and regional distribution of CAC and the risk and type of future coronary revascularization remains unknown.
Methods:
A total of 6,540 participants in the MESA (Multi-Ethnic Study of Atherosclerosis) (subjects aged 45 to 84 years, free of known baseline cardiovascular disease) with vessel-specific CAC measurements were followed for a median of 8.5 years (interquartile range: 7.7 to 8.6 years). Annualized rates and multivariate-adjusted hazard ratios for revascularization and revascularization type were analyzed according to CAC score category, number of vessels with CAC (0 to 4, including the left main coronary artery), and involvement of individual coronary arteries.
Results:
A total of 265 revascularizations (4.2%) occurred during follow-up, and 206 (78% of the total) were preceded by adjudicated symptoms. Revascularization was uncommon when CAC score was 0.0 (0.6%), with a graded increase over both rising CAC burden and increasingly diffuse CAC distribution. The revascularization rates per 1,000 person-years for CAC scores of 1 to 100, 101 to 400, and >400 were 4.9, 11.7, and 25.4, respectively; for 1, 2, 3, and 4 vessels with CAC, the rates were 3.0, 8.0, 16.1, and 24.8, respectively. In multivariate models adjusting for CAC score, the number of vessels with CAC remained predictive of revascularization and mode of revascularization. Independent predictors of CABG versus percutaneous coronary intervention included 3- or 4-vessel CAC, higher CAC burden, and involvement of the left main coronary artery. Risk for CABG was extremely low with <3-vessel baseline CAC. Results were similar when considering only symptom-driven revascularizations.
Conclusions:
In this multiethnic cohort of asymptomatic subjects, baseline CAC was highly predictive of future coronary revascularization procedures, with measures of CAC burden and distribution each independently predicting need for percutaneous coronary intervention versus CABG over an 8.5-year follow-up.
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