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Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of
John W McEvoy1, Seth S Martin2, Zeina A Dardari2
1From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.). jmcevoy1@jhmi.edu.
Insights
Coronary artery calcium (CAC) imaging can help personalize systolic blood pressure (SBP) treatment intensity. CAC, combined with atherosclerotic cardiovascular disease (ASCVD) risk, guides SBP goals, especially for those with prehypertension or mild hypertension.
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Imaging
Background:
- Personalizing systolic blood pressure (SBP) treatment goals using atherosclerotic cardiovascular disease (ASCVD) risk is increasingly important.
- Coronary artery calcium (CAC) imaging may offer further guidance on antihypertensive treatment intensity.
Purpose of the Study:
- To investigate if CAC imaging can refine treatment intensity allocation for SBP.
- To assess the role of CAC in stratifying cardiovascular risk beyond traditional ASCVD risk scores.
Main Methods:
- Analysis of 3733 Multi-Ethnic Study of Atherosclerosis (MESA) participants with SBP 120-179 mm Hg.
- Stratification by SBP, 10-year ASCVD risk, and CAC score (0, 1-100, >100).
- Comparison of multivariable-adjusted hazard ratios for ASCVD or heart failure, and estimation of number-needed-to-treat for intensive SBP goals.
Main Results:
- In individuals with SBP <160 mm Hg, CAC significantly stratified event risk, particularly when ASCVD risk was <15%.
- For example, among those with ASCVD risk <15% and SBP 120-159 mm Hg, higher CAC scores correlated with increased hazard ratios for events.
- No clear association between CAC and events was observed when SBP was 160-179 mm Hg, irrespective of ASCVD risk.
Conclusions:
- Combined CAC imaging and ASCVD risk assessment can guide personalized SBP treatment goals (e.g., 140 vs. 120 mm Hg).
- This approach is particularly beneficial for adults with 5%-15% estimated ASCVD risk and prehypertension or mild hypertension.
- CAC imaging adds value in risk stratification for individuals not meeting higher ASCVD risk thresholds.
Background:
The use of atherosclerotic cardiovascular disease (ASCVD) risk to personalize systolic blood pressure (SBP) treatment goals is a topic of increasing interest. Therefore, we studied whether coronary artery calcium (CAC) can further guide the allocation of anti-hypertensive treatment intensity.
Methods:
We included 3733 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with SBP between 120 and 179 mm Hg. Within subgroups categorized by both SBP (120-139 mm Hg, 140-159 mm Hg, and 160-179 mm Hg) and estimated 10-year ASCVD risk (using the American College of Cardiology/American Heart Assocation pooled-cohort equations), we compared multivariable-adjusted hazard ratios for the composite outcome of incident ASCVD or heart failure after further stratifying by CAC (0, 1-100, or >100). We estimated 10-year number-needed-to-treat for an intensive SBP goal of 120 mm Hg by applying the treatment benefit recorded in meta-analyses to event rates within CAC strata.
Results:
The mean age was 65 years, and 642 composite events took place over a median of 10.2 years. In persons with SBP <160 mm Hg, CAC stratified risk for events. For example, among those with an ASCVD risk of <15% and who had an SBP of either 120 to 139 mm Hg or 140 to 159 mm Hg, respectively, we found increasing hazard ratios for events with CAC 1 to 100 (1.7 [95% confidence interval, 1.0-2.6] or 2.0 [1.1-3.8]) and CAC >100 (3.0 [1.8-5.0] or 5.7 [2.9-11.0]), all relative to CAC=0. There appeared to be no statistical association between CAC and events when SBP was 160 to 179 mm Hg, irrespective of ASCVD risk level. Estimated 10-year number-needed-to-treat for a SBP goal of 120mmHg varied substantially according to CAC levels when predicted ASCVD risk <15% and SBP <160mmHg (eg, 10-year number-needed-to-treat of 99 for CAC=0 and 24 for CAC>100, when SBP 120-139mm Hg). However, few participants with ASCVD risk <5% had elevated CAC. Furthermore, 10-year number-needed-to-treat estimates were consistently low and varied less among CAC strata when SBP was 160 to 179 mm Hg or when ASCVD risk was ≥15% at any SBP level.
Conclusions:
Combined CAC imaging and assessment of global ASCVD risk has the potential to guide personalized SBP goals (eg, choosing a traditional goal of 140 or a more intensive goal of 120 mm Hg), particularly among adults with an estimated ASCVD risk of 5% to 15% and prehypertension or mild hypertension.
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