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Published on: August 28, 2018
Use of Coronary Artery Calcium Quantification and Distribution for Coronary Vascular Disease Risk Reclassification in
Adel Hajj Ali1, Michael Nakhla1, Leslie Cho1
1Heart Vascular Thoracic Institute (HVTI), Cleveland Clinic, Cleveland, Ohio.
Insights
Coronary artery calcium scoring (CACS) significantly reclassifies cardiovascular disease risk compared to traditional scores. Multiethnic Study on Subclinical Atherosclerosis CACS (MESA-CACS) offers a more accurate primary prevention assessment than ASCVD and Reynolds risk scores.
Area of Science:
- Cardiology
- Preventive Medicine
- Radiology
Background:
- Cardiovascular disease (CVD) risk stratification is crucial for primary prevention.
- Traditional risk scores like ASCVD and Reynolds risk score (RRS) have limitations in accurately assessing risk in asymptomatic individuals.
- Subclinical atherosclerosis detection, particularly coronary artery calcium scoring (CACS), may improve risk prediction.
Purpose of the Study:
- To compare the risk reclassification provided by Multiethnic Study on Subclinical Atherosclerosis CACS (MESA-CACS) against established atherosclerotic cardiovascular disease (ASCVD) and Reynolds risk score (RRS).
- To evaluate the impact of CACS on risk stratification in asymptomatic middle-aged individuals undergoing primary prevention screening.
Main Methods:
- A cohort of 5,324 asymptomatic middle-aged individuals (57 ± 8 years, 76% male) who underwent CACS screening was analyzed.
- 10-year ASCVD, RRS, and MESA-CACS risk scores were calculated and categorized.
- Risk reclassification (upgrades and downgrades) was compared between MESA-CACS and the traditional scores.
Main Results:
- MESA-CACS reclassified risk in 45% of patients compared to ASCVD (31% downgrade, 14% upgrade).
- MESA-CACS reclassified risk in 41% of patients compared to RRS (26% downgrade, 15% upgrade).
- ASCVD overestimated risk in patients with 0-1 diseased arteries, while RRS overestimated risk with 0 CAC but underestimated with any CAC.
Conclusions:
- MESA-CACS, combined with coronary artery calcium (CAC) distribution, significantly reclassifies 10-year coronary vascular disease risk in primary prevention.
- MESA-CACS provides a more accurate risk assessment than ASCVD and RRS, with RRS underestimating and ASCVD overestimating risk in certain patient subgroups.
Abstract:
In a large screening program of asymptomatic middle-aged individuals, we sought to assess the degree of risk reclassification provided by comparing multiethnic study on subclinical atherosclerosis coronary artery calcium scoring (CACS) versus atherosclerotic cardiovascular disease (ASCVD) and Reynolds risk score (RRS) score. All 5,324 consecutive patients (aged 57 ± 8 years, 76% male) who underwent CACS screening at the Cleveland Clinic as part of a primary prevention executive health between March 16 and October 21 were included. The 10-year ASCVD, RRS, and multiethnic study on subclinical atherosclerosis CACS (MESA-CACS) risk scores were calculated and categorized as <1, 1 to 4.99, 5 to 9.99, and ≥10%. Compared with ASCVD, using MESA-CACS resulted in a downgraded risk in 1,667 subjects (31%), whereas 738 (14%) had an upgrade in risk (total of 45% reclassification). Similarly, compared with RRS, using MESA-CACS resulted in an upgraded risk in 797 (15%) and a downgrade in 1,380 (26%) subjects (total of 41% reclassification). However, by further dividing by the distribution of the coronary calcification, ASCVD overestimates the risk only for patients with coronary artery calcium (CAC) in 0 or 1 coronary artery only, whereas MESA-CACS overestimates if the CAC was noted in ≥2 arteries. Similarly, RRS only overestimates the risk for patients with 0 CAC, whereas it underestimates the risk for patients with any CAC. In conclusion, the use of MESA-CACS, along with CAC distribution in primary prevention clinics, results in differential and significant reclassification of traditional scores when calculating the 10-years coronary vascular disease risk. Overall, RRS underestimates and ASCVD overestimates the cardiovascular disease risk compared with MESA-CACS.
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