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Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000
Alexander C Razavi1, Leslee J Shaw2, Daniel S Berman3
1Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
Insights
For patients with high coronary artery calcium (CAC) scores (≥1,000), diabetes and severe left main CAC identify very high atherosclerotic cardiovascular disease (ASCVD) risk. These factors indicate a need for intensified preventive therapies.
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Imaging
Background:
- A coronary artery calcium (CAC) score of ≥1,000 signifies subclinical atherosclerosis, a threshold for considering combination lipid-lowering therapy.
- However, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient group remains undefined.
Purpose of the Study:
- To identify specific risk factors associated with very high ASCVD mortality rates among individuals with a CAC score of ≥1,000.
- To refine risk stratification for asymptomatic patients with significant subclinical atherosclerosis.
Main Methods:
- The study analyzed 2,246 asymptomatic patients with CAC ≥1,000 and no prior ASCVD events.
- Cox proportional hazards regression was used to model ASCVD mortality over an 11.3-year median follow-up.
- Crude mortality rates were compared to established very high-risk criteria from secondary prevention trials.
Main Results:
- Diabetes (HR: 2.04) and severe left main (LM) CAC (CAC ≥300, HR: 2.32) were significantly associated with ASCVD mortality.
- ASCVD mortality rates per 100 person-years were elevated for diabetes (1.4) and severe LM CAC (1.3).
- Patients with both diabetes and severe LM CAC exhibited a markedly higher mortality rate (7.1).
Conclusions:
- Diabetes and severe LM CAC are key indicators of very high ASCVD risk in asymptomatic individuals with CAC ≥1,000.
- These findings highlight patient subgroups who may benefit from more aggressive preventive strategies.
- Intensified therapies, including statin therapy for LDL-cholesterol reduction, are warranted for these high-risk individuals.
Background:
Although a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined.
Objectives:
Among persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates.
Methods:
The authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years).
Results:
The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]).
Conclusions:
Among asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.
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