Long-term all-cause and cause-specific mortality in asymptomatic patients with CAC ≥ 1000: Results from the Coronary Artery Calcium Consortium

• Type of Material: Article
• Authors: Allison W. Peng, Johns Hopkins University; Mohammadhassan Mirbolouk, Johns Hopkins University; Olusola A. Orimoloye, Johns Hopkins University; Albert D. Osei, Johns Hopkins University; Zeina Dardari, Johns Hopkins University; Omar Dzaye, Johns Hopkins University; Matthew J. Budoff, Harbor-UCLA Medical Center; Leslee Shaw, Emory University; Michael D. Miedema, Minneapolis Heart Institute; John Rumberger, Princeton Longevity Center; Daniel S. Berman, Cedars-Sinai Medical Center; Alan Rozanski, Mount Sinai School of Medicine; Mouaz H. Al-Mallah, Houston Methodist Hospital; Khurram Nasir, Yale University; Michael J. Blaha, Johns Hopkins University
• Language: English
• Date: 2020-01-01
• Publisher: Elsevier
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2020 by the American College of Cardiology Foundation. Published by Elsevier.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jcmg.2019.02.005
• Title of Journal or Parent Work: JACC: Cardiovascular Imaging
• Volume: 13
• Issue: 1 Pt 1
• Start Page: 83
• End Page: 93
• Grant/Funding Information: MJB is supported by NIH/NHLBI L30 HL110027. There are no financial disclosures to support.
• Keywords: cardiovascular imaging; risk scoring; coronary artery calcium; primary prevention; high risk
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management; Health Sciences, Pathology

Abstract

Objectives We thoroughly explored the demographic and imaging characteristics, as well as all-cause and cause-specific mortality of CAC≥1000 patients in the largest dataset of this population to date. Background Coronary artery calcium (CAC) is commonly used to quantify cardiovascular risk. Current guidelines classify CAC>300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with CAC≥1000. Methods We included 66,636 asymptomatic adults from the CAC Consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for CVD, CHD, cancer, and all-cause mortality. Using multivariable Cox proportional hazards regression models adjusted for age, sex, and traditional risk factors, we assessed the relative mortality hazard of individuals with CAC≥1000 compared first against a reference of CAC=0, and then against CAC 400–999. Results There were 2,869 patients with CAC≥1000 (86.3% male, mean age 66.3 ± 9.7 years). Most CAC≥1000 patients had 4-vessel CAC (mean 3.5 ± 0.6 vessels), and had greater total CAC area, higher mean CAC density, and more extra-coronary calcium (79% with TAC, 46% with AVC, 21% with MVC) compared to CAC 400–999. After full adjustment, those with CAC≥1000 had 5.04 (3.92–6.48), 6.79 (4.74–9.73), 1.55 (1.23–1.95), and 2.89-fold (2.53–3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC=0. The CAC≥1000 group had a 1.71- (1.41–2.08), 1.84- (1.43–2.36), 1.36- (1.07–1.73), and 1.51-fold (1.33–1.70) increased CVD, CHD, cancer, and all-cause mortality compared to CAC 400–999. Graphical analysis of CAC≥1000 revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau. Conclusions Patients with extensive CAC (CAC≥1000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC≥1000 a distinct risk group which may benefit from the most aggressive preventive therapy.