Coronary Artery Calcium Scores Indicating Secondary Prevention Level Risk: Findings from the CAC Consortium and FOURIER Trial

• Authors: Omar Dzaye, Johns Hopkins University; Alexander C Razavi, Johns Hopkins University; Erin D Michos, Johns Hopkins University; Martin Bødtker Mortensen, Johns Hopkins University; Zeina A Dardari, Johns Hopkins University; Khurram Nasir, Houston Methodist DeBakey Heart & Vascular Center, Houston; Albert D Osei, Johns Hopkins University; Allison W Peng, Johns Hopkins University; Ron Blankstein, Brigham and Women’s Hospital and Harvard Medical School; John H Page, Center for Observational Research, Amgen Inc., Thousand Oaks, CA, United States; Michael J Blaha, Johns Hopkins University
• Journal Title: ATHEROSCLEROSIS
• Volume: Volume 347
• Publisher: Elsevier | 2022-04-01, Pages 70-76
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.atherosclerosis.2022.02.006
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Oncology
• Keywords: coronary artery calcium; coronary artery disease; risk assessment

Abstract

Aims: Coronary artery calcium (CAC) burden displays a stepwise association with atherosclerotic cardiovascular disease (ASCVD) risk. Among primary prevention patients, we sought to determine the CAC scores equivalent to ASCVD mortality rates observed in the FOURIER trial, a modern secondary prevention cohort. Methods and Results: For the main analysis, we included participants from the CAC Consortium ≥50 years old with a 10-year ASCVD risk ≥7.5% (n=20,207). Poisson regression was used to define the relationship between CAC and annual ASCVD mortality. Equations generated from the regression models were then used to derive CAC scores associated with equivalent annual ASCVD mortality as observed in FOURIER placebo participants from the overall trial and in key trial subgroups. The CAC Consortium participants had a similar age (65.5 versus 62.5 years) and sex (22% versus 24% female) distribution as FOURIER. The annualized ASCVD mortality rate in FOURIER participants (0.766 per 100 person-years) corresponded to a CAC score of 781 (418–1467). A CAC score of 255 (162–394) corresponded to an ASCVD mortality rate equivalent to the lowest risk FOURIER subgroup (presence of myocardial infarction >2 years prior to trial enrollment). No CAC score produced a risk equivalent to high-risk FOURIER subgroups, particularly those with symptomatic peripheral arterial disease and/or multivessel coronary heart disease. Conclusion: Primary prevention individuals with increased CAC burden may have annualized ASCVD mortality rates equivalent to persons with stable secondary prevention-level risk. These findings argue for a risk continuum between higher risk primary prevention and stable secondary prevention patients, as their ASCVD risks may overlap.