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Abstract
The level of coronary artery calcium (CAC) can effectively stratify cardiovascular risk in middle-aged and older adults, but its utility for young adults is unclear. To determine the prevalence of CAC in adults aged 30 to 49 years and the subsequent association of CAC with coronary heart disease (CHD), cardiovascular disease (CVD), and all-cause mortality. A multicenter retrospective cohort study was conducted among 22 346 individuals from the CAC Consortium who underwent CAC testing (baseline examination, 1991-2010, with follow-up through June 30, 2014; CAC quantified using nonconrast, cardiac-gated computed tomography scans) for clinical indications and were followed up for cause-specific mortality. Participants were free of clinical CVD at baseline. Statistical analysis was performed from June 1, 2017, to May 31, 2018. The prevalence of CAC and the subsequent rates of CHD, CVD, and all-cause mortality. Competing risks regression modeling was used to calculate multivariable-adjusted subdistribution hazard ratios for CHD and CVD mortality. The sample of 22 346 participants (25.0% women and 75.0% men; mean [SD] age, 43.5 [4.5] years) had a high prevalence of hyperlipidemia (49.6%) and family history of CHD (49.3%) but a low prevalence of current smoking (11.0%) and diabetes (3.9%). The prevalence of any CAC was 34.4%, with 7.2% having a CAC score of more than 100. During follow-up (mean [SD], 12.7 [4.0] years), there were 40 deaths related to CHD, 84 deaths related to CVD, and 298 total deaths. A total of 27 deaths related to CHD (67.5%) occurred among individuals with CAC at baseline. The CHD mortality rate per 1000 person-years was 10-fold higher among those with a CAC score of more than 100 (0.69; 95% CI, 0.41-1.16) compared with those with a CAC score of 0 (0.07; 95% CI, 0.04-0.12). After multivariable adjustment, those with a CAC score of more than 100 had a significantly increased risk of CHD (subdistribution hazard ratio, 5.6; 95% CI, 2.5-12.7), CVD (subdistribution hazard ratio, 3.3; 95% CI, 1.8-6.2), and all-cause mortality (hazard ratio, 2.6; 95% CI, 1.9-3.6) compared with those with a CAC score of 0. In a large sample of young adults undergoing CAC testing for clinical indications, 34.4% had CAC, and those with elevated CAC scores had significantly higher rates of CHD and CVD mortality. Coronary artery calcium may have potential utility for clinical decision-making among select young adults at elevated risk of cardiovascular disease.
Highlights
Multiple current cardiovascular guidelines rely on estimates of 10-year absolute risk of cardiovascular disease (CVD) to guide decisions regarding the allocation of preventive CVD medications.[1,2,3,4] Coronary heart disease (CHD) and CVD risk equations are heavily driven by age; as a result, younger adults are typically estimated to have a low 10-year risk of CVD despite the presence of nonoptimal risk factors and an elevated lifetime risk of CVD.[5]
During follow-up, there were 40 deaths related to CHD, 84 deaths related to CVD, and 298 total deaths
Those with a CAC score of more than 100 had a significantly increased risk of CHD, CVD, and all-cause mortality compared with those with a CAC score of 0
Summary
Multiple current cardiovascular guidelines rely on estimates of 10-year absolute risk of cardiovascular disease (CVD) to guide decisions regarding the allocation of preventive CVD medications.[1,2,3,4] Coronary heart disease (CHD) and CVD risk equations are heavily driven by age; as a result, younger adults are typically estimated to have a low 10-year risk of CVD despite the presence of nonoptimal risk factors and an elevated lifetime risk of CVD.[5] Experts have suggested that earlier treatment for young adults holds the potential to regress and suppress early atherosclerosis, who to treat and when to treat remain unclear.[6]. Coronary artery calcium (CAC) is a direct marker of atherosclerosis that can robustly stratify risk for individuals without known CVD,[7] allowing it to serve as a tool to aid clinical decision-making regarding preventive therapies for middle-aged adults.[8,9,10,11,12] The utility of CAC in younger populations is less clear. Prior CAC studies for younger adults have been limited by small sample sizes, a short duration of follow-up, and a lack of cause-specific mortality.[13,14,15] In response to calls for further research on this subject,[16] we sought to provide data from the CAC Consortium to help determine what role, if any, CAC may play in the identification of young adults at higher risk for CVD who may be candidates for more aggressive therapy for CVD prevention
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