Abstract
BackgroundCardiovascular calcification outside of the coronary tree, known as extracoronary calcification (ECC), is highly prevalent, often occurs concurrently in multiple sites, and yet its prognostic value is unclear. ObjectiveTo determine whether multisite ECC is associated with coronary heart disease (CHD) events, CHD mortality, and all-cause mortality. MethodsWe evaluated 5903 participants from the Multi-Ethnic Study of Atherosclerosis without diabetes who underwent CT imaging for calcification of the aortic valve, aortic root, mitral valve, and thoracic aorta. Participants were followed for 10.3 years. Multivariable adjusted hazard ratios estimated risk of outcomes for increasing numbers of ECC sites (0, 1, 2, 3, and 4), and receiver operator characteristic analysis assessed model discrimination. ResultsPrevalence of any ECC was 45%; median age was 62 years. Compared with those without ECC, those with ECC in 4 sites had increased hazards of 4.5, 7.1 and 2.3 for CHD events, CHD mortality, and all-cause mortality, respectively, independent of traditional risk factors (TRF; all P ≤ .05), and had ≥2-fold increased hazards for outcomes independent of coronary artery calcification (CAC). Each additional site of ECC was positively associated with each outcome in a graded fashion. When added to TRF, ECC significantly increased the area under the receiver operator characteristic curve for all outcomes and modestly increased the area under the curve for mortality beyond TRF + CAC (0.799 to 0.802; P = .03). ConclusionIncreasing multisite ECC has a graded association with higher CHD and mortality risk, contributing information beyond TRF. Multisite ECC incidentally identified on imaging can be used to improve individualized risk prediction.
Highlights
Despite vigorous prevention efforts, 2 times as many coronary heart disease (CHD) events occur as first-time, rather than recurrent, events,[1] highlighting the need for improved CHD risk assessment and earlier intervention
extracoronary calcification (ECC) has the advantage of being identifiable on the same CT scan as CAC, as well as on noncardiac CT scans and a wide variety of imaging modalities, including plain radiography, dual-energy X-ray absorptiometry, echocardiography, and ultrasonography.2,6e8 calcification outside of the coronary tree a priori is not expected to predict CHD events more effectively than coronary calcification, ECC represents readily available informationeparticularly when found incidentallyewhich can be used to inform clinical decision making beyond traditional risk scores
Chinese were less likely than other ethnicities to have multisite ECC
Summary
2 times as many coronary heart disease (CHD) events occur as first-time, rather than recurrent, events,[1] highlighting the need for improved CHD risk assessment and earlier intervention. The preferential development of atherosclerosis in different cardiovascular locations among different patient populations invokes the possibility to improve subclinical CHD detection by measuring ECC.[5] studies have correlated individual sites of ECC with outcomes such as CHD events and mortality,[2,3,6] the significance of multisite ECC concurrently present in a given individual is not well characterized. Determining the prognostic value of ECC may allow the use of ECC information from various sources, possibly even without additional cost or harm to the patient, to direct primary prevention and improve cardiovascular risk prediction. The aim of this study is to use a simple, clinically applicable assessment of ECC to evaluate the hypothesis that multisite ECC is associated with and incrementally improves risk prediction for CHD events, CHD mortality, and all-cause mortality. Multivariable adjusted hazard ratios estimated risk of outcomes for increasing numbers of ECC sites (0, 1, 2, 3, and 4), and receiver operator characteristic analysis assessed model discrimination
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