Time for a Policy Change for Coronary Artery Calcium Testing in Asymptomatic People?

Greenland, Philip; Polonsky, Tamar S.

doi:10.1016/j.jacc.2011.06.048

Cited by 8 publications

(5 citation statements)

References 17 publications

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“…Given the potential for increased future use of CAC quantification to assess individual cardiac risk 17 , as well as the expected increase in CT-based lung cancer screening in smokers 12 , it is important to evaluate whether all those with CAC=0 are uniformly at low risk for future events. While longer follow-up will be needed to confirm our finding of increased mortality in smokers with CAC=0 compared to nonsmokers with CAC=0, it seems prudent that the former group not be presently considered as low risk as the latter.…”

Section: Discussionmentioning

confidence: 99%

Mortality Rates in Smokers and Nonsmokers in the Presence or Absence of Coronary Artery Calcification

McEvoy¹,

Blaha²,

Rivera³

et al. 2012

JACC: Cardiovascular Imaging

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Objectives To further study the interplay between smoking status, Coronary Artery Calcium (CAC) and all-cause mortality. Background Prior studies have not directly compared the relative prognostic impact of CAC in smokers versus non-smokers. In particular, while zero CAC is a known favorable prognostic-marker, whether smokers without CAC have as good a prognosis as non-smokers without CAC is unknown. Given computed tomography (CT) screening for lung cancer appears effective in smokers, the relative prognostic implications of visualizing any CAC versus no CAC on such screening also deserve study. Methods Our study cohort consisted of 44,042 asymptomatic individuals referred for non-contrast cardiac CT (age 54±11 years, 54% males). Subjects were followed for a mean of 5.6 years. The primary endpoint was all-cause mortality. Results Approximately 14% (n=6020) of subjects were active smokers at enrollment. There were 901 deaths (2.05%) overall, with increased mortality in smokers vs. non-smokers (4.3% vs. 1.7%, p<0.0001). Smoking remained a risk factor for mortality across increasing strata of CAC scores (1-100, 101-400, and >400). In multivariable analysis within these strata, we found mortality hazard ratios (HRs) of 3.8 (95% CI, 2.8-5.2), 3.5 (2.6-4.9), and 2.7 (2.1-3.5), respectively, in smokers compared to nonsmokers. At each stratum of elevated CAC score, mortality in smokers was consistently higher than mortality in non-smokers from the CAC stratum above. However, among the 19,898 individuals with CAC=0, the mortality HR for smokers without CAC was 3.6 (95% CI, 2.3-5.7), compared to non-smokers without CAC. Conclusion Smoking is a risk factor for death across the entire spectrum of subclinical coronary atherosclerosis. Smokers with any coronary calcification are at significantly increased future mortality risk than smokers without CAC. However, the absence of CAC may not be as useful a “negative risk factor” in active smokers; as this group has mortality rates similar to non-smokers with mild to moderate atherosclerosis.

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Section: Discussionmentioning

confidence: 99%

Mortality Rates in Smokers and Nonsmokers in the Presence or Absence of Coronary Artery Calcification

McEvoy¹,

Blaha²,

Rivera³

et al. 2012

JACC: Cardiovascular Imaging

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“…5,6 As angina is not predictive for the presence or extent of CAC, a CAC screening in asymptomatic people has been proposed, but the applicability of a CAC examination as a risk stratification tool in the general population remains controversial. [7][8][9][10] Current guidelines on CVD prevention from the European Society of Cardiology and on the assessment of cardiovascular risk in asymptomatic adults from the American College of Cardiology Foundation/American Heart Association provides Class IIb recommendations for the use of CAC in asymptomatic adults at intermediate risk. 11,12 However, the previous studies on the impact of CAC on cardiovascular stratification in cohorts from the general population might be biased by issues such as relatively low response rates or selective recruitment by lists of residents, telephone company customers or other local sources, [13][14][15] and follow-up of nonparticipants has never been performed.…”

Section: Introductionmentioning

confidence: 99%

External validity of a cardiovascular screening including a coronary artery calcium examination in middle-aged individuals from the general population

Grønhøj

Gerke

Mickley

et al. 2018

Eur J Prev Cardiolog

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Background Coronary artery calcium is important in cardiovascular risk stratification, but this knowledge is based on studies with a significant selection bias. This study aims to evaluate the external validity of a screening programme including coronary artery calcium examination, and the association between coronary artery calcium and cardiovascular events. Design Multi-centre population based study. Methods Randomly selected middle-aged men and women ( N = 1751) free of cardiovascular disease were invited to the examination during 2009–2010. Participation rate in the examination was 70%. Participants ( n = 1227) and non-participants ( n = 524) were compared regarding: cardiovascular medical treatment, Charlson comorbidity index and socioeconomic status (evaluated by cohabitation, gross income and education). Study endpoints were cardiovascular events and mortality. Results Non-participants had a significant higher comorbidity ( p = 0.003) and a lower socioeconomic status ( p < 0.0001), while cardiovascular medical treatment was alike. Over a median follow-up time of 6.5 years the cardiovascular event and mortality rates were equal (6.7% vs. 6.4%, p = 0.80 and 0.4% vs. 0.5%, p = 0.76, respectively). Adjusted hazard ratio was 0.90 (95% confidence interval (CI) 0.63–1.37). Among participants, the extent of coronary artery calcium was significantly associated with increased risk of cardiovascular events (hazard ratio 1.92, 95% CI 1.03–3.54, hazard ratio 3.66, 95% CI 1.82–7.32, hazard ratio 6.51, 95% CI 3.17–13.36 for coronary artery calcium scores 1–99, 100–399, ≥400 AU, respectively). Conclusions Non-participants had a higher comorbidity index and a lower socioeconomic status, but the cardiovascular event and mortality rates were equal to those of participants. Thus, a screening programme including a coronary artery calcium examination had a high external validity regarding cardiovascular risk, but also a significant social imbalance.

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“…where risk-based treatment decisions are uncertain [3,19]. Given the additional healthcare costs, radiation exposure and inconvenience associated with a screening strategy using CAC, it is important to consider cost-effectiveness [20]. The few studies that investigated this in general favored a CAC strategy, particularly in men [21,22,23].…”

Section: Coronary Artery Calcium Scorementioning

confidence: 99%

Cardiac imaging and circulating biomarkers for primary prevention in the era of precision medicine

Myhre

Lyngbakken

Tveit

et al. 2019

Expert Review of Precision Medicine and Drug Development

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Introduction: Current primary prevention guidelines do not strongly support the use of cardiovascular imaging and circulating biomarkers in the risk assessment. Still, an increasing body of evidence suggests that important prognostic information can be obtained from imaging and biomarker measurements. Areas covered: In this review, we will describe the most important imaging modalities (coronary computed tomography, myocardial perfusion imaging, carotid intima media thickness, echocardiography and cardiac magnetic resonance imaging) and circulating biomarkers (cardiac troponins, B-type natriuretic peptides and C-reactive protein) for risk prediction in people without known cardiovascular disease. We will discuss both the prognostic performance and clinical utility of these biomarkers in the era of primary prevention with increased focus on precision medicine. Finally, we will comment on the use of cardiac biomarkers in screening for additional work-up with cardiac imaging and the combination of the entities in risk prediction. Expert opinion: We believe future primary prevention should to a larger extent integrate measurements of cardiovascular biomarkers and non-invasive imaging to enhance the precision of subclinical disease detection and risk stratification. The use of cardiovascular biomarkers as a screening tool for further testing with non-invasive imaging may be a costeffective strategy.

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Time for a Policy Change for Coronary Artery Calcium Testing in Asymptomatic People?

Abstract: Recent clinical practice guidelines for coronary artery calcium (CAC) testing in asymptomatic people vary in their advice about routine testing from moderately enthusiastic support to frank opposition. The

Cited by 8 publications

References 17 publications

Mortality Rates in Smokers and Nonsmokers in the Presence or Absence of Coronary Artery Calcification

Mortality Rates in Smokers and Nonsmokers in the Presence or Absence of Coronary Artery Calcification

External validity of a cardiovascular screening including a coronary artery calcium examination in middle-aged individuals from the general population

Cardiac imaging and circulating biomarkers for primary prevention in the era of precision medicine

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