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Observational Study
. 2014 May;7(5):476-486.
doi: 10.1016/j.jcmg.2014.03.005.

Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: multi-ethnic study of atherosclerosis

Michael G Silverman #  1 , James R Harkness #  1 , Ron Blankstein  2 , Matthew J Budoff  3 , Arthur S Agatston  4 , J Jeffrey Carr  5 , Joao A Lima  6 , Roger S Blumenthal  1 , Khurram Nasir  1   4 , Michael J Blaha  1
Affiliations
Observational Study

Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: multi-ethnic study of atherosclerosis

Michael G Silverman et al. JACC Cardiovasc Imaging. 2014 May.

Abstract

Objectives: The aim of this study was to evaluate the impact of coronary artery calcium (CAC) burden and regional distribution on the need for and type of future coronary revascularization-percutaneous versus surgical (coronary artery bypass graft [CABG])-among asymptomatic subjects.

Background: The need for coronary revascularization and the chosen mode of revascularization are thought to be functions of disease burden and anatomic distribution. The association between the baseline burden and regional distribution of CAC and the risk and type of future coronary revascularization remains unknown.

Methods: A total of 6,540 participants in the MESA (Multi-Ethnic Study of Atherosclerosis) (subjects aged 45 to 84 years, free of known baseline cardiovascular disease) with vessel-specific CAC measurements were followed for a median of 8.5 years (interquartile range: 7.7 to 8.6 years). Annualized rates and multivariate-adjusted hazard ratios for revascularization and revascularization type were analyzed according to CAC score category, number of vessels with CAC (0 to 4, including the left main coronary artery), and involvement of individual coronary arteries.

Results: A total of 265 revascularizations (4.2%) occurred during follow-up, and 206 (78% of the total) were preceded by adjudicated symptoms. Revascularization was uncommon when CAC score was 0.0 (0.6%), with a graded increase over both rising CAC burden and increasingly diffuse CAC distribution. The revascularization rates per 1,000 person-years for CAC scores of 1 to 100, 101 to 400, and >400 were 4.9, 11.7, and 25.4, respectively; for 1, 2, 3, and 4 vessels with CAC, the rates were 3.0, 8.0, 16.1, and 24.8, respectively. In multivariate models adjusting for CAC score, the number of vessels with CAC remained predictive of revascularization and mode of revascularization. Independent predictors of CABG versus percutaneous coronary intervention included 3- or 4-vessel CAC, higher CAC burden, and involvement of the left main coronary artery. Risk for CABG was extremely low with <3-vessel baseline CAC. Results were similar when considering only symptom-driven revascularizations.

Conclusions: In this multiethnic cohort of asymptomatic subjects, baseline CAC was highly predictive of future coronary revascularization procedures, with measures of CAC burden and distribution each independently predicting need for percutaneous coronary intervention versus CABG over an 8.5-year follow-up.

Keywords: cardiac CT; coronary artery calcium; coronary artery disease; revascularization.

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Figures

Figure 1
Figure 1. Time Elapsed Between MESA Adjudicated MI or Angina and Revascularization
A majority of all revascularizations occurred within 10 days after adjudicated symptoms.
Figure 2AB
Figure 2AB. Revascularization Rate by CAC Score Group and Number of Coronary Arteries with CAC
There is a strong, statistically significant increase in revascularization with both increasing CAC score group and increasingly diffuse CAC.
Figure 2AB
Figure 2AB. Revascularization Rate by CAC Score Group and Number of Coronary Arteries with CAC
There is a strong, statistically significant increase in revascularization with both increasing CAC score group and increasingly diffuse CAC.
Figure 3AB
Figure 3AB. Kaplan Meier Estimates of Revascularization-Free Survival by CAC Burden and Distrubution
Logrank p<0.001 for both models.
Figure 3AB
Figure 3AB. Kaplan Meier Estimates of Revascularization-Free Survival by CAC Burden and Distrubution
Logrank p<0.001 for both models.
Figure 4AB
Figure 4AB. Rates of CABG vs. PCI by CAC Burden and Distribution
There is a strong, statistically significant increase in both PCI and CABG with both increasing CAC score group and increasing number of coronary arteries with CAC.
Figure 4AB
Figure 4AB. Rates of CABG vs. PCI by CAC Burden and Distribution
There is a strong, statistically significant increase in both PCI and CABG with both increasing CAC score group and increasing number of coronary arteries with CAC.
Figure 5ABC
Figure 5ABC. Proportion of Revascularizations that are PCI vs. CABG by CAC Burden and Distribution
CABG is more frequent with increasing CAC score group and with more diffusely distributed CAC. CABG becomes the predominant mode of revasculariation when all coronary arteries are diseased at baseline.
Figure 5ABC
Figure 5ABC. Proportion of Revascularizations that are PCI vs. CABG by CAC Burden and Distribution
CABG is more frequent with increasing CAC score group and with more diffusely distributed CAC. CABG becomes the predominant mode of revasculariation when all coronary arteries are diseased at baseline.
Figure 5ABC
Figure 5ABC. Proportion of Revascularizations that are PCI vs. CABG by CAC Burden and Distribution
CABG is more frequent with increasing CAC score group and with more diffusely distributed CAC. CABG becomes the predominant mode of revasculariation when all coronary arteries are diseased at baseline.
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