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. 2015 Aug;8(8):900-9.
doi: 10.1016/j.jcmg.2015.01.025. Epub 2015 Jul 15.

A 15-Year Warranty Period for Asymptomatic Individuals Without Coronary Artery Calcium: A Prospective Follow-Up of 9,715 Individuals

Valentina Valenti  1 , Bríain Ó Hartaigh  2 , Ran Heo  1 , Iksung Cho  1 , Joshua Schulman-Marcus  3 , Heidi Gransar  4 , Quynh A Truong  1 , Leslee J Shaw  5 , Joseph Knapper  5 , Anita A Kelkar  5 , Pratik Sandesara  5 , Fay Y Lin  6 , Sebastiano Sciarretta  7 , Hyuk-Jae Chang  8 , Tracy Q Callister  9 , James K Min  10
Affiliations

A 15-Year Warranty Period for Asymptomatic Individuals Without Coronary Artery Calcium: A Prospective Follow-Up of 9,715 Individuals

Valentina Valenti et al. JACC Cardiovasc Imaging. 2015 Aug.

Abstract

Objectives: The aim of this study was to examine the long-term prognosis in asymptomatic individuals with a coronary artery calcium (CAC) score of 0 and its associated warranty period.

Background: Emerging evidence supports a CAC score of 0 as a favorable cardiovascular short-to intermediate-term prognostic factor.

Methods: A total of 9,715 individuals undergoing CAC imaging were stratified by age, Framingham risk score (FRS), and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) categories and followed for a mean of 14.6 years (range 12.9 to 16.8 years). Cox regression, area under the receiver-operating characteristic curve, and net reclassification information were used to assess all-cause mortality, discrimination, and reclassification of a CAC score of 0 compared with the FRS and NCEP ATP III, respectively. A warranty period was pre-defined as <1% annual mortality rate. Vascular age was estimated by linear regression.

Results: In 4,864 individuals with a baseline CAC score of 0 (mean age, 52.1 ± 10.8 years; 57.9% male), 229 deaths occurred. The warranty period of a CAC score of 0 was almost 15 years for individuals at low and intermediate risk with no significant differences regarding age and sex. A CAC score of 0 was associated with a vascular age of 1, 10, 20, and 30 years less than the chronological age of individuals between 50 and 59, 60 and 69, 70 and 79, and 80 years of age and older, respectively. The CAC score was the strongest predictor of death (hazard ratio: 2.67, 95% confidence interval: 2.29 to 3.11) that enabled discrimination and consistent reclassification beyond the FRS (area under the receiver-operating characteristic curve: 0.71 vs. 0.64, p < 0.001) and NCEP ATP III (area under the receiver-operating characteristic curve: 0.72 vs. 0.64, p < 0.001).

Conclusions: A CAC score of 0 confers a 15-year warranty period against mortality in individuals at low to intermediate risk that is unaffected by age or sex. Furthermore, in individuals considered at high risk by clinical risk scores, a CAC score of 0 confers better survival than in individuals at low to intermediate risk but with any CAC score.

Keywords: computed tomography; coronary artery calcium; mortality; prognosis; warranty period.

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Figures

Figure 1
Figure 1. 15-year cumulative mortality rate for the study period
15-year cumulative mortality rate according to the overall study population and individuals considered low risk by Framingham Risk (blue line), National Cholesterol Education Program Adult Treatment Panel III (purple line), the absence of any CAD risk factor (yellow line), and CAC = 0 (green line).
Figure 2
Figure 2. Hazard ratios for risk of all-cause mortality
Hazard ratios for risk of all-cause mortality among individuals with and without coronary artery calcification according to: (A) Framingham Risk Score, and (B) National Cholesterol Education Program Adult Treatment Panel III.
Figure 3
Figure 3. Annual mortality rate during the study period
An annual mortality rate below 1% was employed in order to classify individuals at low-risk of cardiovascular events.
Figure 4
Figure 4. Observed warranty period for absence of CAC compared with the presence of CAC
Observed warranty period (time to exceed 1% risk) for a CAC = 0 compared with the presence of any coronary artery calcium across 15 years of follow-up among 9715 asymptomatic individuals stratified by coronary artery calcium score, age, gender, Framingham risk score (FRS) and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III).
Figure 5
Figure 5. Differences between chronologic and vascular age
(A) Differences between chronologic versus vascular age in patients with zero coronary artery calcium score and (B) the corresponding annual mortality rate.
See this image and copyright information in PMC

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