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Multicenter Study

. 2019 May;12(5):852-861.

doi: 10.1016/j.jcmg.2017.12.017. Epub 2018 Feb 14.

Coronary Artery Calcium Scores and Atherosclerotic Cardiovascular Disease Risk Stratification in Smokers

Adam Leigh¹, John W McEvoy², Parveen Garg³, J Jeffrey Carr⁴, Veit Sandfort⁵, Elizabeth C Oelsner⁶, Matthew Budoff⁷, David Herrington¹, Joseph Yeboah⁸

Affiliations

Affiliations

¹ Heart and Vascular Center of Excellence, Wake Forest University School of Medicine, Winston Salem, North Carolina.
² Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.
³ Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.
⁴ Departments of Cardiology and Radiology, Vanderbilt University School of Medicine, Nashville, Tennessee.
⁵ Clinical Center, National Institutes of Health, Bethesda, Maryland.
⁶ Departments of Medicine and Epidemiology, Columbia University, New York, New York.
⁷ Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles, Torrance California.
⁸ Heart and Vascular Center of Excellence, Wake Forest University School of Medicine, Winston Salem, North Carolina. Electronic address: jyeboah@wakehealth.edu.

PMID: 29454784
PMCID: PMC6085167
DOI: 10.1016/j.jcmg.2017.12.017

Multicenter Study

Coronary Artery Calcium Scores and Atherosclerotic Cardiovascular Disease Risk Stratification in Smokers

Adam Leigh et al. JACC Cardiovasc Imaging. 2019 May.

. 2019 May;12(5):852-861.

doi: 10.1016/j.jcmg.2017.12.017. Epub 2018 Feb 14.

Authors

Adam Leigh¹, John W McEvoy², Parveen Garg³, J Jeffrey Carr⁴, Veit Sandfort⁵, Elizabeth C Oelsner⁶, Matthew Budoff⁷, David Herrington¹, Joseph Yeboah⁸

Affiliations

¹ Heart and Vascular Center of Excellence, Wake Forest University School of Medicine, Winston Salem, North Carolina.
² Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.
³ Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.
⁴ Departments of Cardiology and Radiology, Vanderbilt University School of Medicine, Nashville, Tennessee.
⁵ Clinical Center, National Institutes of Health, Bethesda, Maryland.
⁶ Departments of Medicine and Epidemiology, Columbia University, New York, New York.
⁷ Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles, Torrance California.
⁸ Heart and Vascular Center of Excellence, Wake Forest University School of Medicine, Winston Salem, North Carolina. Electronic address: jyeboah@wakehealth.edu.

PMID: 29454784
PMCID: PMC6085167
DOI: 10.1016/j.jcmg.2017.12.017

Abstract

Objectives: This study assessed the utility of the pooled cohort equation (PCE) and/or coronary artery calcium (CAC) for atherosclerotic cardiovascular disease (ASCVD) risk assessment in smokers, especially those who were lung cancer screening eligible (LCSE).

Background: The U.S. Preventive Services Task Force recommended and the Centers for Medicare & Medicaid Services currently pays for annual screening for lung cancer with low-dose computed tomography scans in a specified group of cigarette smokers. CAC can be obtained from these low-dose scans. The incremental utility of CAC for ASCVD risk stratification remains unclear in this high-risk group.

Methods: Of 6,814 MESA (Multi-Ethnic Study of Atherosclerosis) participants, 3,356 (49.2% of total cohort) were smokers (2,476 former and 880 current), and 14.3% were LCSE. Kaplan-Meier, Cox proportional hazards, area under the curve, and net reclassification improvement (NRI) analyses were used to assess the association between PCE and/or CAC and incident ASCVD. Incident ASCVD was defined as coronary death, nonfatal myocardial infarction, or fatal or nonfatal stroke.

Results: Smokers had a mean age of 62.1 years, 43.5% were female, and all had a mean of 23.0 pack-years of smoking. The LCSE sample had a mean age of 65.3 years, 39.1% were female, and all had a mean of 56.7 pack-years of smoking. After a mean of 11.1 years of follow-up 13.4% of all smokers and 20.8% of LCSE smokers had ASCVD events; 6.7% of all smokers and 14.2% of LCSE smokers with CAC = 0 had an ASCVD event during the follow-up. One SD increase in the PCE 10-year risk was associated with a 68% increase risk for ASCVD events in all smokers (hazard ratio: 1.68; 95% confidence interval: 1.57 to 1.80) and a 22% increase in risk for ASCVD events in the LCSE smokers (hazard ratio: 1.22; 95% confidence interval: 1.00 to 1.47). CAC was associated with increased ASCVD risk in all smokers and in LCSE smokers in all the Cox models. The C-statistic of the PCE for ASCVD was higher in all smokers compared with LCSE smokers (0.693 vs. 0.545). CAC significantly improved the C-statistics of the PCE in all smokers but not in LCSE smokers. The event and nonevent net reclassification improvements for all smokers and LCSE smokers were 0.018 and -0.126 versus 0.16 and -0.196, respectively.

Conclusions: In this well-characterized, multiethnic U.S. cohort, CAC was predictive of ASCVD in all smokers and in LCSE smokers but modestly improved discrimination over and beyond the PCE. However, 6.7% of all smokers and 14.2% of LCSE smokers with CAC = 0 had an ASCVD event during follow-up.

Keywords: atherosclerotic cardiovascular disease; cigarette smokers; coronary artery calcium; pooled cohort equation.

Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosure: None.

Figures

Figure 1. CAC categories by ASCVD events in smokers
Percent of all smokers and lung cancer screening eligible smokers within coronary calcium score categories with Atherosclerotic Cardiovascular Disease event after a mean of 11.1 years of follow up.

Figure 2. Degree of smoking by CAC categories and ASCVD events
Display of tertiles of pack year of cigarette smoking by coronary artery calcium (CAC) scores categories and atherosclerotic cardiovascular disease (ASCVD) events in MESA.

Figure 3. Survival of smokers by CAC categories
A: Survival Curves showing the Atherosclerotic Cardiovascular Disease Event -free survival of all Cigarette smokers with coronary artery calcium (CAC) score / CAC categories and those with CAC absent at baseline MESA exam. B: Survival Curves showing the Atherosclerotic Cardiovascular Disease Event -free survival of lung cancer screening eligible smokers with coronary artery calcium (CAC) score / CAC categories and those with CAC absent at baseline MESA exam

Figure 3. Survival of smokers by CAC categories
A: Survival Curves showing the Atherosclerotic Cardiovascular Disease Event -free survival of all Cigarette smokers with coronary artery calcium (CAC) score / CAC categories and those with CAC absent at baseline MESA exam. B: Survival Curves showing the Atherosclerotic Cardiovascular Disease Event -free survival of lung cancer screening eligible smokers with coronary artery calcium (CAC) score / CAC categories and those with CAC absent at baseline MESA exam

See this image and copyright information in PMC

Comment in

Coronary Calcium and Selection for Risk Reduction: Reverend Bayes Has His Say.
Marwick TH. Marwick TH. JACC Cardiovasc Imaging. 2019 May;12(5):862-864. doi: 10.1016/j.jcmg.2018.03.030. Epub 2018 Nov 15. JACC Cardiovasc Imaging. 2019. PMID: 30448147 No abstract available.

References

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1. Anonymous. Final Recommendation Statement: Lung Cancer: Screening. US Preventive Services Task Force; [Accessed December 7, 2016]. Available at https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendati....
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1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics—2015 Update A Report From the American Heart Association. Circulation. 2015;131:e29–e322. - PubMed

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