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. 2021 May;14(5):990-1002.
doi: 10.1016/j.jcmg.2020.06.048. Epub 2020 Oct 28.

Warranty Period of a Calcium Score of Zero: Comprehensive Analysis From MESA

Omar Dzaye  1 , Zeina A Dardari  2 , Miguel Cainzos-Achirica  2 , Ron Blankstein  3 , Arthur S Agatston  4 , Matthias Duebgen  5 , Joseph Yeboah  6 , Moyses Szklo  7 , Matthew J Budoff  8 , Joao A C Lima  9 , Roger S Blumenthal  2 , Khurram Nasir  10 , Michael J Blaha  11
Affiliations

Warranty Period of a Calcium Score of Zero: Comprehensive Analysis From MESA

Omar Dzaye et al. JACC Cardiovasc Imaging. 2021 May.

Abstract

Objectives: This study sought to quantify and model conversion of a normal coronary artery calcium (CAC) scan to an abnormal CAC scan.

Background: Although the absence of CAC is associated with excellent prognosis, progression to CAC >0 confers increased risk. The time interval for repeated scanning remains poorly defined.

Methods: This study included 3,116 participants from the MESA (Multi-Ethnic Study of Atherosclerosis) with baseline CAC = 0 and follow-up scans over 10 years after baseline. Prevalence of incident CAC, defined by thresholds of CAC >0, CAC >10, or CAC >100, was calculated and time to progression was derived from a Weibull parametric survival model. Warranty periods were modeled as a function of sex, race/ethnicity, cardiovascular risk, and desired yield of repeated CAC testing. Further analysis was performed of the proportion of coronary events occurring in participants with baseline CAC = 0 that preceded and followed repeated CAC testing at different time intervals.

Results: Mean participants' age was 58 ± 9 years, with 63% women, and mean 10-year cardiovascular risk of 14%. Prevalence of CAC >0, CAC >10, and CAC >100 was 53%, 36%, and 8%, respectively, at 10 years. Using a 25% testing yield (number needed to scan [NNS] = 4), the estimated warranty period of CAC >0 varied from 3 to 7 years depending on sex and race/ethnicity. Approximately 15% of participants progressed to CAC >10 in 5 to 8 years, whereas 10-year progression to CAC >100 was rare. Presence of diabetes was associated with significantly shorter warranty period, whereas family history and smoking had small effects. A total of 19% of all 10-year coronary events occurred in CAC = 0 prior to performance of a subsequent scan at 3 to 5 years, whereas detection of new CAC >0 preceded 55% of future events and identified individuals at 3-fold higher risk of coronary events.

Conclusions: In a large population of individuals with baseline CAC = 0, study data provide a robust estimation of the CAC = 0 warranty period, considering progression to CAC >0, CAC >10, and CAC >100 and its impact on missed versus detectable 10-year coronary heart disease events. Beyond age, sex, race/ethnicity, diabetes also has a significant impact on the warranty period. The study suggests that evidence-based guidance would be to consider rescanning in 3 to 7 years depending on individual demographics and risk profile.

Keywords: coronary artery calcium; coronary artery disease; risk assessment.

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Conflict of interest statement

Funding Support and Author Disclosures This research was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168 and N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences (NCATS). This publication was developed under the Science to Achieve Results (STAR) research assistance agreements, No. RD831697 (MESA Air) and RD-83830001 (MESA Air Next Stage), awarded by the U.S Environmental Protection Agency. It has not been formally reviewed by the EPA. The views expressed in this document are solely those of the authors and the EPA does not endorse any products or commercial services mentioned in this publication. All authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1.
Figure 1.. Cumulative annual incidence and prevalence of CAC, by incident CAC burden and ASCVD risk
A Cumulative annual incidence and B prevalence of CAC>0, CAC>10, CAC>100 among CAC=0 MESA participants who were re-scanned during follow-up. C Cumulative annual incidence and D prevalence of CAC>0 by ASCVD risk categories in the study population. ASCVD=Atherosclerotic cardiovascular disease risk; CAC=Coronary artery calcium.
Figure 2.
Figure 2.. Warranty period (in years) of CAC=0 in the total population and by race, sex, and desired yield of testing
Warranty period (in years) of CAC=0 in the total population as a function of race, sex and desired yield of testing (NNS). CAC=Coronary artery calcium; NNS=Number needed to screen.
Figure 3.
Figure 3.. Warranty period (in years) of CAC=0 in key subgroups
A Diabetes versus no diabetes B current smokers versus never-smokers and C family history of CHD versus no family history of CHD; warranty period shown as a function of sex and desired yield of testing. CAC=Coronary artery calcium; NNS=Number needed to screen.
Figure 4.
Figure 4.. Warranty period (in years) of CAC=0 in the total population using higher thresholds of detectable CAC (>10, >100), by estimated 10-year ASCVD risk, age. and desired yield of testing
Warranty period (in years) of CAC=0 in the total population using higher thresholds of detectable CAC (>10, >100) as a function of estimated 10-year atherosclerotic cardiovascular disease risk A, age B and desired yield of testing (NNS). ASCVD=Atherosclerotic cardiovascular disease risk; CAC=Coronary artery calcium; NNS=Number needed to screen.
Figure 5.
Figure 5.. CHD events in sub-cohorts of participants defined by rescan interval
CHD events in sub-cohorts of participants defined by rescan interval A 2–4 years; B 4–6 years; and C 6–10 years. CAC=Coronary artery calcium; CHD=Coronary heart disease.
Central Illustration.
Central Illustration.. Warranty period of zero coronary artery calcium
(Top left) Cumulative annual prevalence of CAC>0, CAC>10, CAC>100 among CAC=0 MESA participants who were re-scanned during follow-up. (Top right) Warranty period (in years) of CAC=0 in the total population by race and diabetes. (Bottom) CHD event rate in sub-cohort of participants defined by 4–6 years rescan interval. CAC=Coronary artery calcium; CHD=Coronary heart disease.
See this image and copyright information in PMC

Comment in

  • Extending the Warranty for Risk-Free Living.
    Shaw LJ. Shaw LJ. JACC Cardiovasc Imaging. 2021 May;14(5):1003-1004. doi: 10.1016/j.jcmg.2021.01.018. Epub 2021 Mar 17. JACC Cardiovasc Imaging. 2021. PMID: 33744137 No abstract available.

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