Multicenter Study

. 2021 Sep 21;144(12):916-929.

doi: 10.1161/CIRCULATIONAHA.121.055340. Epub 2021 Sep 20.

Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population

Göran Bergström^{1

2}, Margaretha Persson^{3

4}, Martin Adiels⁵, Elias Björnson¹, Carl Bonander⁵, Håkan Ahlström⁶, Joakim Alfredsson^{7

8}, Oskar Angerås^{1

9}, Göran Berglund³, Anders Blomberg¹⁰, John Brandberg^{11

12}, Mats Börjesson^{13

14

15}, Kerstin Cederlund¹⁶, Ulf de Faire¹⁷, Olov Duvernoy⁶, Örjan Ekblom¹⁸, Gunnar Engström³, Jan E Engvall^{8

19

20}, Erika Fagman^{11

12}, Mats Eriksson²¹, David Erlinge²², Björn Fagerberg^{1

15}, Agneta Flinck^{11

12}, Isabel Gonçalves²³, Emil Hagström^{24

25}, Ola Hjelmgren^{1

2}, Lars Lind²⁶, Eva Lindberg²⁷, Per Lindqvist²⁸, Johan Ljungberg¹⁰, Martin Magnusson^{3

29

30

31}, Maria Mannila³², Hanna Markstad^{33

34}, Moman A Mohammad²², Fredrik H Nystrom⁸, Ellen Ostenfeld³⁵, Anders Persson^{8

36

20}, Annika Rosengren^{1

15}, Anette Sandström¹⁰, Anders Själander¹⁰, Magnus C Sköld^{37

38}, Johan Sundström^{26

39}, Eva Swahn^{7

8}, Stefan Söderberg¹⁰, Kjell Torén^{40

15}, Carl Johan Östgren^{8

20}, Tomas Jernberg⁴¹

Affiliations

¹ Department of Molecular and Clinical Medicine (G. Bergström, E.B., O.A., B.F., O.H., A.R.), University of Gothenburg, Sweden.
² Departments of Clinical Physiology (G. Bergström, O.H.), Region Västra Götaland, Gothenburg, Sweden.
³ Department of Clinical Sciences (M.P., G. Berglund, G.E., M. Magnusson), Lund University, Malmö, Sweden.
⁴ Departments of Internal Medicine (M.P.), Skåne University Hospital, Malmö, Sweden.
⁵ Sahlgrenska Academy, and School of Public Health and Community Medicine, Institute of Medicine (M.A., C.B.), University of Gothenburg, Sweden.
⁶ Section of Radiology, Department of Surgical Sciences (H.A., O.D.), Uppsala University, Sweden.
⁷ Departments of Cardiology (J.A., E.S.), Linköping University, Sweden.
⁸ Health, Medicine and Caring Sciences (J.A., E.S., J.E.E., F.H.N., C.J.Ö., A.P.), Linköping University, Sweden.
⁹ Cardiology (O.A.), Region Västra Götaland, Gothenburg, Sweden.
¹⁰ Department of Public Health and Clinical Medicine, Medicine and Heart Centre (A.B., J.L., A. Sandström, A. Själander, S.S.), Umeå University, Sweden.
¹¹ Department of Radiology, Institute of Clinical Sciences (J.B., E.F., A.F.), University of Gothenburg, Sweden.
¹² Radiology (J.B., E.F., A.F.), Region Västra Götaland, Gothenburg, Sweden.
¹³ Institute of Medicine (M.B.), University of Gothenburg, Sweden.
¹⁴ Center for Health and Performance (M.B.), University of Gothenburg, Sweden.
¹⁵ Sahlgrenska University Hospital (M.B., B.F., A.R., K.T.), Region Västra Götaland, Gothenburg, Sweden.
¹⁶ Department of Clinical Science, Intervention and Technology (K.C.), Karolinska Institutet, Stockholm, Sweden.
¹⁷ Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine (U.d.F.), Karolinska Institutet, Stockholm, Sweden.
¹⁸ Department of Physical Activity and Health, The Swedish School of Sport and Health Sciences (GIH), Stockholm, Sweden (Ö.E.).
¹⁹ Clinical Physiology (J.E.E.), Linköping University, Sweden.
²⁰ CMIV, Centre of Medical Image Science and Visualization (J.E.E., A.P., C.J.Ö.), Linköping University, Sweden.
²¹ Department of Endocrinology, Metabolism & Diabetes and Clinical Research Center, Karolinska University Hospital Huddinge, Stockholm, Sweden (M.E.).
²² Department of Clinical Sciences Lund, Cardiology, Lund University and Skåne University Hospital, Lund, Sweden (D.E., M.A.M.).
²³ Department of Clinical Sciences Malmö (I.G.), Lund University and Skåne University Hospital, Lund, Sweden.
²⁴ Cardiology (E.H.), Uppsala University, Sweden.
²⁵ Department of Medical Sciences, and Uppsala Clinical Research Center (E.H.), Uppsala University, Sweden.
²⁶ Clinical Epidemiology (L.L., J.S.), Uppsala University, Sweden.
²⁷ Respiratory, Allergy and Sleep Research (E.L.), Uppsala University, Sweden.
²⁸ Department of Surgical and Perioperative Sciences (P.L.), Umeå University, Sweden.
²⁹ Cardiology (M. Magnusson), Skåne University Hospital, Malmö, Sweden.
³⁰ Wallenberg Center for Molecular Medicine, Lund University, Sweden (M. Magnusson).
³¹ North-West University, Hypertension in Africa Research Team (HART), Potchefstroom, South Africa (M. Magnusson).
³² Heart and Vascular Theme, Department of Cardiology, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden (M. Mannila).
³³ Experimental Cardiovascular Research, Clinical Research Center, Clinical Sciences Malmö (H.M.), Lund University, Malmö, Sweden.
³⁴ Center for Medical Imaging and Physiology (H.M.), Lund University and Skåne University Hospital, Lund, Sweden.
³⁵ Department of Clinical Sciences Lund, Clinical Physiology (E.O.), Lund University and Skåne University Hospital, Lund, Sweden.
³⁶ Radiology (A.P.), Linköping University, Sweden.
³⁷ Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine (M.C.S.), Karolinska Institutet, Stockholm, Sweden.
³⁸ Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden (M.C.S.).
³⁹ The George Institute for Global Health, University of New South Wales, Sydney, Australia (J.S.).
⁴⁰ Occupational and Environmental Medicine/School of Public Health and Community Medicine (K.T.), University of Gothenburg, Sweden.
⁴¹ Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institutet, Stockholm, Sweden.

PMID: 34543072
PMCID: PMC8448414
DOI: 10.1161/CIRCULATIONAHA.121.055340

Multicenter Study

Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population

Göran Bergström et al. Circulation. 2021.

. 2021 Sep 21;144(12):916-929.

doi: 10.1161/CIRCULATIONAHA.121.055340. Epub 2021 Sep 20.

Authors

Affiliations

¹ Department of Molecular and Clinical Medicine (G. Bergström, E.B., O.A., B.F., O.H., A.R.), University of Gothenburg, Sweden.
² Departments of Clinical Physiology (G. Bergström, O.H.), Region Västra Götaland, Gothenburg, Sweden.
³ Department of Clinical Sciences (M.P., G. Berglund, G.E., M. Magnusson), Lund University, Malmö, Sweden.
⁴ Departments of Internal Medicine (M.P.), Skåne University Hospital, Malmö, Sweden.
⁵ Sahlgrenska Academy, and School of Public Health and Community Medicine, Institute of Medicine (M.A., C.B.), University of Gothenburg, Sweden.
⁶ Section of Radiology, Department of Surgical Sciences (H.A., O.D.), Uppsala University, Sweden.
⁷ Departments of Cardiology (J.A., E.S.), Linköping University, Sweden.
⁸ Health, Medicine and Caring Sciences (J.A., E.S., J.E.E., F.H.N., C.J.Ö., A.P.), Linköping University, Sweden.
⁹ Cardiology (O.A.), Region Västra Götaland, Gothenburg, Sweden.
¹⁰ Department of Public Health and Clinical Medicine, Medicine and Heart Centre (A.B., J.L., A. Sandström, A. Själander, S.S.), Umeå University, Sweden.
¹¹ Department of Radiology, Institute of Clinical Sciences (J.B., E.F., A.F.), University of Gothenburg, Sweden.
¹² Radiology (J.B., E.F., A.F.), Region Västra Götaland, Gothenburg, Sweden.
¹³ Institute of Medicine (M.B.), University of Gothenburg, Sweden.
¹⁴ Center for Health and Performance (M.B.), University of Gothenburg, Sweden.
¹⁵ Sahlgrenska University Hospital (M.B., B.F., A.R., K.T.), Region Västra Götaland, Gothenburg, Sweden.
¹⁶ Department of Clinical Science, Intervention and Technology (K.C.), Karolinska Institutet, Stockholm, Sweden.
¹⁷ Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine (U.d.F.), Karolinska Institutet, Stockholm, Sweden.
¹⁸ Department of Physical Activity and Health, The Swedish School of Sport and Health Sciences (GIH), Stockholm, Sweden (Ö.E.).
¹⁹ Clinical Physiology (J.E.E.), Linköping University, Sweden.
²⁰ CMIV, Centre of Medical Image Science and Visualization (J.E.E., A.P., C.J.Ö.), Linköping University, Sweden.
²¹ Department of Endocrinology, Metabolism & Diabetes and Clinical Research Center, Karolinska University Hospital Huddinge, Stockholm, Sweden (M.E.).
²² Department of Clinical Sciences Lund, Cardiology, Lund University and Skåne University Hospital, Lund, Sweden (D.E., M.A.M.).
²³ Department of Clinical Sciences Malmö (I.G.), Lund University and Skåne University Hospital, Lund, Sweden.
²⁴ Cardiology (E.H.), Uppsala University, Sweden.
²⁵ Department of Medical Sciences, and Uppsala Clinical Research Center (E.H.), Uppsala University, Sweden.
²⁶ Clinical Epidemiology (L.L., J.S.), Uppsala University, Sweden.
²⁷ Respiratory, Allergy and Sleep Research (E.L.), Uppsala University, Sweden.
²⁸ Department of Surgical and Perioperative Sciences (P.L.), Umeå University, Sweden.
²⁹ Cardiology (M. Magnusson), Skåne University Hospital, Malmö, Sweden.
³⁰ Wallenberg Center for Molecular Medicine, Lund University, Sweden (M. Magnusson).
³¹ North-West University, Hypertension in Africa Research Team (HART), Potchefstroom, South Africa (M. Magnusson).
³² Heart and Vascular Theme, Department of Cardiology, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden (M. Mannila).
³³ Experimental Cardiovascular Research, Clinical Research Center, Clinical Sciences Malmö (H.M.), Lund University, Malmö, Sweden.
³⁴ Center for Medical Imaging and Physiology (H.M.), Lund University and Skåne University Hospital, Lund, Sweden.
³⁵ Department of Clinical Sciences Lund, Clinical Physiology (E.O.), Lund University and Skåne University Hospital, Lund, Sweden.
³⁶ Radiology (A.P.), Linköping University, Sweden.
³⁷ Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine (M.C.S.), Karolinska Institutet, Stockholm, Sweden.
³⁸ Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden (M.C.S.).
³⁹ The George Institute for Global Health, University of New South Wales, Sydney, Australia (J.S.).
⁴⁰ Occupational and Environmental Medicine/School of Public Health and Community Medicine (K.T.), University of Gothenburg, Sweden.
⁴¹ Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institutet, Stockholm, Sweden.

PMID: 34543072
PMCID: PMC8448414
DOI: 10.1161/CIRCULATIONAHA.121.055340

Abstract

Background: Early detection of coronary atherosclerosis using coronary computed tomography angiography (CCTA), in addition to coronary artery calcification (CAC) scoring, may help inform prevention strategies. We used CCTA to determine the prevalence, severity, and characteristics of coronary atherosclerosis and its association with CAC scores in a general population.

Methods: We recruited 30 154 randomly invited individuals age 50 to 64 years to SCAPIS (the Swedish Cardiopulmonary Bioimage Study). The study includes individuals without known coronary heart disease (ie, no previous myocardial infarctions or cardiac procedures) and with high-quality results from CCTA and CAC imaging performed using dedicated dual-source CT scanners. Noncontrast images were scored for CAC. CCTA images were visually read and scored for coronary atherosclerosis per segment (defined as no atherosclerosis, 1% to 49% stenosis, or ≥50% stenosis). External validity of prevalence estimates was evaluated using inverse probability for participation weighting and Swedish register data.

Results: In total, 25 182 individuals without known coronary heart disease were included (50.6% women). Any CCTA-detected atherosclerosis was found in 42.1%; any significant stenosis (≥50%) in 5.2%; left main, proximal left anterior descending artery, or 3-vessel disease in 1.9%; and any noncalcified plaques in 8.3% of this population. Onset of atherosclerosis was delayed on average by 10 years in women. Atherosclerosis was more prevalent in older individuals and predominantly found in the proximal left anterior descending artery. Prevalence of CCTA-detected atherosclerosis increased with increasing CAC scores. Among those with a CAC score >400, all had atherosclerosis and 45.7% had significant stenosis. In those with 0 CAC, 5.5% had atherosclerosis and 0.4% had significant stenosis. In participants with 0 CAC and intermediate 10-year risk of atherosclerotic cardiovascular disease according to the pooled cohort equation, 9.2% had CCTA-verified atherosclerosis. Prevalence estimates had excellent external validity and changed marginally when adjusted to the age-matched Swedish background population.

Conclusions: Using CCTA in a large, random sample of the general population without established disease, we showed that silent coronary atherosclerosis is common in this population. High CAC scores convey a significant probability of substantial stenosis, and 0 CAC does not exclude atherosclerosis, particularly in those at higher baseline risk.

Keywords: coronary angiography; coronary artery disease; epidemiology; plaque, atherosclerotic; primary prevention; tomography.

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Figures

**Figure 1.**
**Prevalence of coronary computed tomography angiography–detected atherosclerosis by sex and category of risk score.** Prevalence of coronary computed tomography angiography–detected coronary atherosclerosis and degree of stenosis in the SCAPIS cohort (Swedish Cardiopulmonary Bioimage Study; n=25 182) divided by sex and category of cardiovascular risk according to pooled cohort equation (PCE; low <5%, borderline/intermediate ≥5 to <20%, and high ≥20% 10-year risk of atherosclerotic cardiovascular disease [fatal/nonfatal]) and Systematic Coronary Risk Evaluation (SCORE; low <2%, moderate 2% to 5%, and high >5% 10-year risk of atherosclerotic cardiovascular disease [fatal]).

**Figure 2.**
**Distribution of coronary computed tomography angiography–detected atherosclerosis.** Frequency of atherosclerosis in the 11 most proximal coronary segments in men (n=12 444) and women (n=12 738) in the SCAPIS cohort (Swedish Cardiopulmonary Bioimage Study). The heat map refers to the frequency of any form of coronary computed tomography angiography–detected atherosclerosis. The numbers within boxes indicate the frequency of different degrees of vessel stenosis (white box, ≥50% stenosis; black box, any form of coronary computed tomography angiography–detected atherosclerosis). Figure modified from Ayoub et al., used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

**Figure 3.**
Segmental distribution of coronary computed tomography angiography–detected atherosclerosis in participants of the SCAPIS cohort (Swedish Cardiopulmonary Bioimage Study) with only 1 affected segment (n=3867). Segment numbers according to the Society of Cardiovascular Computed Tomography. Segment numbers are indicated in parentheses. Cx indicates circumflex artery; LAD, left anterior descending artery; and RCA, right coronary artery.

**Figure 4.**
Distribution of the number of coronary artery segments with coronary computed tomography angiography (CCTA)–detected atherosclerosis, divided by coronary artery calcification (CAC) category and sex.

See this image and copyright information in PMC

Comment in

Population Screening With Coronary Computed Tomography Angiography and the Prevention of Coronary Events.
Lee KK, Wereski R, Williams MC, Mills NL. Lee KK, et al. Circulation. 2021 Sep 21;144(12):930-933. doi: 10.1161/CIRCULATIONAHA.121.055784. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543070 No abstract available.

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Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population

Affiliations

Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population

Authors

Affiliations

Abstract

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LinkOut - more resources

Full Text Sources

Medical