Author + information
- Received December 11, 2013
- Revision received March 16, 2014
- Accepted March 19, 2014
- Published online May 1, 2014.
- Michael G. Silverman, MD∗,
- James R. Harkness, MD∗,
- Ron Blankstein, MD†,
- Matthew J. Budoff, MD‡,
- Arthur S. Agatston, MD§,
- J. Jeffrey Carr, MD, MSc‖,
- Joao A. Lima, MD¶,
- Roger S. Blumenthal, MD∗,
- Khurram Nasir, MD, MPH∗,§ and
- Michael J. Blaha, MD, MPH∗∗ ()
- ∗Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, Maryland
- †Brigham and Women's Hospital, Boston, Massachusetts
- ‡Los Angeles Biomedical Research Institute, Torrance, California
- §Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, Florida
- ‖Vanderbilt University, Nashville, Tennessee
- ¶Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
- ↵∗Reprint requests and correspondence:
Dr. Michael J. Blaha, Carnegie 565A, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, Maryland 21287.
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.
This research was supported by the National Heart, Lung, and Blood Institute (grants N01-HC-95159 through N01-HC-95169); National Heart, Lung, and Blood Institute grant T32-HL-7227-36 to Drs. Silverman, Harkness, and Blaha; and National Institutes of Health grant L30 HL110027 to Dr. Blaha. Dr. Lima has received grant support from Toshiba Medical Systems and has received contrast provided to the MESA MRI study from Bayer Pharmaceuticals. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Silverman and Harkness contributed equally to this work and are co-first authors.
- Received December 11, 2013.
- Revision received March 16, 2014.
- Accepted March 19, 2014.
- American College of Cardiology Foundation