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J Am Coll Cardiol, 2005; 46:807-814, doi:10.1016/j.jacc.2005.05.049 (Published online 24 August 2005).
© 2005 by the American College of Cardiology Foundation
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PROGNOSTIC MARKERS IN CAD

Coronary Calcium Independently Predicts Incident Premature Coronary Heart Disease Over Measured Cardiovascular Risk Factors

Mean Three-Year Outcomes in the Prospective Army Coronary Calcium (PACC) Project

Allen J. Taylor, MD*, Jody Bindeman, BSN, Irwin Feuerstein, MD, Felix Cao, MS, Michael Brazaitis, MD and Patrick G. O'Malley, MD, MPH

Departments of Medicine and Radiology, Walter Reed Army Medical Center, Washington, DC

Manuscript received February 25, 2005; revised manuscript received April 29, 2005, accepted May 17, 2005.

* Reprint requests and correspondence: Dr. Allen J. Taylor, Cardiology Service, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 2, Room 3L28, Washington, DC 20307-5001 (Email: allen.taylor{at}na.amedd.army.mil).

OBJECTIVES: We sought to examine the independent predictive value of coronary artery calcium detection for coronary outcomes in a non-referred cohort of healthy men and women ages 40 to 50 years.

BACKGROUND: Existing studies have suggested that coronary calcium might have incremental predictive value for coronary outcomes above standard coronary risk factors. However, additional data from non-referred and younger populations are needed.

METHODS: Participants (n = 2,000; mean age 43 years) were evaluated with measured coronary risk variables and coronary calcium detected with electron beam tomography. Incident acute coronary syndromes and sudden cardiac death were ascertained via annual telephonic contacts, with follow-up (mean, 3.0 ± 1.4 years; range, 1 to 6 years) in 99.2% of the cohort.

RESULTS: Coronary calcium was found in 22.4% of men and 7.9% of women. A total of 9 acute events occurred in men at a mean age of 46 years, including 7 of 364 men with coronary calcium (1.95%) and 2 of 1,263 men without coronary calcium (0.16%; p < 0.0001 by log-rank). No events occurred in women. In these men, coronary calcium was associated with an 11.8-fold increased risk for incident coronary heart disease (CHD) (p = 0.002) in a Cox model controlling for the Framingham risk score. Among those with coronary artery calcification, the risk of coronary events increased incrementally across tertiles of coronary calcium severity (hazard ratio 4.3 per tertile). A family history of premature CHD was also predictive of incident events. The marginal cost effectiveness, assuming a 30% improvement in survival associated with primary prevention among at-risk men, was modeled to be $37,633 per quality-adjusted life year saved.

CONCLUSIONS: In young, asymptomatic men, the presence of coronary artery calcification provides substantial, cost-effective, independent prognostic value in predicting incident CHD that is incremental to measured coronary risk factors.

Abbreviations and Acronyms
  BMI = body mass index
  CAC = coronary artery calcium
  CHD = coronary heart disease
  CT = computed tomography
  EBCT = electron beam computed tomography
  FRS = Framingham risk score
  HDL = high-density lipoprotein
  LDL = low-density lipoprotein
  PACC = Prospective Army Coronary Calcium
  QALY = quality-adjusted life years




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P. Greenland, R. O. Bonow, B. H. Brundage, M. J. Budoff, M. J. Eisenberg, S. M. Grundy, M. S. Lauer, W. S. Post, P. Raggi, R. F. Redberg, et al.
ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain: A Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) Developed in Collaboration With the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography
J. Am. Coll. Cardiol., January 23, 2007; 49(3): 378 - 402.
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J Am Coll CardiolHome page
G. Pundziute, J. D. Schuijf, J. W. Jukema, E. Boersma, A. de Roos, E. E. van der Wall, and J. J. Bax
Prognostic Value of Multislice Computed Tomography Coronary Angiography in Patients With Known or Suspected Coronary Artery Disease
J. Am. Coll. Cardiol., January 2, 2007; 49(1): 62 - 70.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
R. J. Gibbons, P. A. Araoz, and E. E. Williamson
The Year in Cardiac Imaging
J. Am. Coll. Cardiol., December 5, 2006; 48(11): 2324 - 2339.
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Arch Intern MedHome page
S. S. Gidding, C. A. McMahan, H. C. McGill, L. A. Colangelo, P. J. Schreiner, O. D. Williams, and K. Liu
Prediction of Coronary Artery Calcium in Young Adults Using the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Risk Score: The CARDIA Study
Arch Intern Med, November 27, 2006; 166(21): 2341 - 2347.
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CirculationHome page
M. J. Budoff, S. Achenbach, R. S. Blumenthal, J. J. Carr, J. G. Goldin, P. Greenland, A. D. Guerci, J. A.C. Lima, D. J. Rader, G. D. Rubin, et al.
Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology
Circulation, October 17, 2006; 114(16): 1761 - 1791.
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Postgrad. Med. J.Home page
T. K Mittal, M. Barbir, and M. Rubens
Role of computed tomography in risk assessment for coronary heart disease.
Postgrad. Med. J., October 1, 2006; 82(972): 664 - 671.
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J. Lipid Res.Home page
J. R. Crouse III
Thematic review series: Patient-Oriented Research. Imaging atherosclerosis: state of the art
J. Lipid Res., August 1, 2006; 47(8): 1677 - 1699.
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J Am Coll CardiolHome page
M. J. Budoff
Prevalence of Soft Plaque Detection With Computed Tomography
J. Am. Coll. Cardiol., July 18, 2006; 48(2): 319 - 321.
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JNMHome page
D. S. Berman, R. Hachamovitch, L. J. Shaw, J. D. Friedman, S. W. Hayes, L. E.J. Thomson, D. S. Fieno, G. Germano, N. D. Wong, X. Kang, et al.
Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Noninvasive Risk Stratification and a Conceptual Framework for the Selection of Noninvasive Imaging Tests in Patients with Known or Suspected Coronary Artery Disease
J. Nucl. Med., July 1, 2006; 47(7): 1107 - 1118.
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CJASNHome page
S. M. Moe and G. M. Chertow
The Case against Calcium-Based Phosphate Binders
Clin. J. Am. Soc. Nephrol., July 1, 2006; 1(4): 697 - 703.
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Arterioscler. Thromb. Vasc. Bio.Home page
X. Qin, M. A. Corriere, L. M. Matrisian, and R. J. Guzman
Matrix Metalloproteinase Inhibition Attenuates Aortic Calcification
Arterioscler Thromb Vasc Biol, July 1, 2006; 26(7): 1510 - 1516.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
P. G. O'Malley
Atherosclerosis imaging of asymptomatic individuals: is the sales cart before the evidence horse?
Arch Intern Med, May 22, 2006; 166(10): 1065 - 1068.
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Psychosom. Med.Home page
T. T. Lewis, S. A. Everson-Rose, L. H. Powell, K. A. Matthews, C. Brown, K. Karavolos, K. Sutton-Tyrrell, E. Jacobs, and D. Wesley
Chronic Exposure to Everyday Discrimination and Coronary Artery Calcification in African-American Women: The SWAN Heart Study
Psychosom Med, May 1, 2006; 68(3): 362 - 368.
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JAMAHome page
L. L. Yan, K. Liu, M. L. Daviglus, L. A. Colangelo, C. I. Kiefe, S. Sidney, K. A. Matthews, and P. Greenland
Education, 15-year risk factor progression, and coronary artery calcium in young adulthood and early middle age: the Coronary Artery Risk Development in Young Adults study.
JAMA, April 19, 2006; 295(15): 1793 - 1800.
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Eur Heart JHome page
L. J. Shaw, P. Raggi, T. Q. Callister, and D. S. Berman
Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers
Eur. Heart J., April 2, 2006; 27(8): 968 - 975.
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Eur Heart JHome page
D. V. Anand, E. Lim, D. Hopkins, R. Corder, L. J. Shaw, P. Sharp, D. Lipkin, and A. Lahiri
Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy
Eur. Heart J., March 2, 2006; 27(6): 713 - 721.
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J Am Coll CardiolHome page
J. A. Rumberger
The Promise of Quantitative Computed Tomography Coronary Angiography and Noninvasive Segmental Coronary Plaque Quantification: Pushing the "Edge"
J. Am. Coll. Cardiol., February 7, 2006; 47(3): 678 - 680.
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CirculationHome page
L. H. Kuller
Prevention of Coronary Heart Disease and the National Cholesterol Education Program
Circulation, February 7, 2006; 113(5): 598 - 600.
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J Am Coll CardiolHome page
A. N. DeMaria, O. Ben-Yehuda, D. Berman, G. K. Feld, G. S. Ginsburg, B. H. Greenberg, W. Y.W. Lew, D. Sahn, and S. Tsimikas
Highlights of the Year in JACC 2005
J. Am. Coll. Cardiol., January 3, 2006; 47(1): 184 - 202.
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