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J Am Coll Cardiol, 2007; 49:1860-1870, doi:10.1016/j.jacc.2006.10.079 (Published online 19 April 2007).
© 2007 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: CARDIAC IMAGING

Long-Term Prognosis Associated With Coronary Calcification

Observations From a Registry of 25,253 Patients

Matthew J. Budoff, MD*,*,1, Leslee J. Shaw, PhD{dagger}, Sandy T. Liu*, Steven R. Weinstein*, Tristen P. Mosler, Philip H. Tseng*, Ferdinand R. Flores*, Tracy Q. Callister, MD{ddagger}, Paolo Raggi, MD§ and Daniel S. Berman, MD{dagger}

* Harbor-UCLA Los Angeles Biomedical Research Institute, Torrance, California
{dagger} Cedars-Sinai Medical Center, Los Angeles, California
{ddagger} EBT Research Foundation, Nashville, Tennessee
§ Division of Cardiology and Department of Radiology, Emory University, Atlanta, Georgia.

Manuscript received March 6, 2006; revised manuscript received September 18, 2006, accepted October 16, 2006.

* Reprint requests and correspondence: Dr. Matthew J. Budoff, Harbor-UCLA Research and Education Institute, 1124 West Carson Street, RB2, Torrance, California 90502. (Email: mbudoff{at}labiomed.org).

Objectives: The purpose of this study was to develop risk-adjusted multivariable models that include risk factors and coronary artery calcium (CAC) scores measured with electron-beam tomography in asymptomatic patients for the prediction of all-cause mortality.

Background: Several smaller studies have documented the efficacy of CAC testing for assessment of cardiovascular risk. Larger studies with longer follow-up will lend strength to the hypothesis that CAC testing will improve outcomes, cost-effectiveness, and safety of primary prevention efforts.

Methods: We used an observational outcome study of a cohort of 25,253 consecutive, asymptomatic individuals referred by their primary physician for CAC scanning to assess cardiovascular risk. Multivariable Cox proportional hazards models were developed to predict all-cause mortality. Risk-adjusted models incorporated traditional risk factors for coronary disease and CAC scores.

Results: The frequency of CAC scores was 44%, 14%, 20%, 13%, 6%, and 4% for scores of 0, 1 to 10, 11 to 100, 101 to 400, 401 to 1,000, and >1,000, respectively. During a mean follow-up of 6.8 ± 3 years, the death rate was 2% (510 deaths). The CAC was an independent predictor of mortality in a multivariable model controlling for age, gender, ethnicity, and cardiac risk factors (model chi-square = 2,017, p < 0.0001). The addition of CAC to traditional risk factors increased the concordance index significantly (0.61 for risk factors vs. 0.81 for the CAC score, p < 0.0001). Risk-adjusted relative risk ratios for CAC were 2.2-, 4.5-, 6.4-, 9.2-, 10.4-, and 12.5-fold for scores of 11 to 100, 101 to 299, 300 to 399, 400 to 699, 700 to 999, and >1,000, respectively (p < 0.0001), when compared with a score of 0. Ten-year survival (after adjustment for risk factors, including age) was 99.4% for a CAC score of 0 and worsened to 87.8% for a score of >1,000 (p < 0.0001).

Conclusions: This large observational data series shows that CAC provides independent incremental information in addition to traditional risk factors in the prediction of all-cause mortality.

Abbreviations and Acronyms
  CAC = coronary artery calcium
  CAD = coronary artery disease
  CHD = coronary heart disease
  CI = confidence interval
  EBT = electron beam tomography
  ROC = receiver-operating characteristic
  RR = risk ratio


Related Article

The Prognostic Accuracy of Coronary Calcification
Alan D. Guerci
J. Am. Coll. Cardiol. 2007 49: 1871-1873. [Full Text] [PDF]



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T. P. Carrigan, D. Nair, P. Schoenhagen, R. J. Curtin, Z. B. Popovic, S. Halliburton, S. Kuzmiak, R. D. White, S. D. Flamm, and M. Y. Desai
Prognostic utility of 64-slice computed tomography in patients with suspected but no documented coronary artery disease
Eur. Heart J., February 1, 2009; 30(3): 362 - 371.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. J. Budoff, K. Nasir, R. L. McClelland, R. Detrano, N. Wong, R. S. Blumenthal, G. Kondos, and R. A. Kronmal
Coronary Calcium Predicts Events Better With Absolute Calcium Scores Than Age-Sex-Race/Ethnicity Percentiles: MESA (Multi-Ethnic Study of Atherosclerosis)
J. Am. Coll. Cardiol., January 27, 2009; 53(4): 345 - 352.
[Abstract] [Full Text] [PDF]

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 BMJHome page
I. A Scott
Evaluating cardiovascular risk assessment for asymptomatic people
BMJ, January 5, 2009; 338(jan05_1): a2844 - a2844.
[Full Text]

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 ESC Textbook of Cardiovascular MedicineHome page
P. J. de Feyter, S. Achenbach, and K. Nieman
CHAPTER 6 Cardiovascular Computed Tomography
ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract] [Full Text] [PDF]

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 HypertensionHome page
M. A. Allison, J. E. Manson, R. D. Langer, A. Aragaki, S. Smoller, C. E. Lewis, A. Thomas, W. Lawson, B. B. Cochrane, J. Hsia, et al.
Association Between Different Measures of Blood Pressure and Coronary Artery Calcium in Postmenopausal Women
Hypertension, November 1, 2008; 52(5): 833 - 840.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. P. Ostrom, A. Gopal, N. Ahmadi, K. Nasir, E. Yang, I. Kakadiaris, F. Flores, S. S. Mao, and M. J. Budoff
Mortality Incidence and the Severity of Coronary Atherosclerosis Assessed by Computed Tomography Angiography
J. Am. Coll. Cardiol., October 14, 2008; 52(16): 1335 - 1343.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
R. S. Elkeles, I. F. Godsland, M. D. Feher, M. B. Rubens, M. Roughton, F. Nugara, S. E. Humphries, W. Richmond, M. D. Flather, and for the PREDICT Study Group
Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study
Eur. Heart J., September 2, 2008; 29(18): 2244 - 2251.
[Abstract] [Full Text] [PDF]

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M. J. Budoff
Not all diabetics are created equal (in cardiovascular risk)
Eur. Heart J., September 2, 2008; 29(18): 2193 - 2194.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
A. Sekikawa, J. D. Curb, H. Ueshima, A. El-Saed, T. Kadowaki, R. D. Abbott, R. W. Evans, B. L. Rodriguez, T. Okamura, K. Sutton-Tyrrell, et al.
Marine-Derived n-3 Fatty Acids and Atherosclerosis in Japanese, Japanese-American, and White Men: A Cross-Sectional Study
J. Am. Coll. Cardiol., August 5, 2008; 52(6): 417 - 424.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
E.-K. Choi, S. I. Choi, J. J. Rivera, K. Nasir, S.-A. Chang, E. J. Chun, H.-K. Kim, D.-J. Choi, R. S. Blumenthal, and H.-J. Chang
Coronary Computed Tomography Angiography as a Screening Tool for the Detection of Occult Coronary Artery Disease in Asymptomatic Individuals
J. Am. Coll. Cardiol., July 29, 2008; 52(5): 357 - 365.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
A. J. Feiring
Footnotes on Critical Limb Ischemia
J. Am. Coll. Cardiol., May 20, 2008; 51(20): 1975 - 1976.
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 CirculationHome page
M. P. Schenker, S. Dorbala, E. C. T. Hong, F. J. Rybicki, R. Hachamovitch, R. Y. Kwong, and M. F. Di Carli
Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease: A Combined Positron Emission Tomography/Computed Tomography Study
Circulation, April 1, 2008; 117(13): 1693 - 1700.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
J. Sanz, P. R. Moreno, and V. Fuster
The Year in Atherothrombosis
J. Am. Coll. Cardiol., March 4, 2008; 51(9): 944 - 955.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
A. N. DeMaria, J. J. Bax, O. Ben-Yehuda, P. Clopton, G. K. Feld, G. S. Ginsburg, B. H. Greenberg, J. D. Knoke, W. Y.W. Lew, J. A.C. Lima, et al.
Highlights of the Year in JACC 2007
J. Am. Coll. Cardiol., January 29, 2008; 51(4): 490 - 512.
[Full Text] [PDF]

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 J Am Coll Cardiol ImgHome page
M. Williams, L. J. Shaw, P. Raggi, D. Morris, V. Vaccarino, S. T. Liu, S. R. Weinstein, T. P. Mosler, P. H. Tseng, F. R. Flores, et al.
Prognostic value of number and site of calcified coronary lesions compared with the total score.
J. Am. Coll. Cardiol. Img., January 1, 2008; 1(1): 61 - 69.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
C. M. Shanahan
Inflammation Ushers in Calcification: A Cycle of Damage and Protection?
Circulation, December 11, 2007; 116(24): 2782 - 2785.
[Full Text] [PDF]

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 Arch Intern MedHome page
S. G. Lakoski, P. Greenland, N. D. Wong, P. J. Schreiner, D. M. Herrington, R. A. Kronmal, K. Liu, and R. S. Blumenthal
Coronary Artery Calcium Scores and Risk for Cardiovascular Events in Women Classified as "Low Risk" Based on Framingham Risk Score: The Multi-Ethnic Study of Atherosclerosis (MESA)
Arch Intern Med, December 10, 2007; 167(22): 2437 - 2442.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
D. V. Anand, E. Lim, D. Darko, P. Bassett, D. Hopkins, D. Lipkin, R. Corder, and A. Lahiri
Determinants of Progression of Coronary Artery Calcification in Type 2 Diabetes: Role of Glycemic Control and Inflammatory/Vascular Calcification Markers
J. Am. Coll. Cardiol., December 4, 2007; 50(23): 2218 - 2225.
[Abstract] [Full Text] [PDF]

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R. Shroff, A. Kerchner, M. Maifeld, E. J. R. Van Beek, D. Jagasia, and A. Dokras
Young Obese Women with Polycystic Ovary Syndrome Have Evidence of Early Coronary Atherosclerosis
J. Clin. Endocrinol. Metab., December 1, 2007; 92(12): 4609 - 4614.
[Abstract] [Full Text] [PDF]

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 Am J EpidemiolHome page
R. D. Abbott, H. Ueshima, B. L. Rodriguez, T. Kadowaki, K. H. Masaki, B. J. Willcox, A. Sekikawa, L. H. Kuller, D. Edmundowicz, C. Shin, et al.
Coronary Artery Calcification in Japanese Men in Japan and Hawaii
Am. J. Epidemiol., December 1, 2007; 166(11): 1280 - 1287.
[Abstract] [Full Text] [PDF]

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J. J. Mahmarian
Computed Tomography Coronary Angiography as an Anatomic Basis for Risk Stratification: Deja Vu or Something New?
J. Am. Coll. Cardiol., September 18, 2007; 50(12): 1171 - 1173.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
K. Nasir, L. J. Shaw, S. T. Liu, S. R. Weinstein, T. R. Mosler, P. R. Flores, F. R. Flores, P. Raggi, D. S. Berman, R. S. Blumenthal, et al.
Ethnic Differences in the Prognostic Value of Coronary Artery Calcification for All-Cause Mortality
J. Am. Coll. Cardiol., September 4, 2007; 50(10): 953 - 960.
[Abstract] [Full Text] [PDF]

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 JWatch Emergency Med.Home page
Coronary Artery Calcium Scores Predict Mortality
Journal Watch Emergency Medicine, June 1, 2007; 2007(601): 2 - 2.
[Full Text]

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A. D. Guerci
The Prognostic Accuracy of Coronary Calcification
J. Am. Coll. Cardiol., May 8, 2007; 49(18): 1871 - 1873.
[Full Text] [PDF]


 
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