Prevalence and prognostic implications of coronary artery calcification in low-risk women: A meta-analysis

Maryam Kavousi, Chintan S. Desai, Colby Ayers, Roger S. Blumenthal, Matthew J. Budoff, Amir Abbas Mahabadi, M. Arfan Ikram, Aad Van Der Lugt, Albert Hofman, Raimund Erbel, Amit Khera, Marie H. Geisel, Karl Heinz Jöckel, Nils Lehmann, Udo Hoffmann, Christopher J. O'Donnell, Joseph M. Massaro, Kiang Liu, Stefan Möhlenkamp, Hongyan NingOscar H. Franco, Philip Greenland

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Abstract

IMPORTANCE The role of coronary artery calcium (CAC) testing for guiding preventive strategies among women at low cardiovascular disease (CVD) risk based on the American College of Cardiology and American Heart Association CVD prevention guidelines is unclear. OBJECTIVE To assess the potential utility of CAC testing for CVD risk estimation and stratification among low-risk women. DESIGN, SETTING, AND PARTICIPANTS Women with 10-year atherosclerotic CVD (ASCVD) risk lower than 7.5%from 5 large population-based cohorts: the Dallas Heart Study (United States), the Framingham Heart Study (United States), the Heinz Nixdorf Recall study (Germany), the Multi-Ethnic Study of Atherosclerosis (United States), and the Rotterdam Study (the Netherlands). The 5 cohorts were selected based on the availability of CAC data in a sizable group of low-risk women from the general population together with the long detailed follow-up data. Across the cohorts, events were assessed from the date of CAC scan (performed from 1998 through 2006) until January 1, 2012; January 1, 2014; or March 6, 2015. Fixed-effects meta-analysis was conducted to combine the results of the 5 studies. EXPOSURES CAC score by computed tomography. MAIN OUTCOMES AND MEASURES Main outcomewas incident ASCVD, including nonfatal myocardial infarction, coronary heart disease (CHD) death, and stroke. Association of CAC with ASCVD was examined using Cox proportional hazards models. To assess whether CAC was associated with improved ASCVD risk predictions beyond the traditional risk factors, the C statistic and the continuous net reclassification improvement (cNRI) index were calculated. RESULTS Among 6739 women with low ASCVD risk from the 5 studies, mean age ranged from 44 to 63 years and CAC was present in 36.1%. Across the cohorts, median follow-up ranged from 7.0 to 11.6 years. A total of 165 ASCVD events occurred (64 nonfatalmyocardial infarctions, 29 CHD deaths, and 72 strokes), with the ASCVD incidence rates ranging from 1.5 to 6.0 per 1000 person-years. Compared with the absence of CAC (CAC = 0), presence of CAC (CAC >0) was associated with an increased risk of ASCVD (incidence rates per 1000 person-years, 1.41 for CAC absence vs 4.33 for CAC presence; difference, 2.92 [95%CI, 2.02-3.83]; multivariable-adjusted hazard ratio, 2.04 [95%CI, 1.44-2.90]). The addition of CAC to traditional risk factors improved the C statistic from 0.73 (95%CI, 0.69-0.77) to 0.77 (95%CI, 0.74-0.81) and provided a cNRI of 0.20 (95%CI, 0.09-0.31) for ASCVD prediction. CONCLUSIONS AND RELEVANCE Among women at low ASCVD risk, CAC was present in approximately one-third and was associated with an increased risk of ASCVD and modest improvement in prognostic accuracy compared with traditional risk factors. Further research is needed to assess the clinical utility and cost-effectiveness of this additional accuracy.

Original languageEnglish (US)
Pages (from-to)2126-2134
Number of pages9
JournalJAMA - Journal of the American Medical Association
Volume316
Issue number20
DOIs
StatePublished - Nov 22 2016

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Meta-Analysis
Coronary Vessels
Calcium
Cardiovascular Diseases
Coronary Disease
Stroke
Incidence
Proportional Hazards Models
Netherlands
Infarction
Population
Cost-Benefit Analysis
Germany
Atherosclerosis
Myocardial Infarction
Tomography
Guidelines

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Kavousi, M., Desai, C. S., Ayers, C., Blumenthal, R. S., Budoff, M. J., Mahabadi, A. A., ... Greenland, P. (2016). Prevalence and prognostic implications of coronary artery calcification in low-risk women: A meta-analysis. JAMA - Journal of the American Medical Association, 316(20), 2126-2134. https://doi.org/10.1001/jama.2016.17020

Prevalence and prognostic implications of coronary artery calcification in low-risk women : A meta-analysis. / Kavousi, Maryam; Desai, Chintan S.; Ayers, Colby; Blumenthal, Roger S.; Budoff, Matthew J.; Mahabadi, Amir Abbas; Ikram, M. Arfan; Van Der Lugt, Aad; Hofman, Albert; Erbel, Raimund; Khera, Amit; Geisel, Marie H.; Jöckel, Karl Heinz; Lehmann, Nils; Hoffmann, Udo; O'Donnell, Christopher J.; Massaro, Joseph M.; Liu, Kiang; Möhlenkamp, Stefan; Ning, Hongyan; Franco, Oscar H.; Greenland, Philip.

In: JAMA - Journal of the American Medical Association, Vol. 316, No. 20, 22.11.2016, p. 2126-2134.

Research output: Contribution to journalArticle

Kavousi, M, Desai, CS, Ayers, C, Blumenthal, RS, Budoff, MJ, Mahabadi, AA, Ikram, MA, Van Der Lugt, A, Hofman, A, Erbel, R, Khera, A, Geisel, MH, Jöckel, KH, Lehmann, N, Hoffmann, U, O'Donnell, CJ, Massaro, JM, Liu, K, Möhlenkamp, S, Ning, H, Franco, OH & Greenland, P 2016, 'Prevalence and prognostic implications of coronary artery calcification in low-risk women: A meta-analysis', JAMA - Journal of the American Medical Association, vol. 316, no. 20, pp. 2126-2134. https://doi.org/10.1001/jama.2016.17020
Kavousi, Maryam ; Desai, Chintan S. ; Ayers, Colby ; Blumenthal, Roger S. ; Budoff, Matthew J. ; Mahabadi, Amir Abbas ; Ikram, M. Arfan ; Van Der Lugt, Aad ; Hofman, Albert ; Erbel, Raimund ; Khera, Amit ; Geisel, Marie H. ; Jöckel, Karl Heinz ; Lehmann, Nils ; Hoffmann, Udo ; O'Donnell, Christopher J. ; Massaro, Joseph M. ; Liu, Kiang ; Möhlenkamp, Stefan ; Ning, Hongyan ; Franco, Oscar H. ; Greenland, Philip. / Prevalence and prognostic implications of coronary artery calcification in low-risk women : A meta-analysis. In: JAMA - Journal of the American Medical Association. 2016 ; Vol. 316, No. 20. pp. 2126-2134.
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title = "Prevalence and prognostic implications of coronary artery calcification in low-risk women: A meta-analysis",
abstract = "IMPORTANCE The role of coronary artery calcium (CAC) testing for guiding preventive strategies among women at low cardiovascular disease (CVD) risk based on the American College of Cardiology and American Heart Association CVD prevention guidelines is unclear. OBJECTIVE To assess the potential utility of CAC testing for CVD risk estimation and stratification among low-risk women. DESIGN, SETTING, AND PARTICIPANTS Women with 10-year atherosclerotic CVD (ASCVD) risk lower than 7.5{\%}from 5 large population-based cohorts: the Dallas Heart Study (United States), the Framingham Heart Study (United States), the Heinz Nixdorf Recall study (Germany), the Multi-Ethnic Study of Atherosclerosis (United States), and the Rotterdam Study (the Netherlands). The 5 cohorts were selected based on the availability of CAC data in a sizable group of low-risk women from the general population together with the long detailed follow-up data. Across the cohorts, events were assessed from the date of CAC scan (performed from 1998 through 2006) until January 1, 2012; January 1, 2014; or March 6, 2015. Fixed-effects meta-analysis was conducted to combine the results of the 5 studies. EXPOSURES CAC score by computed tomography. MAIN OUTCOMES AND MEASURES Main outcomewas incident ASCVD, including nonfatal myocardial infarction, coronary heart disease (CHD) death, and stroke. Association of CAC with ASCVD was examined using Cox proportional hazards models. To assess whether CAC was associated with improved ASCVD risk predictions beyond the traditional risk factors, the C statistic and the continuous net reclassification improvement (cNRI) index were calculated. RESULTS Among 6739 women with low ASCVD risk from the 5 studies, mean age ranged from 44 to 63 years and CAC was present in 36.1{\%}. Across the cohorts, median follow-up ranged from 7.0 to 11.6 years. A total of 165 ASCVD events occurred (64 nonfatalmyocardial infarctions, 29 CHD deaths, and 72 strokes), with the ASCVD incidence rates ranging from 1.5 to 6.0 per 1000 person-years. Compared with the absence of CAC (CAC = 0), presence of CAC (CAC >0) was associated with an increased risk of ASCVD (incidence rates per 1000 person-years, 1.41 for CAC absence vs 4.33 for CAC presence; difference, 2.92 [95{\%}CI, 2.02-3.83]; multivariable-adjusted hazard ratio, 2.04 [95{\%}CI, 1.44-2.90]). The addition of CAC to traditional risk factors improved the C statistic from 0.73 (95{\%}CI, 0.69-0.77) to 0.77 (95{\%}CI, 0.74-0.81) and provided a cNRI of 0.20 (95{\%}CI, 0.09-0.31) for ASCVD prediction. CONCLUSIONS AND RELEVANCE Among women at low ASCVD risk, CAC was present in approximately one-third and was associated with an increased risk of ASCVD and modest improvement in prognostic accuracy compared with traditional risk factors. Further research is needed to assess the clinical utility and cost-effectiveness of this additional accuracy.",
author = "Maryam Kavousi and Desai, {Chintan S.} and Colby Ayers and Blumenthal, {Roger S.} and Budoff, {Matthew J.} and Mahabadi, {Amir Abbas} and Ikram, {M. Arfan} and {Van Der Lugt}, Aad and Albert Hofman and Raimund Erbel and Amit Khera and Geisel, {Marie H.} and J{\"o}ckel, {Karl Heinz} and Nils Lehmann and Udo Hoffmann and O'Donnell, {Christopher J.} and Massaro, {Joseph M.} and Kiang Liu and Stefan M{\"o}hlenkamp and Hongyan Ning and Franco, {Oscar H.} and Philip Greenland",
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month = "11",
day = "22",
doi = "10.1001/jama.2016.17020",
language = "English (US)",
volume = "316",
pages = "2126--2134",
journal = "JAMA - Journal of the American Medical Association",
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TY - JOUR

T1 - Prevalence and prognostic implications of coronary artery calcification in low-risk women

T2 - A meta-analysis

AU - Kavousi, Maryam

AU - Desai, Chintan S.

AU - Ayers, Colby

AU - Blumenthal, Roger S.

AU - Budoff, Matthew J.

AU - Mahabadi, Amir Abbas

AU - Ikram, M. Arfan

AU - Van Der Lugt, Aad

AU - Hofman, Albert

AU - Erbel, Raimund

AU - Khera, Amit

AU - Geisel, Marie H.

AU - Jöckel, Karl Heinz

AU - Lehmann, Nils

AU - Hoffmann, Udo

AU - O'Donnell, Christopher J.

AU - Massaro, Joseph M.

AU - Liu, Kiang

AU - Möhlenkamp, Stefan

AU - Ning, Hongyan

AU - Franco, Oscar H.

AU - Greenland, Philip

PY - 2016/11/22

Y1 - 2016/11/22

N2 - IMPORTANCE The role of coronary artery calcium (CAC) testing for guiding preventive strategies among women at low cardiovascular disease (CVD) risk based on the American College of Cardiology and American Heart Association CVD prevention guidelines is unclear. OBJECTIVE To assess the potential utility of CAC testing for CVD risk estimation and stratification among low-risk women. DESIGN, SETTING, AND PARTICIPANTS Women with 10-year atherosclerotic CVD (ASCVD) risk lower than 7.5%from 5 large population-based cohorts: the Dallas Heart Study (United States), the Framingham Heart Study (United States), the Heinz Nixdorf Recall study (Germany), the Multi-Ethnic Study of Atherosclerosis (United States), and the Rotterdam Study (the Netherlands). The 5 cohorts were selected based on the availability of CAC data in a sizable group of low-risk women from the general population together with the long detailed follow-up data. Across the cohorts, events were assessed from the date of CAC scan (performed from 1998 through 2006) until January 1, 2012; January 1, 2014; or March 6, 2015. Fixed-effects meta-analysis was conducted to combine the results of the 5 studies. EXPOSURES CAC score by computed tomography. MAIN OUTCOMES AND MEASURES Main outcomewas incident ASCVD, including nonfatal myocardial infarction, coronary heart disease (CHD) death, and stroke. Association of CAC with ASCVD was examined using Cox proportional hazards models. To assess whether CAC was associated with improved ASCVD risk predictions beyond the traditional risk factors, the C statistic and the continuous net reclassification improvement (cNRI) index were calculated. RESULTS Among 6739 women with low ASCVD risk from the 5 studies, mean age ranged from 44 to 63 years and CAC was present in 36.1%. Across the cohorts, median follow-up ranged from 7.0 to 11.6 years. A total of 165 ASCVD events occurred (64 nonfatalmyocardial infarctions, 29 CHD deaths, and 72 strokes), with the ASCVD incidence rates ranging from 1.5 to 6.0 per 1000 person-years. Compared with the absence of CAC (CAC = 0), presence of CAC (CAC >0) was associated with an increased risk of ASCVD (incidence rates per 1000 person-years, 1.41 for CAC absence vs 4.33 for CAC presence; difference, 2.92 [95%CI, 2.02-3.83]; multivariable-adjusted hazard ratio, 2.04 [95%CI, 1.44-2.90]). The addition of CAC to traditional risk factors improved the C statistic from 0.73 (95%CI, 0.69-0.77) to 0.77 (95%CI, 0.74-0.81) and provided a cNRI of 0.20 (95%CI, 0.09-0.31) for ASCVD prediction. CONCLUSIONS AND RELEVANCE Among women at low ASCVD risk, CAC was present in approximately one-third and was associated with an increased risk of ASCVD and modest improvement in prognostic accuracy compared with traditional risk factors. Further research is needed to assess the clinical utility and cost-effectiveness of this additional accuracy.

AB - IMPORTANCE The role of coronary artery calcium (CAC) testing for guiding preventive strategies among women at low cardiovascular disease (CVD) risk based on the American College of Cardiology and American Heart Association CVD prevention guidelines is unclear. OBJECTIVE To assess the potential utility of CAC testing for CVD risk estimation and stratification among low-risk women. DESIGN, SETTING, AND PARTICIPANTS Women with 10-year atherosclerotic CVD (ASCVD) risk lower than 7.5%from 5 large population-based cohorts: the Dallas Heart Study (United States), the Framingham Heart Study (United States), the Heinz Nixdorf Recall study (Germany), the Multi-Ethnic Study of Atherosclerosis (United States), and the Rotterdam Study (the Netherlands). The 5 cohorts were selected based on the availability of CAC data in a sizable group of low-risk women from the general population together with the long detailed follow-up data. Across the cohorts, events were assessed from the date of CAC scan (performed from 1998 through 2006) until January 1, 2012; January 1, 2014; or March 6, 2015. Fixed-effects meta-analysis was conducted to combine the results of the 5 studies. EXPOSURES CAC score by computed tomography. MAIN OUTCOMES AND MEASURES Main outcomewas incident ASCVD, including nonfatal myocardial infarction, coronary heart disease (CHD) death, and stroke. Association of CAC with ASCVD was examined using Cox proportional hazards models. To assess whether CAC was associated with improved ASCVD risk predictions beyond the traditional risk factors, the C statistic and the continuous net reclassification improvement (cNRI) index were calculated. RESULTS Among 6739 women with low ASCVD risk from the 5 studies, mean age ranged from 44 to 63 years and CAC was present in 36.1%. Across the cohorts, median follow-up ranged from 7.0 to 11.6 years. A total of 165 ASCVD events occurred (64 nonfatalmyocardial infarctions, 29 CHD deaths, and 72 strokes), with the ASCVD incidence rates ranging from 1.5 to 6.0 per 1000 person-years. Compared with the absence of CAC (CAC = 0), presence of CAC (CAC >0) was associated with an increased risk of ASCVD (incidence rates per 1000 person-years, 1.41 for CAC absence vs 4.33 for CAC presence; difference, 2.92 [95%CI, 2.02-3.83]; multivariable-adjusted hazard ratio, 2.04 [95%CI, 1.44-2.90]). The addition of CAC to traditional risk factors improved the C statistic from 0.73 (95%CI, 0.69-0.77) to 0.77 (95%CI, 0.74-0.81) and provided a cNRI of 0.20 (95%CI, 0.09-0.31) for ASCVD prediction. CONCLUSIONS AND RELEVANCE Among women at low ASCVD risk, CAC was present in approximately one-third and was associated with an increased risk of ASCVD and modest improvement in prognostic accuracy compared with traditional risk factors. Further research is needed to assess the clinical utility and cost-effectiveness of this additional accuracy.

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