title: All-cause mortality in asymptomatic persons with extensive Agatston scores above 1000.
abstract: BACKGROUND
  Risk assessment in the extensive calcified plaque phenotype has been limited by small sample size.
  
  
  OBJECTIVE
  We studied all-cause mortality rates among asymptomatic patients with markedly elevated Agatston scores > 1000.
  
  
  METHODS
  We studied a clinical cohort of 44,052 asymptomatic patients referred for coronary calcium scans. Mean follow-up was 5.6 years (range, 1-13 years). All-cause mortality rates were calculated after stratifying by Agatston score (0, 1-1000, 1001-1500, 1500-2000, and >2000). A multivariable Cox regression model adjusting for self-reported traditional risk factors was created to assess the relative mortality hazard of Agatston scores 1001 to 1500, 1501 to 2000, and >2000. With the use of post-estimation modeling, we assessed for the presence of an upper threshold of risk with high Agatston scores.
  
  
  RESULTS
  A total of 1593 patients (4% of total population) had Agatston score > 1000. There was a continuous graded decrease in estimated 10-year survival across increasing Agatston score, continuing when Agatston score > 1000 (Agatston score 1001-1500, 78%; Agatston score 1501-2000, 74%; Agatston score > 2000, 51%). After multivariable adjustment, Agatston scores 1001 to 1500, 1501 to 2000, and >2000 were associated with an 8.05-, 7.45-, and 13.26-fold greater mortality risk, respectively, than for Agatston score of 0. Compared with Agatston score 1001 to 1500, Agatston score 1501 to 2000 had a similar all-cause mortality risk, whereas Agatston score > 2000 had an increased relative risk (Agatston score 1501-2000: hazard ratio [HR], 1.01 [95% CI, 0.67-1.51]; Agatston score > 2000: HR, 1.79 [95% CI, 1.30-2.46]). Graphical assessment of the predicted survival model suggests no upper threshold for risk associated with calcified plaque in coronary arteries.
  
  
  CONCLUSIONS
  Increasing calcified plaque in coronary arteries continues to predict a graded decrease in survival among patients with extensive Agatston score > 1000 with no apparent upper threshold.
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Division of Internal Medicine, Virginia Commonwealth University Medical Center-Medical College of Virginia, 1200 E Broad Street, Richmond, VA 23298, USA. Electronic address: jaideepatel@hotmail.com.
authors.forename: Jaideep
authors.initials: J
authors.lastname: Patel
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: John W
authors.initials: JW
authors.lastname: McEvoy
authors.affiliation: Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, NY, USA.
authors.forename: Sadia
authors.initials: S
authors.lastname: Qadir
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Division of Cardiology, Danbury Hospital, Danbury, CT, USA.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Tota-Maharaj
authors.affiliation: Division of Cardiology, Emory University, Atlanta, GA, USA.
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.affiliation: Princeton Longevity Center, Princeton, NJ, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Rumberger
authors.affiliation: Tennessee Heart and Vascular Center, Hendersonville, TN, USA.
authors.forename: Tracy Q
authors.initials: TQ
authors.lastname: Callister
authors.affiliation: Cedars-Sinai Medical Center and the Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Cedars-Sinai Medical Center and the Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: James K
authors.initials: JK
authors.lastname: Min
authors.affiliation: Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.
authors.forename: Paolo
authors.initials: P
authors.lastname: Raggi
authors.affiliation: Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA.
authors.forename: Arthur A
authors.initials: AA
authors.lastname: Agatston
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Roger S
authors.initials: RS
authors.lastname: Blumenthal
authors.affiliation: Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA.
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
mesh_terms: D000368:Aged; D002114:Calcinosis / Q000000981:diagnostic imaging* / Q000401:mortality*; D015897:Comorbidity; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality*; D006801:Humans; D008875:Middle Aged; D015995:Prevalence; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000379:methods*; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Agatston score > 1000; Calcified plaque in coronary arteries paradox; Coronary artery calcium; Stable plaque