Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: multi-ethnic study of atherosclerosis.
OBJECTIVE
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.
Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.
Michael G
MG
Silverman
Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.
James R
JR
Harkness
Brigham and Women's Hospital, Boston MA.
Ron
R
Blankstein
Los Angeles Biomedical Research Institute, Torrance, CA.
Matthew J
MJ
Budoff
Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL.
Arthur S
AS
Agatston
Vanderbilt University, Nashville, TN.
J Jeffrey
JJ
Carr
Johns Hopkins Hospital, Division of Cardiology, Baltimore MD.
Joao A
JA
Lima
Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.
Roger S
RS
Blumenthal
Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.|Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL.
Khurram
K
Nasir
Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD.
Michael J
MJ
Blaha
D000368:Aged; D000369:Aged, 80 and over; D050197:Atherosclerosis / Q000175:diagnosis / Q000208:ethnology* / Q000601:surgery; D002114:Calcinosis / Q000175:diagnosis / Q000208:ethnology* / Q000601:surgery; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000208:ethnology* / Q000601:surgery; D005006:Ethnicity; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014481:United States / Q000453:epidemiology
cardiac CT; coronary artery calcium; coronary artery disease; revascularization