title: The effects of multiple coronary artery disease risk factors on subclinical atherosclerosis in a rural population in the United States.
abstract: The risk factors for cardiovascular disease (CVD) are associated with coronary atherosclerosis and having multiple risk factors potentiates atherosclerosis. This study examined the prevalence of multiple biological and lifestyle/behavioral risk factors and their association with coronary artery calcium (CAC), a marker for subclinical coronary atherosclerosis.
  
  
  
  This is a cross-sectional study of 1607 community-dwelling asymptomatic individuals from central Appalachia who participated in CAC screening between January 2011 and December 2012. Data on demographics (sex and age) and 7 traditional risk factors for coronary artery disease (CAD) were collected and categorized into 5 groups (0-1, 2, 3, 4, and ≥5). Prevalence of these risk factors and CAC scores (0, 1-99, 100-399, ≥400) were assessed, and the impact of the number of risk factors on CAC scores were delineated using multiple logistic regression.
  
  
  
  Over 98% of participants had ≥1 risk factor. While obesity, diabetes, hypertension, and family history of CAD significantly increased the odds of having CAC, CAC scores significantly increased with number of risk factors. After adjusting for demographic factors, having 3, 4, and ≥5 risk factors was significantly associated with increased odds of having higher CAC scores when compared to zero CAC score by more than one and half times [OR=1.65, CI (1.20-2.25)], two times [OR=2.32, CI (1.67-3.23)] and three times [OR=3.45, CI (2.42-4.92)], respectively.
  
  
  
  The high prevalence of multiple risk factors in the study population suggests the need for aggressive multiple risk factors interventions for primary prevention of CAD, which could address CVD health disparities.
authors.affiliation: Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN, United States. Electronic address: mamudu@etsu.edu.
authors.forename: Hadii M
authors.initials: HM
authors.lastname: Mamudu
authors.affiliation: Division of Cardiology, James. H. Quillen College of Medicine, East Tennessee State University, 329 N State of Franklin Rd, Johnson City, TN 37604, United States. Electronic address: pault@etsu.edu.
authors.forename: Timir K
authors.initials: TK
authors.lastname: Paul
authors.affiliation: Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, United States. Electronic address: WANGL2@etsu.edu.
authors.forename: Liang
authors.initials: L
authors.lastname: Wang
authors.affiliation: Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, United States. Electronic address: spveeran@utmb.edu.
authors.forename: Sreenivas P
authors.initials: SP
authors.lastname: Veeranki
authors.affiliation: Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37604, United States. Electronic address: hemangbpanchal@gmail.com.
authors.forename: Hemang B
authors.initials: HB
authors.lastname: Panchal
authors.affiliation: Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, United States. Electronic address: ALAMIAN@etsu.edu.
authors.forename: Arsham
authors.initials: A
authors.lastname: Alamian
authors.affiliation: Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, United States. Electronic address: sarnosky@goldmail.etsu.edu.
authors.forename: Kamrie
authors.initials: K
authors.lastname: Sarnosky
authors.affiliation: Los Angeles Biomedical Research Institute, 1124 W Carson Street, Torrance, CA 90502, United States. Electronic address: mbudoff@labiomed.org.
authors.forename: Matthew
authors.initials: M
authors.lastname: Budoff
mesh_terms: D001061:Appalachian Region / Q000453:epidemiology; D050197:Atherosclerosis / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications; D008019:Life Style; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012424:Rural Population; D014057:Tomography, X-Ray Computed; D014481:United States
keywords: Appalachia; Clustering of risk factors; Coronary artery calcium; Coronary artery disease; Multiple risk factors; Subclinical atherosclerosis