title: Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy.
abstract: BACKGROUND
  The use of atherosclerotic cardiovascular disease (ASCVD) risk to personalize systolic blood pressure (SBP) treatment goals is a topic of increasing interest. Therefore, we studied whether coronary artery calcium (CAC) can further guide the allocation of anti-hypertensive treatment intensity.
  
  
  METHODS
  We included 3733 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with SBP between 120 and 179 mm Hg. Within subgroups categorized by both SBP (120-139 mm Hg, 140-159 mm Hg, and 160-179 mm Hg) and estimated 10-year ASCVD risk (using the American College of Cardiology/American Heart Assocation pooled-cohort equations), we compared multivariable-adjusted hazard ratios for the composite outcome of incident ASCVD or heart failure after further stratifying by CAC (0, 1-100, or >100). We estimated 10-year number-needed-to-treat for an intensive SBP goal of 120 mm Hg by applying the treatment benefit recorded in meta-analyses to event rates within CAC strata.
  
  
  RESULTS
  The mean age was 65 years, and 642 composite events took place over a median of 10.2 years. In persons with SBP <160 mm Hg, CAC stratified risk for events. For example, among those with an ASCVD risk of <15% and who had an SBP of either 120 to 139 mm Hg or 140 to 159 mm Hg, respectively, we found increasing hazard ratios for events with CAC 1 to 100 (1.7 [95% confidence interval, 1.0-2.6] or 2.0 [1.1-3.8]) and CAC >100 (3.0 [1.8-5.0] or 5.7 [2.9-11.0]), all relative to CAC=0. There appeared to be no statistical association between CAC and events when SBP was 160 to 179 mm Hg, irrespective of ASCVD risk level. Estimated 10-year number-needed-to-treat for a SBP goal of 120mmHg varied substantially according to CAC levels when predicted ASCVD risk <15% and SBP <160mmHg (eg, 10-year number-needed-to-treat of 99 for CAC=0 and 24 for CAC>100, when SBP 120-139mm Hg). However, few participants with ASCVD risk <5% had elevated CAC. Furthermore, 10-year number-needed-to-treat estimates were consistently low and varied less among CAC strata when SBP was 160 to 179 mm Hg or when ASCVD risk was ≥15% at any SBP level.
  
  
  CONCLUSIONS
  Combined CAC imaging and assessment of global ASCVD risk has the potential to guide personalized SBP goals (eg, choosing a traditional goal of 140 or a more intensive goal of 120 mm Hg), particularly among adults with an estimated ASCVD risk of 5% to 15% and prehypertension or mild hypertension.
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.). jmcevoy1@jhmi.edu.
authors.forename: John W
authors.initials: JW
authors.lastname: McEvoy
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Seth S
authors.initials: SS
authors.lastname: Martin
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Zeina A
authors.initials: ZA
authors.lastname: Dardari
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Michael D
authors.initials: MD
authors.lastname: Miedema
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Veit
authors.initials: V
authors.lastname: Sandfort
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Joseph
authors.initials: J
authors.lastname: Yeboah
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: David C
authors.initials: DC
authors.lastname: Goff
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Psaty
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Wendy S
authors.initials: WS
authors.lastname: Post
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Roger S
authors.initials: RS
authors.lastname: Blumenthal
authors.affiliation: From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D050197:Atherosclerosis / Q000188:drug therapy*; D001794:Blood Pressure / Q000187:drug effects; D002118:Calcium / Q000097:blood*; D003324:Coronary Artery Disease / Q000517:prevention & control; D003331:Coronary Vessels / Q000187:drug effects* / Q000378:metabolism; D005260:Female; D006333:Heart Failure / Q000517:prevention & control; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors
chemical_list: D000959:Antihypertensive Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002118:Calcium
keywords: antihypertensive therapy; cardiovascular disease risk; coronary artery calcium; systolic blood pressure