title: Prognostic implications of coronary artery calcium in the absence of coronary artery luminal narrowing.
abstract: Coronary artery calcium (CAC) scoring is a predictor of future adverse clinical events, and a surrogate measure of overall coronary artery plaque burden. Coronary computed tomographic angiography (CCTA) is a contrast-enhanced method that allows for visualization of plaque as well as whether that plaque causes luminal narrowing. To date, the prognosis of individuals with CAC but without stenosis has not been reported. We explored the prevalence of CAC>0 and its prognostic utility for future mortality for patients without luminal narrowing by CCTA.
  
  
  
  From 17 sites in 9 countries, we identified patients without known coronary artery disease, who underwent CAC scoring and CCTA, and were followed for >3 years. CCTA was graded for % stenosis according to a modified American Heart Association 16-segment model. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) for incident mortality and compared risk of death for patients as a function of presence or absence of CAC and presence or absence of luminal narrowing by CCTA.
  
  
  
  Among 6656 patients who underwent CCTA and CAC scoring, 399 patients (6.0%) had no coronary luminal narrowing but CAC>0. During a median follow-up of 5.1 years (IQR: 3.9-5.9 years), 456 deaths occurred. Compared to individuals without luminal narrowing or CAC, individuals without luminal narrowing but CAC>0 were older, more likely to be male and had higher rates of diabetes, hypertension, and dyslipidemia. Individuals without luminal narrowing but CAC experienced a 2-fold increased risk of mortality, with increasing risk of mortality with higher CAC score. Following adjustment, incident death persisted (HR, 1.8; 95% CI, 1.1-2.9, p = 0.02) among patients without luminal narrowing but with CAC>0 compared with patients whose CACS = 0. Individuals without luminal narrowing but CAC ≥100 had mortality risks similar to individuals with non-obstructive CAD (0 < stenosis<50%) by CCTA [HR 2.5 (95% CI 1.3-4.9) and 2.2 (95% CI 1.6-3.0), respectively].
  
  
  
  Patients without luminal narrowing but with CAC experience greater risk of 5-year mortality. Patients with CAC score ≥100 and no coronary luminal narrowing experience death rates similar to those with non-obstructive CAD.
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.
authors.forename: Iksung
authors.initials: I
authors.lastname: Cho
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA; Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, Adler Geriatric Center, New Haven, USA.
authors.forename: Bríain
authors.initials: B
authors.lastname: Ó Hartaigh
authors.affiliation: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Heidi
authors.initials: H
authors.lastname: Gransar
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.
authors.forename: Valentina
authors.initials: V
authors.lastname: Valenti
authors.affiliation: Department of Medicine, NewYork-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA.
authors.forename: Fay Y
authors.initials: FY
authors.lastname: Lin
authors.affiliation: Department of Medicine, University of Erlangen, Erlangen, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Achenbach
authors.affiliation: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.
authors.forename: Tracy Q
authors.initials: TQ
authors.lastname: Callister
authors.affiliation: Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Mouaz H
authors.initials: MH
authors.lastname: Al-Mallah
authors.affiliation: Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Filippo
authors.initials: F
authors.lastname: Cademartiri
authors.affiliation: William Beaumont Hospital, Royal Oaks, MI, USA.
authors.forename: Kavitha
authors.initials: K
authors.lastname: Chinnaiyan
authors.affiliation: Department of Medicine and Radiology, University of Ottawa, ON, Canada.
authors.forename: Benjamin J W
authors.initials: BJW
authors.lastname: Chow
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Allison M
authors.initials: AM
authors.lastname: Dunning
authors.affiliation: Capitol Cardiology Associates, Albany, NY, USA.
authors.forename: Augustin
authors.initials: A
authors.lastname: DeLago
authors.affiliation: Department of Medicine, Walter Reed Medical Center, Washington, DC, USA.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Villines
authors.affiliation: Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Hadamitzky
authors.affiliation: Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.
authors.forename: Joerg
authors.initials: J
authors.lastname: Hausleiter
authors.affiliation: Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.affiliation: University Hospital, Zurich, Switzerland.
authors.forename: Philipp A
authors.initials: PA
authors.lastname: Kaufmann
authors.affiliation: Baptist Cardiac and Vascular Institute, Miami, FL, USA.
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.affiliation: Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Feuchtner
authors.affiliation: Seoul National University Hospital, Seoul, South Korea.
authors.forename: Yong-Jin
authors.initials: YJ
authors.lastname: Kim
authors.affiliation: Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Erica
authors.initials: E
authors.lastname: Maffei
authors.affiliation: William Beaumont Hospital, Royal Oaks, MI, USA.
authors.forename: Gilbert
authors.initials: G
authors.lastname: Raff
authors.affiliation: Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Pontone
authors.affiliation: Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Andreini
authors.affiliation: Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.
authors.forename: Hyuk-Jae
authors.initials: HJ
authors.lastname: Chang
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA. Electronic address: jkm2001@med.cornell.edu.
authors.forename: James K
authors.initials: JK
authors.lastname: Min
mesh_terms: D000328:Adult; D000368:Aged; D058070:Asymptomatic Diseases; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D007557:Israel / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009656:North America / Q000453:epidemiology; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D061205:Vascular Calcification / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality
keywords: Coronary artery calcium scoring; Coronary artery disease; Coronary computed tomographic angiography