Yuichiro Yano1,2, Christopher J O'Donnell3,4, Lewis Kuller5, Maryam Kavousi6, Raimund Erbel7, Hongyan Ning1, Ralph D'Agostino8, Anne B Newman5, Khurram Nasir9, Albert Hofman6,10, Nils Lehmann11, Klodian Dhana6, Ron Blankstein12, Udo Hoffmann13, Stefan Möhlenkamp14, Joseph M Massaro8, Amir-Abbas Mahabadi7, Joao A C Lima15, M Arfan Ikram16, Karl-Heinz Jöckel11, Oscar H Franco6, Kiang Liu1, Donald Lloyd-Jones1, Philip Greenland1. 1. Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. 2. Department of Preventive Medicine, University of Mississippi Medical Center, Jackson. 3. National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts. 4. Associate Editor. 5. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. 6. Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands. 7. Department of Cardiology, West German Heart and Vascular Center, University Clinic Essen, University of Duisburg-Essen, Essen, Germany. 8. Biostatistics, Boston University School of Public Health, Boston, Massachusetts. 9. Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, Florida. 10. Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. 11. Institute of Medical Informatics, Biometry, and Epidemiology, University Clinic Essen, University of Duisburg-Essen, Essen, Germany. 12. Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts. 13. Cardiovascular Imaging, Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 14. Clinic of Cardiology and Intensive Care Medicine, Bethanien Hospital Moers, Moers, Germany. 15. Department of Cardiology, Johns Hopkins University, Baltimore, Maryland. 16. Departments of Epidemiology, Radiology, and Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Abstract
Importance: Besides age, other discriminators of atherosclerotic cardiovascular disease (ASCVD) risk are needed in older adults. Objectives: To examine the predictive ability of coronary artery calcium (CAC) score vs age for incident ASCVD and how risk prediction changes by adding CAC score and removing only age from prediction models. Design, Setting, and Participants: We conducted an analysis of pooled US population-based studies, including the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Results were compared with 2 European cohorts, the Rotterdam Study and the Heinz Nixdorf Recall Study. Participants underwent CAC scoring between 1998 and 2006 using cardiac computed tomography. The participants included adults older than 60 years without known ASCVD at baseline. Exposures: Coronary artery calcium scores. Main Outcomes and Measures: Incident ASCVD events including coronary heart disease (CHD) and stroke. Results: The study included 4778 participants from 3 US cohorts, with a mean age of 70.1 years; 2582 (54.0%) were women, and 2431 (50.9%) were nonwhite. Over 11 years of follow-up (44 152 person-years), 405 CHD and 228 stroke events occurred. Coronary artery calcium score (vs age) had a greater association with incident CHD (C statistic, 0.733 vs 0.690; C statistics difference, 0.043; 95% CI of difference, 0.009-0.075) and modestly improved prediction of incident stroke (C statistic, 0.695 vs 0.670; C statistics difference, 0.025; 95% CI of difference, -0.015 to 0.064). Adding CAC score to models including traditional cardiovascular risk factors, with only age being removed, provided improved discrimination for incident CHD (C statistic, 0.735 vs 0.703; C statistics difference, 0.032; 95% CI of difference, 0.002-0.062) but not for stroke. Coronary artery calcium score was more likely than age to provide higher category-free net reclassification improvement among participants who experienced an ASCVD event (0.390; 95% CI, 0.312-0.467 vs 0.08; 95% CI -0.001 to 0.181) and to result in more accurate reclassification of risk for ASCVD events among these individuals. The findings were similar in the 2 European cohorts (n = 4990). Conclusions and Relevance: Coronary artery calcium may be an alternative marker besides age to better discriminate between lower and higher CHD risk in older adults. Whether CAC score can assist in guiding the decision to initiate statin treatment for primary prevention in older adults requires further investigation.
Importance: Besides age, other discriminators of atherosclerotic cardiovascular disease (ASCVD) risk are needed in older adults. Objectives: To examine the predictive ability of coronary artery calcium (CAC) score vs age for incident ASCVD and how risk prediction changes by adding CAC score and removing only age from prediction models. Design, Setting, and Participants: We conducted an analysis of pooled US population-based studies, including the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Results were compared with 2 European cohorts, the Rotterdam Study and the Heinz Nixdorf Recall Study. Participants underwent CAC scoring between 1998 and 2006 using cardiac computed tomography. The participants included adults older than 60 years without known ASCVD at baseline. Exposures: Coronary artery calcium scores. Main Outcomes and Measures: Incident ASCVD events including coronary heart disease (CHD) and stroke. Results: The study included 4778 participants from 3 US cohorts, with a mean age of 70.1 years; 2582 (54.0%) were women, and 2431 (50.9%) were nonwhite. Over 11 years of follow-up (44 152 person-years), 405 CHD and 228 stroke events occurred. Coronary artery calcium score (vs age) had a greater association with incident CHD (C statistic, 0.733 vs 0.690; C statistics difference, 0.043; 95% CI of difference, 0.009-0.075) and modestly improved prediction of incident stroke (C statistic, 0.695 vs 0.670; C statistics difference, 0.025; 95% CI of difference, -0.015 to 0.064). Adding CAC score to models including traditional cardiovascular risk factors, with only age being removed, provided improved discrimination for incident CHD (C statistic, 0.735 vs 0.703; C statistics difference, 0.032; 95% CI of difference, 0.002-0.062) but not for stroke. Coronary artery calcium score was more likely than age to provide higher category-free net reclassification improvement among participants who experienced an ASCVD event (0.390; 95% CI, 0.312-0.467 vs 0.08; 95% CI -0.001 to 0.181) and to result in more accurate reclassification of risk for ASCVD events among these individuals. The findings were similar in the 2 European cohorts (n = 4990). Conclusions and Relevance: Coronary artery calcium may be an alternative marker besides age to better discriminate between lower and higher CHD risk in older adults. Whether CAC score can assist in guiding the decision to initiate statin treatment for primary prevention in older adults requires further investigation.
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