Yonsei Med J.  2019 Jul;60(7):619-625. 10.3349/ymj.2019.60.7.619.

Predictors of Severe or Moderate Coronary Artery Disease in Asymptomatic Individuals with Extremely Low Coronary Calcium Scores

• Park HB
• Jeong H
• Lee JH
• Suh Y
• Hwang ES
• Cho YH
• Cho DK

• KMID: 2450401
• DOI: http://doi.org/10.3349/ymj.2019.60.7.619

Abstract

PURPOSE
To evaluate predictors of severe or moderate coronary artery disease (CAD) in individuals with zero or very low (<10) coronary artery calcium (CAC) scores.
MATERIALS AND METHODS
The 1175 asymptomatic persons with zero or very low (<10) CAC scores were analyzed for CAD stenosis using coronary computed tomography angiography. Moderate and severe CADs were defined as having more than 50% and more than 70% stenosis in any of the major coronary arteries, respectively. Age, gender, body mass index, hypertension, type II diabetes, dyslipidemia, lipid profile, creatinine, and smoking status were evaluated as predictors for moderate and severe CAD.
RESULTS
In the study population, moderate and severe CADs were found in 7.5% and 3.3%, respectively. Among evaluated risk factors, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02−1.07, p<0.001], current smoking status (OR 3.12, 95% CI 1.82−5.34, p<0.001), and CAC 1−9 (OR 1.80, 95% CI 1.08−3.00, p=0.024) were significantly associated with moderate CAD. Meanwhile, age (OR 1.05, 95% CI 1.02−1.08, p=0.003), low high density lipoprotein (HDL) (OR 0.96, 95% CI 0.93−0.99, p=0.003), and current smoking status (OR 2.34, 95% CI 1.14−5.30, p=0.022) were found to be significantly associated with severe CAD. Improvement of discrimination power for predicting severe CAD was observed when smoking and HDL cholesterol were serially added into the age model.
CONCLUSION
Smoking showed significant correlations with moderate or severe CAD, and low HDL cholesterol also proved to be a predictor of severe CAD in asymptomatic individuals with extremely low CAC scores.

Keyword

Asymptomatic condition; coronary artery disease; calcium; computed tomography angiography

MeSH Terms

Angiography
Asymptomatic Diseases
Body Mass Index
Calcium*
Cholesterol, HDL
Constriction, Pathologic
Coronary Artery Disease*
Coronary Vessels*
Creatinine
Discrimination (Psychology)
Dyslipidemias
Humans
Hypertension
Lipoproteins
Risk Factors
Smoke
Smoking
Calcium
Cholesterol, HDL
Creatinine
Lipoproteins
Smoke

Figure

• 

  Fig. 1 Prevalence of moderate CAD (A) and severe CAD (B) between the less than 10 CAC score group and zero CAC score group. CAD, coronary artery disease; CAC, coronary artery calcium.

• 

  Fig. 2 Comparison of C-statistics among the “Age+Smoking+HDL cholesterol” vs. “Age+Smoking” vs. “Age” model for predicting severe CAD. HDL, high density lipoprotein; CAD, coronary artery disease; AUC, area under the receiver operating characteristic curve.

Reference

1. Hecht HS. Coronary artery calcium scanning: past, present, and future. JACC Cardiovasc Imaging. 2015; 8:579–596. PMID: 25937196.

2. Iwasaki K, Matsumoto T. Relationship between coronary calcium score and high-risk plaque/significant stenosis. World J Cardiol. 2016; 8:481–487. PMID: 27621776.

3. Alluri K, Joshi PH, Henry TS, Blumenthal RS, Nasir K, Blaha MJ. Scoring of coronary artery calcium scans: history, assumptions, current limitations, and future directions. Atherosclerosis. 2015; 239:109–117. PMID: 25585030.

4. Choi EK, Choi SI, Rivera JJ, Nasir K, Chang SA, Chun EJ, et al. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol. 2008; 52:357–365. PMID: 18652943.

5. Gottlieb I, Miller JM, Arbab-Zadeh A, Dewey M, Clouse ME, Sara L, et al. The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography. J Am Coll Cardiol. 2010; 55:627–634. PMID: 20170786.

6. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990; 15:827–832. PMID: 2407762.

7. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988; 44:837–845. PMID: 3203132.

8. Rumberger JA, Simons DB, Fitzpatrick LA, Sheedy PF, Schwartz RS. Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area. A histopathologic correlative study. Circulation. 1995; 92:2157–2162. PMID: 7554196.

9. Sangiorgi G, Rumberger JA, Severson A, Edwards WD, Gregoire J, Fitzpatrick LA, et al. Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology. J Am Coll Cardiol. 1998; 31:126–133. PMID: 9426030.

10. Libby P. Mechanisms of acute coronary syndromes and their implications for therapy. N Engl J Med. 2013; 368:2004–2013. PMID: 23697515.

11. Hayward RA, Krumholz HM, Zulman DM, Timbie JW, Vijan S. Optimizing statin treatment for primary prevention of coronary artery disease. Ann Intern Med. 2010; 152:69–77. PMID: 20083825.

12. Yeboah J, McClelland RL, Polonsky TS, Burke GL, Sibley CT, O'Leary D, et al. Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA. 2012; 308:788–795. PMID: 22910756.

13. Budoff MJ, Nasir K, McClelland RL, Detrano R, Wong N, Blumenthal RS, et al. Coronary calcium predicts events better with absolute calcium scores than age-sex-race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2009; 53:345–352. PMID: 19161884.

14. Villines TC, Hulten EA, Shaw LJ, Goyal M, Dunning A, Achenbach S, et al. Prevalence and severity of coronary artery disease and adverse events among symptomatic patients with coronary artery calcification scores of zero undergoing coronary computed tomography angiography: results from the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry. J Am Coll Cardiol. 2011; 58:2533–2540. PMID: 22079127.

15. Koulaouzidis G, Charisopoulou D, Jenkins PJ, Koulaouzidis A, McArthur T. Prevalence of noncalcified coronary plaque in patients with calcium score of 0: the silent enemy. Angiology. 2013; 64:205–210. PMID: 22492253.

16. Rubinshtein R, Gaspar T, Halon DA, Goldstein J, Peled N, Lewis BS. Prevalence and extent of obstructive coronary artery disease in patients with zero or low calcium score undergoing 64-slice cardiac multidetector computed tomography for evaluation of a chest pain syndrome. Am J Cardiol. 2007; 99:472–475. PMID: 17293187.

17. Lee MS, Chun EJ, Kim KJ, Kim JA, Yoo JY, Choi SI. Asymptomatic subjects with zero coronary calcium score: coronary CT angiographic features of plaques in event-prone patients. Int J Cardiovasc Imaging. 2013; 29(Suppl 1):29–36.

18. Katsiki N, Papadopoulou SK, Fachantidou AI, Mikhailidis DP. Smoking and vascular risk: are all forms of smoking harmful to all types of vascular disease. Public Health. 2013; 127:435–441. PMID: 23453194.

19. Chelland Campbell S, Moffatt RJ, Stamford BA. Smoking and smoking cessation- the relationship between cardiovascular disease and lipoprotein metabolism: a review. Atherosclerosis. 2008; 201:225–235. PMID: 18565528.

20. Leone A. Smoking, haemostatic factors, and cardiovascular risk. Curr Pharm Des. 2007; 13:1661–1667. PMID: 17584096.