Endocrinol Metab.  2023 Oct;38(5):568-577. 10.3803/EnM.2023.1770.

Coronary Artery Calcium Score as a Sensitive Indicator of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus: A Long-Term Cohort Study

• Koo DJ
• Lee MY
• Moon SJ
• Kwon H
• Lee SM
• Park SE
• Park CY
• Lee WY
• Oh KW
• Cho SR
• Jeong YH
• Rhee EJ

• KMID: 2546987
• DOI: http://doi.org/10.3803/EnM.2023.1770

Abstract

Background
Coronary artery calcium score (CACS) has become an important tool for evaluating cardiovascular disease (CVD). This study evaluated the significance of CACS for future CVD through more than 10 years of follow-up in asymptomatic Korean populations with type 2 diabetes mellitus (T2DM) known to have a relatively low CACS burden.
Methods
We enrolled 981 asymptomatic T2DM patients without CVD at baseline who underwent CACS evaluation using multidetector computed tomography between January 2008 and December 2014. They were grouped into five predefined CACS categories based on Agatston scores and followed up by August 2020. The primary endpoint was incident CVD events, including coronary, cerebrovascular, and peripheral arterial disease.
Results
The relative risk of CVD was significantly higher in patients with CACS ≥10, and the significance persisted after adjustment for known confounders. A higher CACS category indicated a higher incidence of future CVD: hazard ratio (95% confidence interval) 4.09 (1.79 to 9.36), 12.00 (5.61 to 25.69), and 38.79 (16.43 to 91.59) for 10≤ CACS <100, 100≤ CACS <400, and CACS ≥400, respectively. During the 12-year follow-up period, the difference in event-free survival more than doubled as the category increased. Patients with CACS below 10 had very low CVD incidence throughout the follow-up. The receiver operating characteristic analysis showed better area under curve when the CACS cutoff was 10 than 100.
Conclusion
CACS can be a sensitive marker of CVD risk. Specifically, CACS above 10 is an indicator of CVD high-risk requiring more intensive medical treatment in Koreans with T2DM.

Keyword

Coronary artery calcium score; Diabetes mellitus, type 2; Cardiovascular diseases; Atherosclerosis; Cohort studies

Figure

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  Fig. 1. Cumulative cardiovascular (CV) event-free survival by coronary artery calcium score (CACS) cutoff 10 (A) and according to CACS categories at baseline (B).

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  Fig. 2. Intergroup difference in the risk of cardiovascular (CV) events between participants with coronary artery calcium score (CACS) ≥10 and CACS <10 at baseline. Adjusted for age, sex, body mass index (BMI), glycated hemoglobin, systolic blood pressure, low-density lipoprotein cholesterol, creatinine, smoking status, alcohol consumption, regular exercise, diabetes mellitus (DM) medications, DM duration, and anti-dyslipidemia (DLP) medications. HR, hazard ratio; CI, confidence interval.

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  Fig. 3. Receiver operating characteristic curve analysis of the optimal coronary artery calcium score (CACS) cutoff for future cardiovascular disease risk. SEN, sensitivity; SPE, specificity; AUC, area under the receiver operating characteristic curve; CI, confidence interval.

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