Visual Coronary and Aortic Calcium Scoring on Chest Computed Tomography Predict Mortality in Patients With Low-Density Lipoprotein-Cholesterol ≥190 mg/dL

Abstract

Background: Current guidelines recommend coronary artery calcium (CAC) scoring for stratification of atherosclerotic cardiovascular disease risk only in patients with borderline to intermediate risk score by the pooled cohort equation with low-density lipoprotein-cholesterol (LDL-C) of 70 to 190 mg/dL. It remains unknown if CAC or thoracic aorta calcification (TAC), detected on routine chest computed tomography, can provide further risk stratification in patients with LDL-C≥190 mg/dL. Methods: From a multisite medical center, we retrospectively identified all patients from March 2005 to June 2021 age ≥40 years, without established atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL who had non-gated non-contrast chest computed tomography within 3 years of LDL-C measurement. Ordinal CAC and TAC scores were measured by visual inspection. Kaplan-Meier curves and multivariable Cox-regression models were built to ascertain the association of CAC and TAC scores with all-cause mortality. Results: We included 811 patients with median age 59 (53–68) years, 262 (32.3%) were male, and LDL-C median level was 203 (194–217) mg/dL. Patients were followed for 6.2 (3.29–9.81) years, and 109 (13.4%) died. Overall, 376 (46.4%) of patients had CAC=0 and 226 (27.9%) had TAC=0. All-cause mortality increased with any CAC and moderate to severe TAC. In a multivariate model, patients with CAC had a significantly higher mortality compared with those without CAC: mild hazard ratio (HR), 1.71 (1.03–2.83), moderate HR, 2.12 (1.14–3.94), and severe HR, 3.49 (1.94–6.27). Patients with moderate TAC (HR, 2.34 [1.19–4.59]) and those with severe TAC (HR, 3.02 [1.36–6.74]) had higher mortality than those without TAC. Conclusions: In patients without history of atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL, the presence and severity of CAC and TAC are independently associated with all-cause mortality.

Association of Segment‐Specific Pulse Wave Velocity With Vascular Calcification: The ARIC (Atherosclerosis Risk in Communities) Study

“…Calcification of elastic fibers in the arterial wall contributes to arterial stiffness. 28 , 29 Although several studies report the association of thoracic aorta calcification (ascending aorta, aortic arch, and descending aorta) with adverse events, 7 , 10 , 11 , 30 , 31 , 32 compared with CAC score, clinical usefulness of descending aorta calcification is less established. If prognostic value of descending aorta calcification beyond CAC is established in the future, cfPWV alone (or in combination with a few other PWV measures) would be helpful to identify individuals who are likely to have descending aorta calcification.…”

Long-Term Mortality in Patients With Severe Hypercholesterolemia Phenotype From a Racial and Ethnically Diverse US Cohort

“…5 However, emerging evidence from our group and others suggests that ASCVD risk may be heterogeneous; some individuals with an LDL-C ≥190 mg/dL develop ASCVD early despite maximal LLT, and others never do despite marked LDL-C elevation. [6][7][8][9] Indeed, it is plausible that a complex interplay of multiple cardiovascular risk modifiers beyond LDL-C may explain the variability of ASCVD expression in patients with severe hypercholesterolemia. 10 Understanding the spectrum of risk and independent contributors may allow better treatment strategies.…”

Imaging subclinical coronary atherosclerosis to guide lipid management, are we there yet?

“…Moreover, in a retrospective study of 811 patients aged ≥40 years with LDL-C ≥190 mg/dL evaluated with non-gated chest CT, visual CAC and thoracic aorta calcification (TAC), quantified using simple “ordinal scores” were found to be independently associated with all-cause mortality [ 51 ].…”