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Increased heart risk for young adults with coronary artery calcium

The presence of any coronary artery calcium among adults ages 32 to 46 years was associated with a 5-fold increase in fatal and nonfatal coronary heart disease events during 12.5 years of follow-up, according to a study.

Coronary artery calcium (CAC) measured by non-contrast cardiac computed tomographic (CT) scan is a non-invasive measure of coronary artery disease that is associated with coronary heart disease (CHD) and cardiovascular disease (CVD) in middle and older age. The Coronary Artery Risk Development in Young Adults (CARDIA) Study previously reported that non-optimal levels of modifiable cardiovascular risk factors at an average age of 25 years were associated with prevalent CAC measured 15 years later at an average age of 40 years. It is unknown if the presence of CAC by midlife increases the risk of CHD clinical events during the next decade in this younger population.

Dr John Jeffrey Carr, of the Vanderbilt University Medical Centre, in Nashville and colleagues conducted follow-up of CARDIA participants who had CAC measured 15, 20, and 25 years after entering the study. At year 15 of the study among 3,043 participants (average age, 40 years), 10% had CAC. Participants were followed up for 12.5 years, with 57 incident CHD events (fatal or nonfatal heart attack, acute coronary syndrome without heart attack, coronary revascularisation, or CHD death) and 108 incident CVD events (CHD, stroke, heart failure, and peripheral arterial disease) observed. After adjusting for demographics, risk factors, and treatments, those with any CAC experienced a 5-fold increase in CHD events and 3-fold increase in CVD events.

“Whether any kind of general screening for CAC is warranted needs further study, although we suggest that a strategy in which all individuals aged 32 to 46 years are screened is not indicated. Rather, a more targeted approach based on measuring risk factors in early adult life to predict individuals at high risk for developing CAC in whom the CT scan would have the greatest value can be considered. The finding that CAC present by ages 32 to 46 years is associated with increased risk of premature CHD and death emphasises the need for reduction of risk factors and primordial prevention beginning in early life,” the authors write.

Abstract
Importance: Coronary artery calcium (CAC) is associated with coronary heart disease (CHD) and cardiovascular disease (CVD); however, prognostic data on CAC are limited in younger adults.
Objective: To determine if CAC in adults aged 32 to 46 years is associated with incident clinical CHD, CVD, and all-cause mortality during 12.5 years of follow-up.
Design, Setting, and Participants: The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a prospective community-based study that recruited 5115 black and white participants aged 18 to 30 years from March 25, 1985, to June 7, 1986. The cohort has been under surveillance for 30 years, with CAC measured 15 (n = 3043), 20 (n = 3141), and 25 (n = 3189) years after recruitment. The mean follow-up period for incident events was 12.5 years, from the year 15 computed tomographic scan through August 31, 2014.
Main Outcomes and Measures: Incident CHD included fatal or nonfatal myocardial infarction, acute coronary syndrome without myocardial infarction, coronary revascularization, or CHD death. Incident CVD included CHD, stroke, heart failure, and peripheral arterial disease. Death included all causes. The probability of developing CAC by age 32 to 56 years was estimated using clinical risk factors measured 7 years apart between ages 18 and 38 years.
Results: At year 15 of the study among 3043 participants (mean [SD] age, 40.3 [3.6] years; 1383 men and 1660 women), 309 individuals (10.2%) had CAC, with a geometric mean Agatston score of 21.6 (interquartile range, 17.3-26.8). Participants were followed up for 12.5 years, with 57 incident CHD events and 108 incident CVD events observed. After adjusting for demographics, risk factors, and treatments, those with any CAC experienced a 5-fold increase in CHD events (hazard ratio [HR], 5.0; 95% CI, 2.8-8.7) and 3-fold increase in CVD events (HR, 3.0; 95% CI, 1.9-4.7). Within CAC score strata of 1-19, 20-99, and 100 or more, the HRs for CHD were 2.6 (95% CI, 1.0-5.7), 5.8 (95% CI, 2.6-12.1), and 9.8 (95% CI, 4.5-20.5), respectively. A CAC score of 100 or more had an incidence of 22.4 deaths per 100 participants (HR, 3.7; 95% CI, 1.5-10.0); of the 13 deaths in participants with a CAC score of 100 or more, 10 were adjudicated as CHD events. Risk factors for CVD in early adult life identified those above the median risk for developing CAC and, if applied, in a selective CAC screening strategy could reduce the number of people screened for CAC by 50% and the number imaged needed to find 1 person with CAC from 3.5 to 2.2.
Conclusions and Relevance: The presence of CAC among individuals aged between 32 and 46 years was associated with increased risk of fatal and nonfatal CHD during 12.5 years of follow-up. A CAC score of 100 or more was associated with early death. Adults younger than 50 years with any CAC, even with very low scores, identified on a computed tomographic scan are at elevated risk of clinical CHD, CVD, and death. Selective use of screening for CAC might be considered in individuals with risk factors in early adulthood to inform discussions about primary prevention.

Authors
John Jeffrey Carr; David R Jacobs Jr; James G Terry; Christina M Shay; Stephen Sidney; Kiang Liu; Pamela J Schreiner; Cora E Lewis; James M Shikany; Jared P Reis; David C Goff Jr

[link url="http://media.jamanetwork.com/news-item/presence-of-coronary-artery-calcium-among-younger-adults-associated-with-increased-risk-of-fatal-heart-disease/"]JAMA material[/link]
[link url="http://jamanetwork.com/journals/jamacardiology/fullarticle/2601071"]JAMA Cardiology abstract[/link]
[link url="http://jamanetwork.com/journals/jamacardiology/article-abstract/2601068"]JAMA Cardiology editorial[/link]

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