Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes

Allison W Peng; Ramzi Dudum; Sneha S Jain; David J Maron; Bhavik N Patel; Nishith Khandwala; David Eng; Akshay S Chaudhari; Alexander T Sandhu; Fatima Rodriguez

doi:10.1016/j.jacc.2023.06.040

Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes

J Am Coll Cardiol. 2023 Sep 19;82(12):1192-1202. doi: 10.1016/j.jacc.2023.06.040.

Authors

Affiliations

¹ Department of Medicine, Stanford University, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA. Electronic address: https://twitter.com/AllisonWPeng.
² Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA.
³ Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California, USA.
⁴ Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA.
⁵ Bunkerhill Health, Palo Alto, California, USA.
⁶ Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Department of Radiology, Stanford University, Stanford, California, USA; Department of Biomedical Data Science, Stanford University, Stanford, California, USA.
⁷ Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Veteran's Affairs Palo Alto Healthcare System, Palo Alto, California, USA. Electronic address: https://twitter.com/ATSandhu.
⁸ Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA. Electronic address: frodrigu@stanford.edu.

Abstract

Background: Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis.

Objectives: The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods.

Methods: Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations.

Results: Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0.

Conclusions: Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.

Keywords: cardiovascular outcomes; coronary artery calcium; nongated computed tomography; primary prevention; risk prediction; screening.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Atherosclerosis*
Calcium
Coronary Vessels / diagnostic imaging
Female
Humans
Male
Myocardial Infarction*
Stroke*
Tomography, X-Ray Computed

Substances

Calcium

Abstract

Publication types

MeSH terms

Substances

Grants and funding