Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland.
Department of Medicine, Harbor-UCLA Medical Center, University of California Los Angeles, Los Angeles, California.
JACC Cardiovasc Imaging. 2020 Jan;13(1 Pt 1):83-93. doi: 10.1016/j.jcmg.2019.02.005. Epub 2019 Mar 15.
This study thoroughly explored the demographic and imaging characteristics, as well as the all-cause and cause-specific mortality risks of patients with a coronary artery calcium (CAC) score ≥1,000 in the largest dataset of this population to date.
CAC is commonly used to quantify cardiovascular risk. Current guidelines classify a CAC score of >300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with a CAC score ≥1,000.
A total of 66,636 asymptomatic adults were included from the CAC consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for patients with cardiovascular disease (CVD), coronary heart disease (CHD), cancer, and all-cause mortality. Multivariate Cox proportional hazards regression models adjusted for age, sex, and conventional risk factors were used to assess the relative mortality hazard of individuals with CAC ≥1,000 compared with, first, a CAC reference of 0, and second, with patients with a CAC score of 400 to 999.
There were 2,869 patients with CAC ≥1,000 (86.3% male, mean 66.3 ± 9.7 years of age). Most patients with CAC ≥1,000 had 4-vessel CAC (mean: 3.5 ± 0.6 vessels) and had greater total CAC area, higher mean CAC density, and more extracoronary calcium (79% with thoracic artery calcium, 46% with aortic valve calcium, and 21% with mitral valve calcium) than those with CAC scores of 400 to 999. After full adjustment, those with CAC ≥1,000 had a 5.04- (95% confidence interval [CI]: 3.92 to 6.48), 6.79- (95% CI: 4.74 to 9.73), 1.55- (95% CI:1.23 to 1.95), and 2.89-fold (95% CI: 2.53 to 3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC score of 0. The CAC ≥1,000 group had a 1.71- (95% CI: 1.41 to 2.08), 1.84- (95% CI: 1.43 to 2.36), 1.36- (95% CI:1.07 to 1.73), and 1.51-fold (95% CI: 1.33 to 1.70) increased risk of CVD, CHD, cancer, and all-cause mortality compared to those with CAC scores 400 to 999. Graphic analysis of CAC ≥1,000 patients revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau.
Patients with extensive CAC (CAC ≥1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC ≥1,000 patients to be a distinct risk group who may benefit from the most aggressive preventive therapy.
本研究深入探讨了迄今为止该人群中最大数据集内冠状动脉钙（CAC）评分≥1000 患者的人口统计学和影像学特征，以及全因和病因特异性死亡率风险。
CAC 常用于量化心血管风险。目前的指南将 CAC 评分＞300 或 400 归类为最高风险组，但对于 CAC 评分≥1000 的个体，其潜在的独特影像学特征和死亡率风险知之甚少。
纳入 CAC 联盟的 66636 名无症状成年人，这是一个大型回顾性多中心临床队列。对于患有心血管疾病（CVD）、冠心病（CHD）、癌症和全因死亡的患者，平均随访时间为 12.3±3.9 年。使用多变量 Cox 比例风险回归模型，根据年龄、性别和常规危险因素进行调整，以评估 CAC≥1000 个体与 CAC 参考值 0、CAC 评分 400 至 999 个体相比的相对死亡率风险。
有 2869 名患者的 CAC≥1000（86.3%为男性，平均年龄 66.3±9.7 岁）。大多数 CAC≥1000 的患者存在 4 支血管 CAC（平均：3.5±0.6 支血管），且总 CAC 面积更大、平均 CAC 密度更高，且存在更多的冠状动脉外钙（79%存在胸动脉钙、46%存在主动脉瓣钙、21%存在二尖瓣钙），这与 CAC 评分 400 至 999 的患者相比。经过充分调整后，与 CAC 评分 0 的患者相比，CAC≥1000 的患者 CVD、CHD、癌症和全因死亡率的风险分别增加了 5.04 倍（95%CI：3.92 至 6.48）、6.79 倍（95%CI：4.74 至 9.73）、1.55 倍（95%CI：1.23 至 1.95）和 2.89 倍（95%CI：2.53 至 3.31）。与 CAC 评分 400 至 999 的患者相比，CAC≥1000 组的 CVD、CHD、癌症和全因死亡率的风险分别增加了 1.71 倍（95%CI：1.41 至 2.08）、1.84 倍（95%CI：1.43 至 2.36）、1.36 倍（95%CI：1.07 至 1.73）和 1.51 倍（95%CI：1.33 至 1.70）。
广泛的 CAC（CAC≥1000）患者代表一种独特的极高风险表型，其死亡率结果与高危二级预防患者相当。未来的指南应考虑将 CAC≥1000 的患者视为一个独特的风险群体，他们可能受益于最积极的预防治疗。
