Discordance Between Coronary Artery Calcium Area and Density Predicts Long-Term Atherosclerotic Cardiovascular Disease Risk

JACC Cardiovasc Imaging. 2022 Nov;15(11):1929-1940. doi: 10.1016/j.jcmg.2022.06.007. Epub 2022 Jul 15.

Abstract

Background: Coronary artery calcium (CAC) is commonly quantified as the product of 2 generally correlated measures: plaque area and calcium density.

Objectives: The authors sought to determine whether discordance between calcium area and density has long-term prognostic importance in atherosclerotic cardiovascular disease (ASCVD) risk.

Methods: The authors studied 10,373 primary prevention participants from the CAC Consortium with CAC >0. Based on their median values, calcium area and mean calcium density were divided into 4 mutually exclusive concordant/discordant groups. Cox proportional hazards regression assessed the association of calcium area/density groups with ASCVD mortality over a median of 11.7 years, adjusting for traditional risk factors and the Agatston CAC score.

Results: The mean age was 56.7 years, and 24% were female. The prevalence of plaque discordance was 19% (9% low calcium area/high calcium density, 10% high calcium area/low calcium density). Female sex (odds ratio [OR]: 1.48 [95% CI: 1.27-1.74]) and body mass index (OR: 0.81 [95% CI: 0.76-0.87], per 5 kg/m2 higher) were significantly associated with high calcium density discordance, whereas diabetes (OR: 2.23 [95% CI: 1.85-3.19]) was most strongly associated with discordantly low calcium density. Compared to those with low calcium area/low calcium density, individuals with low calcium area/high calcium density had a 71% lower risk of ASCVD death (HR: 0.29 [95% CI: 0.09-0.95]).

Conclusions: For a given CAC score, high calcium density relative to plaque area confers lower long-term ASCVD risk, likely serving as an imaging marker of biological resilience for lesion vulnerability. Additional research is needed to define a robust definition of calcium area/density discordance for routine clinical risk prediction.

Keywords: calcium density; cardiovascular diseases; coronary artery calcium; multidetector computed tomography.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Atherosclerosis* / pathology
  • Calcium
  • Cardiovascular Diseases* / pathology
  • Coronary Artery Disease*
  • Coronary Vessels / diagnostic imaging
  • Coronary Vessels / pathology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Plaque, Atherosclerotic*
  • Predictive Value of Tests
  • Risk Assessment
  • Risk Factors
  • Vascular Calcification*

Substances

  • Calcium