Elsevier

Progress in Cardiovascular Diseases

Volume 78, May–June 2023, Pages 67-73
Progress in Cardiovascular Diseases

Coronary artery calcium, hepatic steatosis, and atherosclerotic cardiovascular disease risk in patients with type 2 diabetes mellitus: Results from the Dallas heart study

https://doi.org/10.1016/j.pcad.2023.03.002Get rights and content

Abstract

Introduction

Cardiovascular disease (CVD) risk amongst those with type 2 diabetes (T2D) is heterogenous. The role of imaging-based cardiometabolic biomarkers (e.g., coronary artery calcium [CAC] score, and hepatic triglyceride content [HTC]) in CVD risk stratification in T2D is unclear. To better understand this, we sought to evaluate the individual and joint associations between CAC and hepatic steatosis (HS) with clinical atherosclerotic CVD (ASCVD) in Dallas Heart Study (DHS) participants with and without T2D.

Methods

We examined participants in the DHS, a multi-ethnic cohort study, without self-reported ASCVD. CAC scoring was performed via computed tomography with the mean of two consecutive scores used. HTC was measured using magnetic resonance spectroscopy, and HS was defined as HTC >5.5% The primary outcome was incident ASCVD, defined as coronary heart disease (CHD; myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery), ischemic stroke, transient ischemic attack, or CVD death. Cox regression analyses, and interaction testing was performed to evaluate the individual and joint associations between CAC and HS with ASCVD. The association between HS and coronary heart disease was validated in the UK Biobank (UKB).

Results

A total of 1252 DHS participants were included with mean age 44.8 ± 9.3 years, mean body mass index 28.7 ± 5.9 kg/m2, 55% female, and 59% black with an overall prevalence of T2D of 9.7%. CAC scores were significantly higher (p < 0.01) and HS was significantly more prevalent in those with T2D (p < 0.01). Over a median of 12.3 years, 8.3% of participants experienced ASCVD events. The ASCVD event rate was significantly higher in participants with T2D (20.5% vs 7.0%, p < 0.01). Continuous CAC was associated with ASCVD events in the overall cohort regardless of T2D status with a significant interaction present between CAC and T2D status on ASCVD, Pinteraction = 0.02. HTC was not associated with ASCVD risk in participants without T2D but was inversely associated with risk in participants with T2D (HR 0.91, 95% CI 0.83–0.99 per 1% increase in HTC, p = 0.02), Pinteraction = 0.02. Amongst 37,266 UKB participants, 4.5% had T2D. CHD events occurred in 2.2% of participants, with 10.2% of events occurring amongst those with T2D. An inverse relationship between HTC and CHD was also found amongst those with T2D in UKB with a significant interaction between T2D status and HTC on CHD (HR per 1% increase in HTC 0.95, 95% CI 0.91–0.99, p = 0.01, Pinteraction = 0.02).

Conclusions

In the DHS, we found that CAC was associated with ASCVD risk independent of T2D status. We did not observe an association between HTC and ASCVD in participants without T2D, but there was an inverse association between HTC and ASCVD in those with T2D that was replicated in the UKB cohort. Further investigation is warranted to understand the possible protective association of HS in participants with T2D.

Section snippets

Study population

DHS is a multi-ethnic, cohort study of Dallas County residents with oversampling of African Americans with the goal of improving the diagnosis, prevention, and treatment of heart disease. Details of the study have been described previously.10 From an overall cohort of 3072 participants with imaging, individuals with prevalent self-reported history of ASCVD (N = 80), heart failure (N = 62), or cardiac arrest (N = 6) or those with a history of excessive alcohol consumption (N = 178) were

Results

A total of 1252 DHS participants were included, of which 122 (9.7%) had T2D. The median age was 45 ± 15 years, median body mass index (BMI)was 27.80 ± 7.54 kg/m2, 55.2% were female, and 58.9% were Black. CAC scores were higher amongst those with T2D (median 2.65 ± 40.51 vs 0 ± 4.30, p < 0.01). Amongst those with T2D, 68 (55.7%) had HS; whereas amongst those without T2D, the prevalence of HS was 27.3% (p < 0.01 compared with T2D, Table 1). There was no significant difference in the age or the

Discussion

In this study of 1252 DHS participants, approximately 10% of participants had T2D. The prevalence of HS was higher amongst those with T2D than without T2D. Similarly, the ASCVD event rate was higher in those with T2D. There was a significant association between continuous CAC with incident ASCVD regardless of T2D or HS status. When CAC was assessed as a categorical variable CAC ≥ 100, but not CAC > 0, was associated with ASCVD in participants with T2D, but this relationship was no longer

Limitations

There are a number of limitations associated with this study. The baseline characteristics of the groups compared were significantly different in a number of ways, including baseline lipid profiles, gender, BMI, and blood pressure/antihypertensive use. Given the known association of these clinical characteristics with ASCVD outcomes, our results were likely influenced by these factors and potential unmeasured confounders. However, our results were adjusted for many of these factors, including

Conclusions

In this analysis of the DHS, we observed a consistent association between continuous CAC and ASCVD outcomes in all groups, with a more nuanced association between categorical CAC and ASCVD amongst those with T2D and those with HS. A significant interaction between both CAC and HTC with T2D status on ASCVD outcomes was observed, with a strong inverse association between HTC and ASCVD outcomes in those with T2D. These findings reinforce the known important association between CAC and ASCVD

Disclosures

Jennifer Linge is an employee at AMRA Medical AB. The remaining authors have no disclosures.

Funding

Supported in part by grant UL1TR001105 from the National Center for Advancing Translational Sciences, National Institutes of Health.

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