- Razavi, Alexander C;
- Uddin, SM Iftekhar;
- Dardari, Zeina A;
- Berman, Daniel S;
- Budoff, Matthew J;
- Miedema, Michael D;
- Osei, Albert D;
- Obisesan, Olufunmilayo H;
- Nasir, Khurram;
- Rozanski, Alan;
- Rumberger, John A;
- Shaw, Leslee J;
- Sperling, Laurence S;
- Whelton, Seamus P;
- Mortensen, Martin Bødtker;
- Blaha, Michael J;
- Dzaye, Omar
Background
Coronary artery calcium (CAC) is a marker of plaque burden. Whether CAC improves risk stratification for incident sudden cardiac death (SCD) beyond atherosclerotic cardiovascular disease (ASCVD) risk factors is unknown.Objectives
SCD is a common initial manifestation of coronary heart disease (CHD); however, SCD risk prediction remains elusive.Methods
The authors studied 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression and C-statistics were used to assess the association between CAC and SCD, adjusting for demographics and traditional risk factors.Results
The mean age was 54.4 years, 33% were women, 11% were of non-White ethnicity, and 55% had CAC >0. A total of 211 SCD events (0.3%) were observed during a median follow-up of 10.6 years, 91% occurring among those with baseline CAC >0. Compared with CAC = 0, there was a stepwise higher risk (P trend < 0.001) in SCD for CAC 100 to 399 (subdistribution hazard ratio [SHR]: 2.8; 95% CI: 1.6-5.0), CAC 400 to 999 (SHR: 4.0; 95% CI: 2.2-7.3), and CAC >1,000 (SHR: 4.9; 95% CI: 2.6-9.9). CAC provided incremental improvements in the C-statistic for the prediction of SCD among individuals with a 10-year risk <7.5% (ΔC-statistic = +0.046; P = 0.02) and 7.5% to 20% (ΔC-statistic = +0.069; P = 0.003), which were larger when compared with persons with a 10-year risk >20% (ΔC-statistic = +0.01; P = 0.54).Conclusions
Higher CAC burden strongly associates with incident SCD beyond traditional risk factors, particularly among primary prevention patients with low-intermediate risk. SCD risk stratification can be useful in the early stages of CHD through the measurement of CAC, identifying patients most likely to benefit from further downstream testing.