• Yuichiro Yano, Christopher J O'Donnell, Lewis Kuller, Maryam Kavousi, Raimund Erbel, Hongyan Ning, Ralph D'Agostino, Anne B Newman, Khurram Nasir, Albert Hofman, Nils Lehmann, Klodian Dhana, Ron Blankstein, Udo Hoffmann, Stefan Möhlenkamp, Joseph M Massaro, Amir-Abbas Mahabadi, Lima Joao A C JAC Department of Cardiology, Johns Hopkins University, Baltimore, Maryland., M Arfan Ikram, Karl-Heinz Jöckel, Oscar H Franco, Kiang Liu, Donald Lloyd-Jones, and Philip Greenland.
• Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
• JAMA Cardiol. 2017 Sep 1; 2 (9): 986-994.

ImportanceBesides age, other discriminators of atherosclerotic cardiovascular disease (ASCVD) risk are needed in older adults.ObjectivesTo examine the predictive ability of coronary artery calcium (CAC) score vs age for incident ASCVD and how risk prediction changes by adding CAC score and removing only age from prediction models.Design, Setting, And ParticipantsWe conducted an analysis of pooled US population-based studies, including the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Results were compared with 2 European cohorts, the Rotterdam Study and the Heinz Nixdorf Recall Study. Participants underwent CAC scoring between 1998 and 2006 using cardiac computed tomography. The participants included adults older than 60 years without known ASCVD at baseline.ExposuresCoronary artery calcium scores.Main Outcomes And MeasuresIncident ASCVD events including coronary heart disease (CHD) and stroke.ResultsThe study included 4778 participants from 3 US cohorts, with a mean age of 70.1 years; 2582 (54.0%) were women, and 2431 (50.9%) were nonwhite. Over 11 years of follow-up (44 152 person-years), 405 CHD and 228 stroke events occurred. Coronary artery calcium score (vs age) had a greater association with incident CHD (C statistic, 0.733 vs 0.690; C statistics difference, 0.043; 95% CI of difference, 0.009-0.075) and modestly improved prediction of incident stroke (C statistic, 0.695 vs 0.670; C statistics difference, 0.025; 95% CI of difference, -0.015 to 0.064). Adding CAC score to models including traditional cardiovascular risk factors, with only age being removed, provided improved discrimination for incident CHD (C statistic, 0.735 vs 0.703; C statistics difference, 0.032; 95% CI of difference, 0.002-0.062) but not for stroke. Coronary artery calcium score was more likely than age to provide higher category-free net reclassification improvement among participants who experienced an ASCVD event (0.390; 95% CI, 0.312-0.467 vs 0.08; 95% CI -0.001 to 0.181) and to result in more accurate reclassification of risk for ASCVD events among these individuals. The findings were similar in the 2 European cohorts (n = 4990).Conclusions And RelevanceCoronary artery calcium may be an alternative marker besides age to better discriminate between lower and higher CHD risk in older adults. Whether CAC score can assist in guiding the decision to initiate statin treatment for primary prevention in older adults requires further investigation.

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