JACC: CARDIOVASCULAR IMAGING
VOL. 9, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-878X/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcmg.2015.09.021
EDITORIAL COMMENT
Imaging Atherosclerosis for Global
Predictive Health and Wellness*
Mosaab Awad, MD, Parham Eshtehardi, MD, Leslee J. Shaw, PHD
A
ge shifts have drastically changed the land-
of non-CVD conditions, such as cancer, pneumonia,
scape of the U.S. population with nearly 1 in
chronic
every 7 Americans being 65 years of age and
chronic kidney disease (CKD), and hip fracture (4).
older (1). As the population ages, the impact on the
At first glance, it is hard to envision how an image of
health care system is expected to be dramatic, in
calcification in the coronary arteries could possibly
particular as it relates to the care of patients with
estimate beyond atherosclerotic disease. One may
chronic comorbid age-related conditions, in addition
consider that CAC scoring is an amazing procedure
to the heavy burden of cardiovascular disease
that seems limitless in its ability to identify patients
(CVD). The structure of health care is anticipated to
at risk of CVD and non-CVD conditions, thus war-
be more complex requiring multispecialty services
ranting full implementation of CAC into every adult
and the already overburdened primary care services
screening program.
obstructive
pulmonary
disease
(COPD),
are required to manage obesity and other modifiable
However, a more thoughtful evaluation of this
CVD risk factors. This is prompting frequent discus-
report (4) integrates the concept of vascular aging and
sions regarding health care system reform to reorient
its proportional relationship with chronologic age. By
care pathways toward patient wellness and popula-
applying the age-old adage “common things being
tion health management.
common,” the strongest connection between CAC and
all of these stated non-CVD conditions is age. As is
SEE PAGE 568
well-established, CAC increases with age in both
Within the field of CVD imaging, much of the
prevalence and extent (5). Based on 1 large registry of
ongoing and published evidence on screening for
35,388 asymptomatic individuals, <1% of those <40
CVD is directly relevant to these discussions on
years of age had a CAC score $400, whereas this rate
patients
Coronary
increased to 29% to 45% for elderly patients in their
artery calcium (CAC) scoring has been at the core of
70s and 80s (6). Importantly, the prevalence of CVD
screening tests applied for more than a decade and
increases with age along with other non-CVD condi-
has a well-established body of evidence of effective
tions, such as COPD, cancer, pneumonia, pulmonary
prognostication for CVD events (2,3). Extending this
embolism, and dementia.
with
frequent
comorbidities.
prior evidence, Handy et al. (4) in this issue of
As we observe a shift in the aging of the popula-
iJACC, using the National Institutes of Health–
tion, the report by Handy et al. (4) on CAC as an
National Heart, Lung Blood Institute sponsored
estimator of an array of ailments has direct impact
MESA
Atherosclerosis),
on public health and society in general. Furthermore,
reported that CAC, as a global measure of health,
this MESA report exemplifies how a disease-specific
was also a long-term (median, w10 years) predictor
screening test, such as CAC, may also serve as a
(Multi-Ethnic
Study
of
global health screening tool, extending beyond the
CVD system to additional major afflictions impacting
older patients. In the current report’s most compre*Editorials published in JACC: Cardiovascular Imaging reflect the views
hensive model comparing CAC >400 with CAC ¼ 0,
of the authors and do not necessarily represent the views of JACC:
the relative hazard was 1.53 for cancer, 1.70 for CKD,
Cardiovascular Imaging or the American College of Cardiology.
From the Emory University Clinical Cardiovascular Research Institute,
Emory University School of Medicine, Atlanta, Georgia. All authors
1.97 for pneumonia, 2.71 for COPD, and 4.29 for hip
fracture; whereas there was no significant difference
have reported that they have no relationships relevant to the contents
in the rate of deep vein thrombosis, pulmonary
of this paper to disclose.
embolism, and dementia. Interestingly, for those
578
Awad et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 9, NO. 5, 2016
MAY 2016:577–9
Editorial Comment
with CAC of 0 the relative hazard for a non-CVD
one may not infer either causality or directionality of
event was reduced 25% when compared with MESA
the association between CAC and non-CVD. More-
enrollees
over, we have observed similar findings in several
with
detectable
and
more
extensive
CAC scores.
prior series reporting on the relationship between
The astute reader of this editorial would retort
CAC and all-cause mortality (12,13). In a recent
that, in some of these conditions, there are in
report examining the independent prognostic value
fact potential underlying mechanisms that would
of CAC for estimation of long-term mortality at
explain the relationship between COPD and CAC,
15-years of follow-up, we posited that CAC may
CKD and CAC, or hip fracture and CAC that also
serve as a marker of global health based on its strong
involve shared risk factors or a common disease
predictive ability for all-cause mortality (12). The
mechanism or pathophysiologic pathway. These
current report from MESA further expands this
interesting connections are some that are known but
concept of CAC as a marker of global health by
others that have yet to be unearthed. Many studies
examining its prognostic power across a diversity of
have shown an influential role of inflammation and
non-CVD conditions.
oxidative stress not only in developing CVD (7) but
Regardless of the directionality or magnitude of
also other age-related non-CVD conditions, such as
the connections between CVD and non-CVD condi-
cancer (8), COPD (9), and CKD (10). All of these
tions, the extent to which CAC guided patient
connections between CVD and non-CVD conditions
adherence to risk factor–modifying and lifestyle rec-
might indicate common pathways or linkages that
ommendations impacted on these non-CVD condi-
underlie the findings within the report by Handy
tions remains an additional link that should be
et al. (4).
explored further. A synthesis of evidence, including
Although the authors applied a sophisticated Cox
the Handy et al. (4) series, now supports the predic-
model accounting for competing risk of fatal CVD, it
tive ability of CAC to estimate cardiac (3), cerebro-
seems that residual confounding from age remains an
vascular (14), and non-CVD conditions (4). We likely
important consideration in this MESA analysis. Con-
should come full circle in the discussion and
founding is defined as 1 or more extraneous factors
acknowledge the far reaching implications of CAC’s
that have an association (i.e., significant p value) to a
predictive ability. Perhaps the index response that
common outcome but do so through different path-
CAC should be fully integrated into all adult wellness
ways. In the Handy et al. (4) report, for example, CAC
and screening evaluations is on target after all.
predicts cancer likely through common covariates,
Although CAC has not been without its critics and is
such as smoking or aging. Interestingly, when anal-
not supported as a reimbursable procedure, its
ysis was limited to MESA enrollees <65 years of age,
expansive evidence warrants a more thoughtful dis-
none of the non-CVD endpoints were significantly
cussion within the CVD community that this powerful
associated with CAC. This illustrates the significant
procedure provides valuable information to guide
association of CAC and non-CVD conditions with age.
health care decision making.
Thus, the heavy burden of these conditions in the
elderly seemed to be the primary impetus for the
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
modeling results.
Leslee
Some have posited that CVD conditions may be
exacerbated
during
other
serious
life-impacting
conditions (11). Therefore, from this MESA series,
J.
Shaw,
Emory
Clinical
Cardiovascular
Research Institute, 1462 Clifton Road NE, Room 529,
Emory University School of Medicine, Atlanta, Georgia 30324. E-mail: [email protected].
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Editorial Comment
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KEY WORDS aging, biologic aging, cancer,
coronary artery calcium, coronary artery disease
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