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Coronary Artery Calcification Stratifies Mortality Risk In Patients With Obesity

Coronary artery calcification can effectively stratify risk for all-cause and cardiovascular (CV) mortality in people with obesity with no prior CV disease.

Obesity increases the likelihood of developing cardiovascular risk factors, such as diabetes and hypertension, and also independently predicts risk for cardiovascular diseases (CVD), including coronary heart disease (CHD), atrial fibrillation, heart failure, and stroke. "The emergence of new therapeutics for obesity, such as glucagon-like peptide-1 agonists (GLP-1 RAs), represents a significant advance in the management of obesity, but the high cost of these new therapies presents a substantial barrier to their widespread use among many patients with obesity," explains Michael J. Blaha, MD, MPH. "Consequently, it's imperative to identify patients at higher cardiovascular risk who would benefit the most from these medications."

The SELECT clinical trial recently demonstrated significant cardiovascular benefits for patients with obesity who received a GLP-1 RA. "Results from the SELECT trial have bolstered the importance of considering personalized treatment strategies for individuals with obesity," Dr. Blaha says. "The findings underscored the need to identify and treat these patients because of their increased risk [for] cardiovascular events and because they're more likely to benefit from these therapies."

Coronary artery calcification (CAC), which is measured noninvasively using cardiac-gated CT scans, is an effective and reliable risk stratification tool across different population subgroups, but it remains unclear whether CT-obtained CAC scores can effectively stratify risk in patients with obesity. For a study published in Obesity, Dr. Blaha and colleagues examined the utility of CAC for risk stratification among people with obesity by evaluating the predictive value of CAC for all-cause, cardiovascular, and CHD mortality.

Data were collected from 9,334 participants with a BMI of 30 or higher from the CAC Consortium, a retrospectively assembled cohort of patients without prior CVD. "The primary objective of our study was to demonstrate that the CAC score is a reliable test for delineating the risk spectrum of patients with obesity," says Dr. Blaha. "Utilizing this score may facilitate more informed discussions regarding obesity management and help guide treatment decisions."

CAC Scores Help Stratify Cardiovascular Risks in Obesity

According to the study findings, 58.5% of the participants had CAC. Compared with patients with a CAC score of 0 Agatston units (AU), patients with CAC scores of 1-99, 100-299, and 300 AU or higher had higher rates per 1000 person-years of all-cause, CVD, and CHD mortality after a mean follow-up of 10.8 years. The presence of CAC was associated with a 1.4-fold higher hazard of all-cause mortality and a 2.1-fold and 2.7-fold higher hazard of cardiovascular and CHD mortality, respectively.

In addition, patients with obesity and CAC levels of 300 AU had an even higher risk for all three outcomes of interest, particularly among patients with class 2 obesity or higher (Figure). "This is important because obesity is commonly a barrier to effective imaging use in clinical practice. Our findings show that CAC scores can function as an effective tool for cardiovascular risk stratification among individuals with obesity."

Using CAC to Identify Candidates for Anti-Obesity Medications

According to Dr. Blaha, findings from the study suggest that CAC scores can be used to enhance approaches to obesity management. "CAC scores can serve as a guide in the shared decision-making process and help ensure that physicians offer therapies to patients who are most likely to benefit from them," he says. "Continued risk assessments are also important because not everyone with obesity has the same risk. Of note, there is a movement to consider patients with very high CAC scores as having 'secondary prevention level risk.' This is important when implementing results from the SELECT trial, which enrolled secondary prevention patients. [Patients with obesity] with very high CAC scores may potentially achieve similar benefits as to what was seen in the SELECT trial."

Dr. Blaha hopes future research will include a next-generation trial of GLP-1 RAs in patients with high CAC scores. "This would potentially extend the indication of GLP-1 RAs for cardiovascular risk lowering to primary prevention patients with so-called advanced subclinical atherosclerosis."


What Is Coronary Artery Disease?

Coronary artery disease (CAD)—sometimes also called coronary heart disease or ischemic heart disease—is a type of heart disease that occurs when the blood vessels (also called arteries) that feed the heart become narrow. The most common cause of CAD is atherosclerosis, which is the buildup of cholesterol plaque in your arteries. When your arteries become narrow enough to impair blood flow to the heart, you can experience symptoms like chest pain and shortness of breath.

Researchers estimate that 5% of adults over the age of 20 in the United States live with CAD. If you're experiencing symptoms of CAD or have a family history of heart disease, it's essential to see your healthcare provider or cardiologist (a doctor who specializes in heart disease) for proper testing. Treatment consists of medication and lifestyle changes, but sometimes includes surgery. Without treatment, you may be at risk of complications like heart attack, heart failure, and even death.

The most common symptom of coronary artery disease is angina (or, chest pain). Your chest pain may cause you to feel pressure, squeezing, and tightness. It's also common to feel like something heavy is sitting on top of your chest. But, angina may also cause discomfort in other parts of the body, such as your arms, jaw, upper abdomen, and back. Aside from chest pain, you might also experience: The primary cause of CAD is atherosclerosis—a condition that occurs when there is too much build-up of cholesterol in your arteries. As a result of the build-up, your blood vessels can become too narrow and create blockages that affect how easily blood can flow to your heart. Atherosclerosis not only causes CAD, but may also increase your risk of a heart attack, blood clots, heart failure, and arrhythmias (or, irregular heartbeats). Risk Factors While atherosclerosis is the most common cause, other biological and environmental factors may also increase your risk of experiencing symptoms of the disease. These risk factors include: If you have symptoms of CAD, it's in your best interest to see your healthcare provider as soon as possible. During your appointment, they will take a detailed medical history to learn about your symptoms and perform a physical exam. They can also order a variety of tests to determine whether atherosclerosis is present and whether or not you're experiencing a restriction of blood flor to your heart. Your provider may use one or more of the following diagnostic measures to better understand your condition and overall heart health: Electrocardiogram (ECG/EKG): Records the electrical signal from your heart to show if you have an impairment in your blood flow or scarring of the heart Echocardiogram: Uses an ultrasound to view the heart and assess its function Stress tests: Asks you to walk or jog on a treadmill to understand how your heart responds to stress during exercise Cardiac computed tomography angiography (CTA): A special type of CT scan of the heart that uses contrast dye and X-rays to see if there's anything blocking your arteries or to measure build-up of cholesterol Coronary angiography: Involves the use of catheters that your provider inserts into your blood vessels (typically in your leg or wrist) to take X-ray photos of the coronary arteries If you received a diagnosis for CAD, your healthcare team will help you figure out the treatment that is right for you. The most common treatment options include lifestyle changes and medications. Depending on how severe your condition is, your provider may sometimes recommend a surgical procedure. Your exact treatment plan will depend on a variety of factors like the symptoms you're experiencing, your age, and whether you have any other health conditions. In addition to treatment, some providers also recommend entering cardiac rehabilitation, which is a structured and supervised exercise program that teaches you how to exercise safely with CAD and advises you on how to incorporate healthy lifestyle changes into your daily routine. Lifestyle Changes An important way to treat CAD is through healthy lifestyle choices. These may include: Eating a heart-healthy diet: Try an eating plan that is high in vegetables, fruits, whole grains, and legumes, and low in saturated and trans fats, processed foods, salt, and sugars Get moving: Do your best to incorporate 150 minutes of moderate exercise or physical activity per week Sleep well: Get enough rest through the night to reduce stress levels and symptoms of CAD Avoid harmful substances: Limit your intake of alcohol and quit smoking—or reach out for care from your provider if you need support on how to make these changes Medications Your healthcare provider may prescribe one or more of the following medications to reduce your symptoms and prevent the risk of heart attack, stroke, or death: Statins and other medications that lower cholesterol Antiplatelet medications like Bayer (aspirin) Beta-blockers Calcium channel blockers Nitrates ACE-inhibitors and angiotensin receptor blockers (ARBs) Medications that control high blood pressure such as Zestril (lisinopril) and high blood sugar such as Glucophage (metformin) Surgical Procedures If lifestyle changes and medication aren't improving your symptoms or slowing the progression of your disease, your provider may consider surgery. Some options for surgical procedures include: Cardiac catheterization: Uses X-rays and contrast dye to recognize where there are blockages in the artery. Once your healthcare provider identifies the affected arteries, they can use a catheter and tiny balloon to open up an artery that has become too narrow to restore blood flow. Coronary artery bypass graft (CABG): A type of open heart surgery that bypasses blocked arteries by creating a new path for blood to flow to your heart. Prevention strategies for CAD look very similar to lifestyle changes you might have to make if you receive a diagnosis for the condition. As such, it's important to start practicing these habits early in order to prevent you from developing this heart disease. These lifestyle changes may include: Making meals that include vegetables, fruits, whole grains, and legumes Limiting foods that are heavily processed or include saturated fats, sugar, and salt Moving your body throughout the week Getting enough sleep at night Avoiding alcohol and tobacco use Researchers are also investigating the relationship between air pollution and heart health, but early studies show a strong association between the two. That said, avoid air pollution when possible, such as by not exercising outdoors when air quality levels are poor. Another important way to prevent CAD is to monitor and treat underlying conditions like diabetes, high blood pressure, and high cholesterol—all of which can increase your risk of heart disease. CAD is a serious condition that can lead to life-threatening complications. Treatment for CAD can help lower your risk of these complications. But without proper treatment, your chances of experiencing the following complications may increase: CAD is the most common type of heart disease and the leading cause of death in the U.S. Regardless of sex. Your prognosis (or, outlook) with CAD varies greatly depending on how severe your condition is and the symptoms you're experiencing. Living with heart disease can be especially challenging. Symptoms of CAD can impair your quality of life and make it difficult to perform physical activities. If you receive a diagnosis for CAD, treatments often include medications that may come with potential side effects. However, with support from your healthcare team and loved ones, you can learn to better manage this condition, reduce its symptoms, prevent your risk of complications, and improve your quality of life. Thankfully, research on CAD has advanced greatly and studies are still underway to learn about more treatments and prevention strategies that can reduce your risk of the condition and slow down the progression of the disease.

What Is Coronary Artery Disease?

Medically reviewed by Christopher Lee, MD

Coronary artery disease (CAD)—sometimes also called coronary heart disease or ischemic heart disease—is a type of heart disease that occurs when the blood vessels (also called arteries) that feed the heart become narrow. The most common cause of CAD is atherosclerosis, which is the buildup of cholesterol plaque in your arteries. When your arteries become narrow enough to impair blood flow to the heart, you can experience symptoms like chest pain and shortness of breath.

Researchers estimate that 5% of adults over the age of 20 in the United States live with CAD. If you're experiencing symptoms of CAD or have a family history of heart disease, it's essential to see your healthcare provider or cardiologist (a doctor who specializes in heart disease) for proper testing. Treatment consists of medication and lifestyle changes, but sometimes includes surgery. Without treatment, you may be at risk of complications like heart attack, heart failure, and even death.

Symptoms

The most common symptom of coronary artery disease is angina (or, chest pain). Your chest pain may cause you to feel pressure, squeezing, and tightness. It's also common to feel like something heavy is sitting on top of your chest. But, angina may also cause discomfort in other parts of the body, such as your arms, jaw, upper abdomen, and back.

Aside from chest pain, you might also experience:

Causes

The primary cause of CAD is atherosclerosis—a condition that occurs when there is too much build-up of cholesterol in your arteries. As a result of the build-up, your blood vessels can become too narrow and create blockages that affect how easily blood can flow to your heart. Atherosclerosis not only causes CAD, but may also increase your risk of a heart attack, blood clots, heart failure, and arrhythmias (or, irregular heartbeats).

Risk Factors

While atherosclerosis is the most common cause, other biological and environmental factors may also increase your risk of experiencing symptoms of the disease. These risk factors include:

Diagnosis

If you have symptoms of CAD, it's in your best interest to see your healthcare provider as soon as possible. During your appointment, they will take a detailed medical history to learn about your symptoms and perform a physical exam. They can also order a variety of tests to determine whether atherosclerosis is present and whether or not you're experiencing a restriction of blood flor to your heart.

Your provider may use one or more of the following diagnostic measures to better understand your condition and overall heart health:

  • Electrocardiogram (ECG/EKG): Records the electrical signal from your heart to show if you have an impairment in your blood flow or scarring of the heart

  • Echocardiogram: Uses an ultrasound to view the heart and assess its function

  • Stress tests: Asks you to walk or jog on a treadmill to understand how your heart responds to stress during exercise

  • Cardiac computed tomography angiography (CTA): A special type of CT scan of the heart that uses contrast dye and X-rays to see if there's anything blocking your arteries or to measure build-up of cholesterol

  • Coronary angiography: Involves the use of catheters that your provider inserts into your blood vessels (typically in your leg or wrist) to take X-ray photos of the coronary arteries

    • Treatment

    If you received a diagnosis for CAD, your healthcare team will help you figure out the treatment that is right for you. The most common treatment options include lifestyle changes and medications. Depending on how severe your condition is, your provider may sometimes recommend a surgical procedure. Your exact treatment plan will depend on a variety of factors like the symptoms you're experiencing, your age, and whether you have any other health conditions.

    In addition to treatment, some providers also recommend entering cardiac rehabilitation, which is a structured and supervised exercise program that teaches you how to exercise safely with CAD and advises you on how to incorporate healthy lifestyle changes into your daily routine.

    Lifestyle Changes

    An important way to treat CAD is through healthy lifestyle choices. These may include:

  • Eating a heart-healthy diet: Try an eating plan that is high in vegetables, fruits, whole grains, and legumes, and low in saturated and trans fats, processed foods, salt, and sugars

  • Get moving: Do your best to incorporate 150 minutes of moderate exercise or physical activity per week

  • Sleep well: Get enough rest through the night to reduce stress levels and symptoms of CAD

  • Avoid harmful substances: Limit your intake of alcohol and quit smoking—or reach out for care from your provider if you need support on how to make these changes

    • Medications

    Your healthcare provider may prescribe one or more of the following medications to reduce your symptoms and prevent the risk of heart attack, stroke, or death:

  • Statins and other medications that lower cholesterol

  • Antiplatelet medications like Bayer (aspirin)

  • Beta-blockers

  • Calcium channel blockers

  • Nitrates

  • ACE-inhibitors and angiotensin receptor blockers (ARBs)

  • Medications that control high blood pressure such as Zestril (lisinopril) and high blood sugar such as Glucophage (metformin)

    • Surgical Procedures

    If lifestyle changes and medication aren't improving your symptoms or slowing the progression of your disease, your provider may consider surgery. Some options for surgical procedures include:

  • Cardiac catheterization: Uses X-rays and contrast dye to recognize where there are blockages in the artery. Once your healthcare provider identifies the affected arteries, they can use a catheter and tiny balloon to open up an artery that has become too narrow to restore blood flow.

  • Coronary artery bypass graft (CABG): A type of open heart surgery that bypasses blocked arteries by creating a new path for blood to flow to your heart.

    • How to Prevent CAD

    Prevention strategies for CAD look very similar to lifestyle changes you might have to make if you receive a diagnosis for the condition. As such, it's important to start practicing these habits early in order to prevent you from developing this heart disease.

    These lifestyle changes may include:

  • Making meals that include vegetables, fruits, whole grains, and legumes

  • Limiting foods that are heavily processed or include saturated fats, sugar, and salt

  • Moving your body throughout the week

  • Getting enough sleep at night

  • Avoiding alcohol and tobacco use

    • Researchers are also investigating the relationship between air pollution and heart health, but early studies show a strong association between the two. That said, avoid air pollution when possible, such as by not exercising outdoors when air quality levels are poor. Another important way to prevent CAD is to monitor and treat underlying conditions like diabetes, high blood pressure, and high cholesterol—all of which can increase your risk of heart disease.

    Complications

    CAD is a serious condition that can lead to life-threatening complications. Treatment for CAD can help lower your risk of these complications. But without proper treatment, your chances of experiencing the following complications may increase:

    Living with CAD

    CAD is the most common type of heart disease and the leading cause of death in the U.S. Regardless of sex. Your prognosis (or, outlook) with CAD varies greatly depending on how severe your condition is and the symptoms you're experiencing.

    Living with heart disease can be especially challenging. Symptoms of CAD can impair your quality of life and make it difficult to perform physical activities. If you receive a diagnosis for CAD, treatments often include medications that may come with potential side effects.

    However, with support from your healthcare team and loved ones, you can learn to better manage this condition, reduce its symptoms, prevent your risk of complications, and improve your quality of life. Thankfully, research on CAD has advanced greatly and studies are still underway to learn about more treatments and prevention strategies that can reduce your risk of the condition and slow down the progression of the disease.

    Frequently Asked Questions

    Does coronary artery disease affect your life expectancy?

    Coronary artery disease decreases your life expectancy. But, life expectancy depends on a variety of factors like age, the severity of disease, other medical conditions you have, and whether you're following your treatment plan.

    What is the difference between coronary heart disease and coronary artery disease?

    Coronary heart disease and coronary artery disease are different terms for the same condition. They refer to blockages in the coronary arteries that feed the heart. This is the most common form of heart disease, and can lead to heart attack, heart failure, and arrhythmias.

    At what age is coronary heart disease more common?

    The risk of coronary heart disease increases with age. People over 65 years of age are most at risk of dying from a heart attack. However, younger people can experience coronary heart disease too—especially if there are risk factors like a family history of heart disease at a young age.

    Does coronary artery disease mean heart failure?

    Coronary artery disease and heart failure are two different conditions that affect the heart. Heart failure is a condition that affects the heart muscle's ability to provide effective blood flow to the body, causing symptoms like shortness of breath and swelling. Coronary artery disease, on the other hand, refers to blockages in the blood vessels that feed the heart. Coronary artery disease can lead to heart failure since the heart muscle relies on blood supply to function.

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