Arterial age as a substitute for chronological age in the AGLA risk function could improve coronary risk prediction
PRINCIPLES: As a result of the relatively low sensitivity of coronary risk charts, such as the Swiss coronary risk calculator (Arbeitsgruppe Lipide und Atherosklerose, AGLA), for detecting subjects with future myocardial infarction, the performance of arterial age (aa) as a surrogate marker for chronological age (ca) was tested.
METHODS: In a practice based sample, burden of carotid plaque was obtained with ultrasound, using total plaque area (TPA). In this derivation cohort, sex-specific 5-year groups of mean TPA were calculated in subjects aged between 35 and 79 years. The arterial age formula was found by fitting an exponential function on these data. AGLAca and AGLAaa were tested externally for their ability to detect 13 myocardial infarctions in 684 subjects (validation cohort).
RESULTS: The derivation cohort included 1,500 subjects (mean age 59 ± 9 years, mean TPA 54 ± 52 mm2, 5% diabetics, 43% women). Arterial age was found to be y = 5.4175e0.0426x in men and y = 4.1942e0.0392x in women. Mean 10-year AGLAca coronary risk was comparable to AGLAaa (8% ± 9% vs 9% ± 15%). Receiver operating characteristic (ROC) analysis of AGLAca and AGLAaa results showed areas under the curve of 0.65 (p = 0.041) and 0.78 (p <0.0001), respectively, (p = 0.041 for the difference = 0.13). This finding was also confirmed by a Cox proportional hazards regression model on patients' event-free survival (p = not significant for AGLAca, p = 0.0003 for AGLAaa).
CONCLUSIONS: Arterial age derived from TPA could be used instead of chronological age in the AGLA coronary risk function. Further studies on the external validity and cost effectiveness of the additional ultrasound imaging study are necessary.
- Grundy SM. Age as a risk factor: you are as old as your arteries. Am J Cardiol. 1999;83:1455–7.
- D'Agostino RB, Vasan RS, Pencina MJ, Wolf P a, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117:743–53.
- Stein JH, Fraizer MC, Aeschlimann SE, Nelson-Worel J, McBride PE, Douglas PS. Vascular age: integrating carotid intima-media thickness measurements with global coronary risk assessment. Clin Cardiol. 2004;27(7):388–92.
- McClelland RL, Nasir K, Budoff M, Blumenthal RS, Kronmal RA. Arterial Age as a Function of Coronary Artery Calcium (from the Multi-Ethnic Study of Atherosclerosis [MESA]). Am J Cardiol. 2009;103:59–63.
- Marma AK, Lloyd-Jones DM. Systematic examination of the updated Framingham heart study general cardiovascular risk profile. Circulation. 2009;120:384–90.
- Rodondi N, Collet T-H, Nanchen D, Locatelli I, Depairon M, Aujesky D, et al. Impact of carotid plaque screening on smoking cessation and other cardiovascular risk factors: a randomized controlled trial. Arch Intern Med. 2012;172:344–52.
- Spence D, Hackam D. Treating arteries instead of risk factors: a paradigm change in management of atherosclerosis. Stroke. 2010;41:1193–9.
- Spence JD. Carotid plaque measurement is superior to IMT Invited editorial comment on: carotid plaque, compared with carotid intima-media thickness, more accurately predicts coronary artery disease events: a meta-analysis-Yoichi Inaba, M.D., Jennifer A. Chen M.D., S. Atherosclerosis. 2012;220:34–5.
- Spence JD, Eliasziw M, DiCicco M, Hackam DG, Galil R, Lohmann T. Carotid Plaque Area: A Tool for Targeting and Evaluating Vascular Preventive Therapy. Stroke. 2002;33:2916–22.
- Mathiesen EB, Johnsen SH, Wilsgaard T, Bønaa KH, Løchen M-L, Njølstad I. Carotid Plaque Area and Intima-Media Thickness in Prediction of First-Ever Ischemic Stroke: A 10–Year Follow-Up of 6584 Men and Women: The Tromso Study. Stroke. 2011;42:972–8.
- Johnsen SH, Mathiesen EB, Joakimsen O, Stensland E, Wilsgaard T, Løchen M-L, et al. Carotid atherosclerosis is a stronger predictor of myocardial infarction in women than in men: a 6–year follow-up study of 6226 persons: the Tromso Study. Stroke. 2007;38:2873–80.
- Romanens M, Ackermann F, Schwenkglenks M, Szucs T, Spence JD. Posterior probabilities in sequential testing improve cardiovascular risk prediction using carotid total plaque area. Kardiovaskuläre Medizin. 2011;14:53–7.
- Inaba Y, Chen JA, Bergmann SR. Carotid plaque, compared with carotid intima-media thickness, more accurately predicts coronary artery disease events: a meta-analysis. Atherosclerosis. 2012;220:128–33.
- Spence JD. Technology Insight: ultrasound measurement of carotid plaque-patient management, genetic research, and therapy evaluation. Nat Clin Pr. Neuro. 2006;2:611–9.
- Romanens M, Ackermann F, Sudano I, Szucs T, Riesen WF, Darioli R, et al. LDL-cholesterol and the potential for coronary risk improvement. Kardiovaskuläre Medizin. 2011;14:345–50.
- Romanens M, Ackermann F, Riesen W, Spence JD, Darioli R. Imaging as a cardiovascular risk modifier in primary care patients using predictor models of the European and inter- national atherosclerosis societies. Kardiovaskuläre Medizin. 2007;10:139–50.
- Eckardstein A. AGLA Guidelines. 2012. Available at: www.agla.ch.
- MedCalc Software bvba, Ostend B. MedCalc Statistical Software version. 2013. Available at: http://www.medcalc.org.
- Delong E, Delong D, Clarke-Pearson D. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44:837–45.
- Pencina MJ, D'Agostino RB, Vasan RS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008;27:157–72.
- Budoff MJ, Young R, Lopez VA, Kronmal RA, Nasir K, Blumenthal RS, et al. Progression of Coronary Calcium and Incident Coronary Heart Disease Events: The Multi-Ethnic Study of Atherosclerosis. J Am Coll Cardiol. 2013;61:1231–9.
- Herder M, Arntzen KA, Johnsen SH, Eggen AE, Mathiesen EB. Long-term use of lipid-lowering drugs slows progression of carotid atherosclerosis: the Tromso study 1994 to 2008. Arterioscler Thromb Vasc Biol. 2013;33(4):858–62.
- Migrino RQ, Bowers M, Harmann L, Prost R, Ladisa JF. Carotid plaque regression following 6–month statin therapy assessed by 3T cardiovascular magnetic resonance: comparison with ultrasound intima media thickness. J Cardiovasc Magn Reson 2011;13:37.
- Stein JH. Carotid intima-media thickness and vascular age: you are only as old as your arteries look. J Am Soc Echocardiogr. 2004;17:686–9.
- DeGoma E. CIMT Arterial Age Calculator. Available at: www.emildegomamd.com/home_htm_files/CIMT Calculator EdG v1.3.xls.
- Folsom AR, Kronmal R a, Detrano RC, O'Leary DH, Bild DE, Bluemke DA, et al. Coronary artery calcification compared with carotid intima-media thickness in the prediction of cardiovascular disease incidence: the Multi-Ethnic Study of Atherosclerosis (MESA). Arch intern Med. 2008;168:1333–9.
- Bots ML, Baldassarre D, Simon A, de Groot E, O'Leary DH, Riley W, et al. Carotid intima-media thickness and coronary atherosclerosis: weak or strong relations? Eur Hear. J 2007;28:398–406.
- Den Ruijter HM, Peters S a E, Anderson TJ, Britton AR, Dekker JM, Eijkemans MJ, et al. Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis. JAMA. 2012;308:796–803.
- Cuende J, Cuende N, Calaveras-Lagartos J. How to calculate vascular age with the SCORE project scales: a new method of cardiovascular risk evaluation. Eur Hear. J 2010;31:2351–8.
- Anon. Insulin Resistance Intervention after Stroke Trial. A Coop. Progr. funded by Natl. Inst. Neurol. Disord. Stroke (A Div. Natl. Institutes Heal. Available at: http://www.iristrial.org/generalinfo.html. Accessed May 23, 2013.