Coronary Calcium Score Plus Family History Better Identifies Individuals at Risk of Heart Disease

MedicalResearch.com Interview with:
Dr. Joan Pinto-Sietsma MD PhD

Department of Clinical Epidemiology, Biostatistics and Bioinformatics
Academic Medical Center
Amsterdam, The Netherlands.

Medical Research: What is the background for this study? What are the main findings?

Response: A positive family history for premature coronary artery disease is an important risk factor for coronary artery disease. Therefore, it is frequently proposed to be included in current risk assessment tools and clinical practice guidelines. On the other hand, a positive family history for coronary artery disease only identifies families at risk, whereas it fails to identify which specific individual within a family is at particular risk. Therefore, its applicability in clinical practice is limited.

The detection of subclinical atherosclerosis as assessed by assessing coronary artery calcification, with CT scanning, has emerged as prognostic evaluation of coronary artery disease. Prospective follow-up studies have shown that coronary artery calcification predicts cardiovascular events, independent of risk factors. Therefore, assessing coronary artery calcifications in families with premature coronary artery disease might help in determining which individuals within such families are at particular risk and therefore help decide regarding treatment.

We analysed the association between a positive family history for premature coronary artery disease and coronary artery calcifications in 704 asymptomatic individuals. Furthermore, we assessed the predictive value of coronary artery calcifications in individuals with a positive family history for premature coronary artery disease in a sub analysis in 834 individuals of the St. Francis Heart Study, in which subjects were followed for about 3.5 years.

We observed, that individuals of high risk families (a positive family history of premature coronary artery disease) had a 2 time higher risk to have a calcium score > the 80th percentile as compared to individuals with a negative family history of premature coronary artery disease. Besides, individuals from high risk families with a high calcium score (> the 80th percentile) had a 2 time higher risk to get a cardiovascular event in 3,5 years, whereas individuals of high risk families without coronary calcifications did not have an increased risk at all.

Medical Research: What should clinicians and patients take away from your report?

Response: The above implicates, that adding coronary calcium scoring to family history, better identifies which individuals from high risk families are at particular risk for future cardiovascular events and which individuals from such families do not need treatment at all. Since in the normal risk score models, such as Framingham or Score, age over represents risk, most individuals from families with premature cardiovascular disease seeking help to estimate their cardiovascular risk are wrongly identified as having a low risk, because of their young age. On the other hand, physicians’ tent to start treatment solely based on the fact that an individual has a positive family history for premature coronary artery disease, hereby possibly unnecessary treating these individuals. Therefore, the standard risk models can’t help in assessing which individuals are of particular risk. Besides, coronary CT scanning for the overall population is not cost effective. Therefore, by identifying families at risk and providing additional risk assessment, by assessing their coronary calcification, individuals at particular risk can be identified. Besides, we previously showed that these individuals benefit from statin treatment, resulting in a 45% reduction in events (Mulders et al. JACC Cardiovasc Imaging. 2012;5:252-560). Therefore, by adding coronary calcification to family history, the actual risk is not only better assessed, but it also helps in individualizing therapy within high risk families.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: Future research should be directed at better organising medical attention for families and young individuals with cardiovascular disease at a young age, since this specific population has not been recognized so far. Therefore, further validation of our previous findings is necessary. first, it should be prospectively investigated, whether a risk assessment that starts with assessing an individual’s family history first, followed by coronary calcification assessment, is better than risk assessment with the classic risk score models. This would alter the way risk is assessed nowadays and could provide a far more precise risk estimate, than the way we assess risk today. Secondly, we need better randomized controlled trials investigating whether individuals from high risk families with coronary calcifications benefit from therapies such as statin or anti-thrombotic therapies. This is important, since the misconception is that, a higher risk for coronary artery disease automatically implies that this can be prevented with the usual therapies. Therefore, this call’s for a joint initiative, to better organise medical attention for families and young individuals with cardiovascular disease at a young age.

Citation:

Coronary Artery Calcification Score as Tool for Risk Assessment among Families with Premature Coronary Artery Disease

Mulders, Ties A. et al.

Atherosclerosis , Published Online:December 10, 2015
http://dx.doi.org/10.1016/j.atherosclerosis.2015.12.008

Dr. Joan Pinto-Sietsma MD PhD (2015). Coronary Calcium Score Plus Family History Better Identifies Individuals at Risk of Heart Disease