Asymptomatic coronary atherosclerosis linked to 8 times higher risk of heart attack

Key points to remember:

• Subclinical obstructive coronary atherosclerosis was associated with a high risk of myocardial infarction in asymptomatic adults.
• The risk of myocardial infarction or death was higher in adults with extensive subclinical coronary atherosclerosis.

According to the researchers, subclinical obstructive coronary atherosclerosis was linked to a more than 8-fold increased risk of myocardial infarction in asymptomatic adults aged 40 or older.

Andreas Fuchs, MD, PhD, from the Department of Cardiology at University Hospital Copenhagen-Rigshospitalet, and colleagues wrote that coronary atherosclerosis can develop at an early age and remain latent in the body for many years.

Coronary atherosclerosis is “the key pathobiological process” that is responsible for the development of myocardial infarction, and together these conditions define ischemic heart disease, the researchers wrote. Subclinical coronary atherosclerosis precedes ischemic heart diseaseand may progress at an early age, even years before clinical disease develops.

“For more than 50 years, obstructive coronary artery disease, defined as coronary luminal stenosis of 50% or greater, has been considered a key feature of high risk,” they wrote. “In recent decades, however, the extent of atherosclerosis in the coronary tree as well as the specific morphological characteristics of the atherosclerotic plaque have been recognized as important risk factors.”

Fuchs and colleagues conducted a prospective observational cohort study to define the characteristics of subclinical coronary atherosclerosis related to the development of myocardial infarction in 9,533 asymptomatic participants aged at least 40 years. without CVD. Their findings were recently published in Annals of Internal Medicine.

“We tested the hypothesis that features of subclinical coronary atherosclerosis are associated with an increased risk of myocardial infarction in asymptomatic individuals without known ischemic heart disease,” they wrote.

The researchers used coronary computed tomography angiography to assess subclinical coronary atherosclerosis. Coronary atherosclerosis was then characterized by luminal extent and obstruction (obstructive being defined as luminal stenosis greater than 50%).

Fuchs and his colleagues found that just over half – 54% – of participants did not have subclinical coronary atherosclerosis, and of the 46% who did, 10% had obstructive disease. Additionally, among those diagnosed, the disease was found more frequently in men than in women (61% versus 36%).

The researchers noted that, in the median follow-up of 3.5 years, 71 participants had an MI and 193 died. The risk of myocardial infarction was higher in people with obstruction (adjusted relative risk [aRR] = 9.19; 95% CI, 4.49-18.11) and extensive (aRR = 7.65; 95% CI, 3.53-16.57) and highest in people with extensive subclinical coronary atherosclerosis and obstructive (aRR=12.48; 95% CI, 5.50-28.12) or obstructive-non-extensive (aRR=8.28; 95% CI, 3.75-18.32).

“Subclinical obstructive coronary atherosclerosis was associated with a more than 8-fold increased risk of myocardial infarction, and the risk of death or myocardial infarction was increased two-fold in people with extensive subclinical coronary atherosclerosis” , they wrote.

Fuchs and colleagues also wrote that regardless of the degree of obstruction, the composite endpoint risk of death or myocardial infarction was increased in people with extensive disease: obstructive-extensive (aRR = 3 .15; 95% CI, 2.05-4.83) and non-obstructive-extended (aRR=2.7 95% CI, 1.72-4.25).

“The identification of subclinical obstructive or extensive coronary atherosclerosis, which we have shown to be associated with high risk, provides a potentially clinically relevant incremental risk assessment in patients without suspected or known ischemic heart disease undergoing cardiac CT and/or EKG-triggered chest CT for other clinical indications,” they wrote.

In an accompanying editorial, Michael McDermott, MBChB, cardiology researcher at the University of Edinburgh, and David E. Newby, MD, Ph.D., The British Heart Foundation’s Duke of Edinburgh’s Chair of Cardiology wrote that “this exceptional and important study now provides a benchmark against which to observe the contemporary natural history of coronary heart disease”.

“It also provides invaluable data on event rates and the prevalence of asymptomatic coronary artery disease that will inform public health prevention strategies and ongoing clinical trials aimed at targeting preventative therapies in people screened for the disease. occult coronary,” McDermott and Newby wrote.

The references: