Coronary Artery Calcium Score for Long-term Risk Classification in Individuals With Type 2 Diabetes and Metabolic Syndrome From the Multi-Ethnic Study of Atherosclerosis

Malik, Shaista; Zhao, Yanglu; Budoff, Matthew; Nasir, Khurram; Blumenthal, Roger S.; Bertoni, Alain G.; Wong, Nathan D.

doi:10.1001/jamacardio.2017.4191

Cited by 215Cardiac Imaging and DiagnosticsDiabetes, Cardiovascular Risks, and LipoproteinsCardiovascular Function and Risk Factors

Coronary Artery Calcium Score for Long-term Risk Classification in Individuals With Type 2 Diabetes and Metabolic Syndrome From the Multi-Ethnic Study of Atherosclerosis

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Malik, Shaista, Zhao, Yanglu, Budoff, Matthew, Nasir, Khurram, Blumenthal, Roger S., Bertoni, Alain G., Wong, Nathan D.·2017·JAMA Cardiology

DOI 10.1001/jamacardio.2017.4191PMC PMC5814996

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Abstract

Importance: Although the risk of type 2 diabetes is considered to be equivalent to coronary heart disease (CHD) risk, there is considerable heterogeneity among individuals for CHD and atherosclerotic cardiovascular disease (ASCVD) risk. It is not known whether coronary artery calcium (CAC) assessment at baseline in individuals with established metabolic syndrome (MetS) or diabetes identifies CHD and ASCVD prognostic indicators during a long follow-up period. Objective: To compare improvement in long-term prognostication of incident CHD and ASCVD using CAC scores among those with diabetes, MetS, or neither condition. Design, Setting, and Participants: This study included participants from the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study of 6814 males and females aged 45 to 84 years without known CVD from 4 race/ethnicity groups (white [38.5%], African American [27.5%], Hispanic [22.1%], and Chinese [11.9%]) recruited from 6 US communities from July 2000 through August 2002. Follow-up for each participant extended to the first occurrence of an incident event, other death, loss to follow-up, or the last follow-up call through December 31, 2013. Data analysis was performed from June 1, 2016, to September 12, 2017. Cox proportional hazards regression models were used to estimate hazard ratios (HRs). Area under the receiver operator characteristic curve and net reclassification improvement were used to compare incremental contributions of CAC score when added to the Framingham risk score, ethnicity/race, and socioeconomic status. Main Outcomes and Measures: CHD events, including myocardial infarction, resuscitated cardiac arrest, or CHD death. Results: Of 6814 MESA participants, 6751 had complete risk factor and follow-up data and were included in this study (mean [SD] age, 62.2 [10.2] years; 3186 [47.2%] male). A total of 881 (13.0%) had diabetes, 1738 (25.7%) had MetS, and 4132 (61.2%) had neither condition. After 11.1 mean years of follow-up, CHD events occurred in 84 participants with diabetes (135 ASCVD events), 115 with MetS (175 ASCVD events), and 157 with neither (250 ASCVD events). The CAC score was independently associated with incident CHD in multivariable analyses in those with diabetes (HR, 1.30; 95% CI, 1.19-1.43), MetS (HR, 1.30; 95% CI, 1.20-1.41), and neither condition (HR, 1.37; 95% CI, 1.27-1.47). For incident CHD, net reclassification improvement with addition of CAC score was 0.23 (95% CI, 0.10-0.37) in those with diabetes, 0.22 (95% CI, 0.09-0.35) in those with MetS, and 0.25 (95% CI, 0.15-0.35) in those with neither condition. The CAC score was also a prognostic indicator of CHD and ASCVD after controlling for diabetes duration of 10 years or longer at baseline, insulin use, and glycemic control. Conclusions and Relevance: In a large multiethnic cohort, the addition of CAC score to global risk assessment was associated with significantly improved risk classification in those with MetS and diabetes, even if diabetes duration was longer than a decade, suggesting a role for the CAC score in risk assessment in such patients.

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Coronary calcium scoring in asymptomatic people with diabetes may help in risk stratification and provide reasoning for treatment intensification and/or guiding informed individual decision-making.
“Coronary calcium scoring in asymptomatic people with diabetes may help in risk stratification (214,215) and provide reasoning for treatment intensification and/or guiding informed individual decision-making and willingness for medication initiation and participation.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [215]
Coronary calcium scoring in asymptomatic people with diabetes may help in risk stratification and provide reasoning for treatment intensification and/or guiding informed individual decision-making.
“Coronary calcium scoring in asymptomatic people with diabetes may help in risk stratification (203,204) and provide reasoning for treatment intensification and/or guiding informed individual decision-making and willingness for medication initiation and participation.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [204]
Coronary artery calcium assessments have been found to significantly improve the risk classification for coronary heart disease and atherosclerotic cardiovascular disease events in people with type 2 diabetes, regardless of the duration of diabetes.
“In addition, coronary artery calcium (CAC) assessments have been found to significantly improve the risk classification for CHD and atherosclerotic CVD events in people with T2DM—regardless of the duration of diabetes [80].”
From Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007–2017 (2018) · cites this paper as [80]

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Authors: Malik, S., Zhao, Y., Budoff, M., Nasir, K., Blumenthal, R. S., Bertoni, A. G., & Wong, N. D.
Affiliations: University of California, Irvine (US)
University of California, Los Angeles (US)
Baptist Hospital of Miami (US)
Johns Hopkins University (US)
Wake Forest University Health Sciences (US)
Corresponding author: Malik, Shaista
ORCID: Malik, Shaista
Zhao, Yanglu
Budoff, Matthew
Nasir, Khurram
Blumenthal, Roger S.
Bertoni, Alain G.
Wong, Nathan D.
Venue: JAMA Cardiology
Publisher: American Medical Association (AMA)
Published: 2017-12-01
Volume: 2
Issue: 12
Pages: 1332
ISSN: 2380-6583 (ISSN-L)
DOI: 10.1001/jamacardio.2017.4191
PMC: PMC5814996
OpenAlex: W2767743404
Cited by: 215
References: 50
Citations by year: 2026: 25 · 2025: 20 · 2024: 19 · 2023: 26 · 2022: 31 · 2021: 28 · 2020: 23 · 2019: 31 · 2018: 12
FWCI: 13.84
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JAMA Cardiology (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
eScholarship (California Digital Library) (submittedVersion)
eScholarship (California Digital Library) (submittedVersion, cc-by)
Funders: National Heart, Lung, and Blood Institute (N01 HC-95159, R01HL128801, N01 HC95169)
Topics: Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords: coronary artery calcium score, type 2 diabetes, metabolic syndrome, coronary artery disease, atherosclerotic cardiovascular disease, long-term risk prediction, myocardial infarction, Framingham risk score, net reclassification improvement, Multi-Ethnic Study of Atherosclerosis, racial and ethnic differences, cardiovascular risk stratification, incident cardiovascular events
MeSH terms: Aged, Aged, 80 and over, Coronary Artery Disease, Coronary Disease, Diabetes Mellitus, Type 2, Ethnicity, Female, Heart Arrest, Humans, Hypoglycemic Agents, Insulin, Male, Middle Aged, Myocardial Infarction, Time Factors, Tomography, X-Ray Computed, United States, Comorbidity, Proportional Hazards Models, Risk Assessment, Area Under Curve, Metabolic Syndrome, Vascular Calcification

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Coronary Artery Calcium Score for Long-term Risk Classification in Individuals With Type 2 Diabetes and Metabolic Syndrome From the Multi-Ethnic Study of Atherosclerosis

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