Coronary Artery Calcium for Risk Stratification of Heart Failure Mortality: The Coronary Artery Calcium Consortium

Background: There is increasing interest in predicting heart failure (HF), a major cause of morbidity and mortality with a significant financial burden. The role of coronary artery calcium (CAC), an accessible and inexpensive test, in predicting long-term HF mortality among asymptomatic adults remains unknown. We aimed to determine whether CAC burden is associated with HF-related mortality in the CAC Consortium. Methods and Results: The study included 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression was used to assess the association between CAC and HF-related mortality adjusting for demographics and traditional risk factors. The mean age was 54.4 years, 67% male, 89% White, and 55% had a CAC of >0. We observed 260 HF-related mortality events during a median follow up of 12.5 years; 75.3% occurred among those with a baseline CAC score of >100. Compared with a CAC of 0, there was a stepwise higher risk (P < .005) of HF mortality for a CAC of 1–100 (subdistribution hazard ratio [SHR] 2.27, 95% CI 1.3–3.99), 100–400 (SHR 3.68, 95% CI 2.1–6.43), and >400 (SHR 7.05, 95% CI 4.05–12.29). This increasing risk of HF mortality across higher CAC scores persisted across age groups, sex, and in the intermediate and high-risk groups as calculated by the pooled cohort equation and Predicting Risk of cardiovascular disease EVENTs (PREVENT) equation. Conclusions: A higher CAC is associated with an increasing incidence of long-term HF-related mortality in the primary prevention population, particularly intermediate and high-risk patients. Early preventive approaches in patients with high CAC must focus on preventing HF and atherosclerotic cardiovascular disease with lifestyle changes and medications.