Both 2D and 3D US more likely to spot progression than CACS

A study of more than 3,500 middle-age healthy adults found that subclinical atherosclerosis progressed in 40% of adults over a period of 3 years, even among low-risk, asymptomatic individuals.

Moreover, the best way to detect this progression was not by use of coronary artery calcium score (CACS), but rather by use of sophisticated 2-D and 3-D vascular ultrasound, PESA-CNIC-Santander (Progression of Early Subclinical Atherosclerosis) investigators reported in the Journal of the American College of Cardiology.

“Subclinical atherosclerosis at baseline was detected in 2,172 participants (61.8%): 2,040 (58.1%) by 2DVUS, 1,520 (43.3%) by 3DVUS, and 614 (17.5%) by CACS,” Beatriz López-Melgar, MD, PhD from the Centro Nacional de Investigaciones Cardiovasculares (CNIC), in Madrid, Spain and colleagues wrote. “The overall 3-year change in disease prevalence was 5.3% (5.9%, 9.1%, and 4.8% by 2DVUS, 3DVUS, and CACS, respectively).”

Over the 3 years, when findings from all three imaging modalities were combined, there was evidence that “atherosclerosis progressed significantly in 41.5% of participants.”

The authors contended that their findings support creation of a “new definition of disease progression that combines the information obtained with different imaging techniques to determine an individual’s status as a ’progressor.’”

Use of the proposed definition would, they argued, allow “detection of substantial disease progression even in individuals categorized as low risk.”

The study enrolled 3,514 adults, average age 45.7, and more than a third (37%) were women. At baseline, the 10-year risk of cardiovascular event was about 2%. The participants were assessed at baseline and again close to 3 years later (2.8 years).

The researchers use ultrasound to evaluate “peripheral atherosclerosis at multiple arterial sites and noncontrast cardiac computed tomography (CT) to quantify CACS.”

“Participants with disease at baseline and/or follow-up had a median change of 1 plaque (IQR: 1 to 2 plaques) in the 2D-Score, 7.8 mm33 ) in 3D-GPV, and 9.8 Agatston units (IQR: 2.2-35.8 Agatston units) by CACS (all P values <0.001),” they wrote.

At baseline, 1,342 subjects had no evidence of disease, and of those 419 who had evidence of athersclerosis 3 years later, “disease onset more frequently [was] found in the peripheral territories by VUS (2DVUS 29.1% [95% confidence interval (CI): 26.6%-31.6%]; 3DVUS 16.6% [95% CI: 14.7%-18.7%]) than in the coronary territory by CACS (2.9% [95% CI: 2.1%-4.0%]).”

Interestingly, among individuals with “any disease at baseline 2DVUS detected an absolute reduction in disease prevalence but a statistically significant increase in disease extent, whereas 3DVUS and CACS identified significant increases in both disease prevalence and extent. In addition, the 3-year rate of conversion to CACS >0 in participants with any extracoronary disease at baseline was twice that of participants without (5.9% versus 2.9%; P < 0.001).”

And, only 432 participants had disease detectable by all three imaging modalities. Not surprisingly, this cohort was characterized by older age, male gender, and more cardiovascular disease risk factors.

In an editorial that accompanied the study, Nathan D. Wong of the Heart Disease Prevention Program at the University of California, Irvine, pointed out that “López-Melgar et al used a binary approach based on estimation of minimum detectable differences in interobserver variability for 2D and 3D plaque VUS volume changes and a previously described square-root methodology for CAC progression, which appears to be reasonable; however, there is no uniform consensus regarding the definitions of progression of multisite let alone single vascular bed atherosclerosis. And, the degrees of progression reported by each vascular territory are very much a function of the definitions used to define progression. Perhaps of greatest need to validate these techniques, as the authors note, are data on the associations of plaque progression assessed by 2DVUS and 3DVUS with future clinical events.”

Wong noted that, if validated, the findings from these modalities “could be a strong motivator for risk factor modification efforts by lifestyle and/or pharmacotherapy and could, with appropriate evidence, be considered for monitoring the effects of preventive therapies. However, although such an approach is appealing, we have to determine whether it provides added value over current guideline-based risk assessment recommendations.”

  1. Be aware that the findings of this study suggest that early subclinical atherosclerosis progresses over 3 years in about 40% of apparently healthy middle-aged men and women.

  2. Note that early progression was “more often detected by 2D/3D ultrasound evaluation of peripheral arterial plaques than by CT imaging of coronary calcification and is associated with cardiovascular risk factors but also occurs in low-risk individuals.”

Peggy Peck, Editor-in-Chief, BreakingMED™

López-Melgar had no disclosures.

Wong reported that he has no relationships relevant to the contents of this paper to disclose.

Cat ID: 102

Topic ID: 74,102,730,102,308,914,192,925