Researchers have shown for the first time that subclinical disease, detected using imaging, predicts mortality. Their findings indicate that plaque burden, visible on 3D vascular ultrasound, and calcium in the coronary arteries, measured with a CT scan, are better predictors of mortality than traditional risk factors.
This research not only underlines the importance of early detection but also has clinical implications, according to Dr. Valentin Fuster, president of the Mount Sinai Fuster Heart Hospital in New York. “This is going to change the playing field,” he says. “What I expect is that we will be evaluating people with risk factors from the age of 30 onwards with imaging. Today, we don't do that until they are 50 according to clinical guidelines.”
Fuster and his team developed 3D vascular ultrasound to measure plaque burden and used this in a prospective cohort study, known as BioImage. They examined 6,102 patients in Chicago, Illinois and Fort Lauderdale, Florida, using 3D carotid ultrasound and another established technique: CT-scan derived coronary artery calcium score.
Participants showed no cardiovascular symptoms, but their plaque burden and calcium score at the start of the study were significantly associated with mortality during the 15 years of follow-up, even after adjustment for risk factors and medication. The results were published in the Journal of the American College of Cardiology.
“There is now no doubt that subclinical disease on imaging predicts mortality,” according to Fuster.
Early Risk Prediction
The study also showed that the risk of mortality increases as the plaque burden in the carotid artery increases over time. Both plaque burden measured with 3D vascular ultrasound and calcium score on CT proved to be better predictors of mortality than traditional risk factors.
Dr. David Maron, a preventive cardiologist at Stanford University School of Medicine, calls this finding “very important”. “The presence of atherosclerosis is crucial information for determining the intensity of therapy and for motivating both patients and clinicians to treat it,” says Maron.
3D Vascular Ultrasound versus Coronary Artery Calcium Score
Although both imaging techniques are better predictors of mortality than cardiovascular risk factors alone, each has its advantages:
For the coronary artery calcium score, there is “a large body of literature demonstrating its association with cardiovascular events, there is a standardised scoring system, and the availability of CT scanners is widespread,” according to Maron. However, paradoxically, the Agatston score can increase after aggressive lowering of LDL cholesterol. “Once calcium is present in the coronary artery, it becomes difficult to interpret a repeat scan, as we don't know if an increase in the score is due to progression or to a higher density of the calcium, which can actually be a sign of healing,” says Maron.
Vascular ultrasound bypasses this problem and can also detect early, non-calcified plaques and monitor their progression before they become visible on a CT scan. Furthermore, ultrasound does not contribute to the cumulative radiation dose, as CT scans do, according to Fuster.
Increasing plaque load increases risk
The finding of any degree of atherosclerosis signifies an increased risk of mortality, but a greater plaque burden further elevates that risk, according to Fuster. Progression of atherosclerosis increases the risk even more. In a sub-study of 732 patients with a median of 8.9 years between their first and second scans, those with progression had a higher risk of mortality than those with regression or no atherosclerosis.
“Progression is much more meaningful in predicting mortality than simply having atherosclerosis,” states Fuster.
According to Maron, this highlights “the two major advantages of non-invasive imaging of atherosclerosis.” It not only detects the presence of atherosclerosis but can also characterise the burden and any calcification. Furthermore, it allows clinicians to monitor the response to interventions such as lifestyle changes and drug therapy. “Serial imaging of plaque burden will really improve the management of atherosclerosis,” says Maron. “If we find someone is deteriorating rapidly, we can intensify the therapy.”
According to Maron, the imaging results also provide the necessary motivation for both clinicians and patients to take action and thus prevent deaths from atherosclerosis.
In Mediport Medical Centre we offer Cardio CT scans and calcium scoring without waiting times, so you can get quick and efficient insight into your cardiovascular health. Don't hesitate to appointment to be made with one of our cardiologists for more information.
Fuster, V, Carcia-Alvarez, A, Devesa, A. et al. Influence of Subclinical Atherosclerosis Burden and Progression on Mortality. JACC. 2024 Oct, 84 (15) 1391-1403.