One of many assessments for coronary atherosclerosis throughout cardiac computed tomography (CT) is coronary artery calcium (CAC) scoring. We carried out evaluation on the determinants of high-risk coronary calcification, represented by CAC rating, amongst ladies as a step to enhance their outcomes and prognosis. This research concerned a complete of 1,129 feminine sufferers from a single centre. There have been 127 sufferers (11.2%) labeled as excessive threat (CAC ≥400). We discovered {that a} historical past of hypertension and diabetes are impartial determinants of getting a high-risk CAC rating. Moreover, this research demonstrated protecting results related to bodily exercise and diastolic blood strain. In conclusion, a historical past of hypertension, diabetes, and excessive uncontrolled systolic blood strain is perhaps used as cues for physicians to prioritise CAC evaluation in ladies, regardless of the absence of chest ache or atypical signs.
Introduction
Latest knowledge point out that heart problems (CVD) stays the main explanation for mortality in ladies.1 However, CVD in ladies worldwide is regularly underdiagnosed and undertreated in contrast with males.2 The cardiac signs in ladies are sometimes misdiagnosed and dismissed as anxiousness associated. Furthermore, South East Asian ladies are recognized to have a significantly longer delay in searching for therapy as a result of schooling stage, socioeconomic causes, and restricted mobility. Consequently, these ladies are much less more likely to get hold of guideline-based therapies similar to statins.3
The applying of non-invasive cardiac imaging methods, notably cardiac computed tomography (CT) angiography, permits a extra handy, patient-friendly, and complete investigation of intra-arterial plaques in ladies. One delicate and particular evaluation for coronary atherosclerosis throughout cardiac CT is coronary artery calcium (CAC) scoring. CAC is a screening device, however it’s only for sufferers at intermediate threat because it facilitates knowledgeable decision-making for preventive measures in ladies.4 Nonetheless, only some research have investigated which cardiovascular threat elements are the primary determinants of high-risk CAC scores in ladies. Moreover, at such a big expense and low assets, additional analysis remains to be needed to find out which feminine sufferers must be prioritised to endure this CAC evaluation. Due to this fact, this research carried out evaluation on the determinants of high-risk coronary calcification represented by CAC rating amongst ladies as a step to enhance their outcomes and prognosis.
Supplies and methodology
Research design, settings and individuals
The research design was a single-centre cross-sectional research. The research consecutively included all feminine sufferers referred to Siloam Hospital Surabaya for CAC evaluation between 1 January and 31 December 2022. Feminine sufferers with full cardiac CT imaging, scientific, and laboratory knowledge information met the inclusion standards. Sufferers with a historical past of vascular or cardiac interventional procedures (coronary stent or coronary bypass grafting) as documented in medical information/CT imaging had been excluded. The Moral Committee of Siloam Hospital Surabaya had permitted this research (No. 15103/DIR-SHSB/III/2022) on 15 March 2022. As this research was retrospective and the evaluation used nameless medical-record knowledge, knowledgeable consent was waived. The procedures utilized within the research had been made in accordance with the moral requirements of the Helsinki Declaration (2008).
Knowledge extraction
Demographic knowledge, CVD threat elements, bodily exercise, and the newest systolic (SBP) and diastolic (DBP) blood strain measurements had been extracted from medical information utilizing a standardised kind. The CVD threat elements comprised hypertension, dyslipidaemia, diabetes mellitus, present smoking, and weight problems. The definition of present/energetic smoking was common tobacco smoking (period >2 years). Sufferers with SBP higher than 140 mmHg or DBP higher than 90 mmHg in the newest report, or any historical past of antihypertensive medicine use, had been outlined as hypertensive.5 Dyslipidaemia was outlined as low-density lipoprotein (LDL)-cholesterol >160 mg/dL, serum complete ldl cholesterol ≥240 mg/dL, triglycerides >200 mg/dL, high-density lipoprotein (HDL)-cholesterol <40 mg/dL, or historical past of taking lipid-lowering medicine.5 Any historical past of a fasting glucose stage ≥126 mg/dL, a random glucose stage ≥200 mg/dL, a glycated haemoglobin A1c (HbA1c) stage ≥7.0%, or the usage of oral antidiabetic medication or insulin was labeled as diabetes. Optimistic familial coronary artery illness historical past was outlined as any historical past of myocardial infarction in first-degree kin. The presence of typical chest ache was outlined based mostly on three traits described by the European Society of Cardiology (ESC).7 Bodily exercise was labeled based mostly on ESC definition as energetic or inactive (sedentary).5 The physique mass index (BMI), calculated utilizing anthropometric measures, along with SBP and DBP (mmHg) as blood strain management indicators, could be reported as a steady variable.
Measurement of CAC
A 64-detector CT scanner was used to acquire the CT angiography (CTA) photos (Philips Medical Programs, Netherlands) with a process beforehand reported in a research by Chen et al. The Agatston methodology was used to find out the presence of calcification. Coronary calcium scores (complete and vessel-based) had been calculated for all calcified lesions bigger than 1 mm2. The Agatston rating was then labeled into high-risk (≥400) and non-high-risk (<400) for the aim of our evaluation. Two skilled cardiologists used a devoted workstation to guage the CT scans in consensus to minimise the bias.
Statistical evaluation
The research offered the info as follows: steady knowledge had been expressed as imply ± commonplace deviation (SD) or median (interquartile vary [IQR]), whereas categorical knowledge had been reported as quantity (%). The variations between these teams relating to baseline traits had been analysed utilizing the impartial t-test or Mann-Whitney U take a look at and the χ2 (relying on knowledge varieties and distribution). To determine the determinants of high-risk CAC scores, this research carried out unadjusted and adjusted logistic-regression mannequin analyses. Unbiased predictors of high-risk CAC rating (CAC ≥400) had been decided utilizing totally adjusted logistic-regression fashions, together with the next covariates: age, hypertension, dyslipidaemia, diabetes, present smoking, bodily exercise, chest ache, BMI, SBP, and DBP. Steady variables had been standardised and outliers eliminated. This research offered odds ratio (OR) with a 95% confidence interval (CI) as estimations of coefficient results. All analyses had been carried out utilizing SPSS model 26 (IBM Inc., Armonk, NY, USA).
Outcomes
This research concerned a complete of 1,129 feminine sufferers. There have been 127 sufferers (11.2%) labeled as excessive threat (CAC ≥400). Within the high-risk CAC group, the proportion of sufferers with hypertension, diabetes, and elevated SBP was considerably larger. The sufferers within the high-risk group had been considerably older than the non-high-risk sufferers (desk 1).
Desk 1. Baseline traits of sufferers with and with out high-risk coronary artery calcium (CAC) rating ≥400
Non-high threat(n=1,002)
Excessive threat(n=127)
p worth
Median age (IQR), years*
59 (35–84)
68 (44–92)
<0.001
Smoking, n (%)
26 (2.6)
3 (2.3)
0.876
Hypertension, n (%)
386 (38.5)
82 (64.5)
<0.001
Diabetes, n (%)
167 (16.7)
48 (37.8)
<0.001
Bodily energetic, n (%)
432 (43.1)
44 (34.6)
0.069
Dyslipidaemia, n (%)
642 (64.0)
83 (65.4)
0.776
Household historical past, n (%)
150 (14.9)
19 (14.9)
0.998
Chest ache, n (%)
308 (30.7)
46 (36.2)
0.210
Imply BMI ± SD, kg/m2
24.79 ± 3.73
25.01 ± 3.96
0.547
Imply SBP ± SD, mmHg*
125 ± 100
130 ± 90
<0.001
Imply DBP ± SD, mmHg
78.68 ± 10.4
76.61 ± 40
0.042
*Not usually distributed, Mann-Whitney U testKey: BMI = physique mass index; DBP = diastolic blood strain; IQR = interquartile vary; SBP = systolic blood strain; SD = commonplace deviation
The chances ratios demonstrating the determinants of high-risk CAC scores are offered in desk 2. The unadjusted regression mannequin noticed that diabetes mellitus, hypertension, SBP, and DBP had been considerably related to CAC rating classification. Nonetheless, when adjusted for age, bodily exercise additionally grew to become related to CAC rating, whereas the ORs of earlier vital elements (hypertension, diabetes, SBP, and DBP) lowered.
Desk 2. Logistic-regression fashions for high-risk CAC rating
Unadjusted
Easy adjusted modela
Absolutely adjusted modelb
Variables
OR
95percentCI
p worth
OR
95percentCI
p worth
OR
95percentCI
p worth
Hypertension
2.91
1.98 to 4.28
<0.001
2.10
1.41 to three.14
<0.001
1.83
1.18 to 2.84
0.007
Dyslipidaemia
1.06
0.72 to 1.56
0.776
0.95
0.63 to 1.42
0.799
0.87
0.57 to 1.33
0.530
Familial historical past
0.99
0.59 to 1.68
0.998
1.18
0.69 to 2.03
0.528
1.12
0.63 to 1.99
0.692
Diabetes
3.04
2.05 to 4.51
<0.001
2.32
1.53 to three.50
<0.001
1.89
1.22 to 2.93
0.004
Bodily energetic
0.69
0.47 to 1.02
0.070
0.65
0.43 to 0.96
0.032
0.63
0.41 to 0.95
0.029
Present energetic smoking
0.90
0.27 to three.04
0.876
1.16
0.33 to 4.08
0.817
1.03
0.27 to three.91
0.966
Chest ache
1.28
0.87 to 1.88
0.211
1.29
0.87 to 1.94
0.206
1.41
0.92 to 2.16
0.119
BMI
1.02
0.97 to 1.07
0.527
1.02
0.97 to 1.07
0.461
0.99
0.95 to 1.05
0.964
SBP
1.02
1.01 to 1.04
<0.001
1.01
1.00 to 1.02
0.039
1.02
1.01 to 1.04
0.003
DBP
0.98
0.96 to 0.99
0.037
0.98
0.96 to 0.99
0.022
0.95
0.93 to 0.97
<0.001
a Easy regression fashions had been adjusted just for age.b Absolutely adjusted regression fashions had been adjusted for age, hypertension, dyslipidaemia, familial historical past, diabetes, bodily exercise, smoking, chest ache, BMI, SBP and DBP.Key: BMI = physique mass index; CI = confidence interval; DBP = diastolic blood strain; OR = odds ratio; SBP = systolic blood strain
The logistic-regression mannequin was statistically vital with χ2(11)=123.064, p<0.001. The totally adjusted mannequin defined 10.3% (Cox and Snell R2) to twenty.4% (Nagelkerke R2) of the variance in high-risk CAC and labeled 88.4% of circumstances appropriately. The Hosmer-Lemeshow checks indicated the info fitted nicely for this mannequin. The chances of high-risk CAC elevated with a historical past of hypertension (OR 1.830, 95percentCI 1.179 to 2.843) or diabetes (OR 1.982, 95percentCI 1.295 to three.305). Elevated SBP was related to an elevated incidence of high-risk CAC (OR 1.023, 95percentCI 1.008 to 1.038), whereas bodily exercise and DBP decrease the chance of exhibiting a high-risk CAC rating. In the meantime, even after adjusting for all elements, dyslipidaemia, familial historical past, smoking, chest ache, and BMI weren’t related to a high-risk CAC rating.
Dialogue
The present research discovered {that a} historical past of hypertension and diabetes are impartial determinants of getting a high-risk CAC rating. Moreover, this research demonstrated protecting results related to bodily exercise and DBP. Every 1 mmHg enhance in SBP raised the chances of getting high-risk CAC by 2.3%, whereas every 1 mmHg enhance in DBP decreased the chances by 5%.
This research discovered that hypertension was independently related to excessive CAC scores in our cohort, much like a previous investigation on the final inhabitants.5 Hypertension and CAC had been urged to be components of a vicious cycle: calcification reduces tunica media flexibility contributing to hypertension growth. Hypertension causes arterial wall trauma on account of elevated arterial strain, or the presence of concurrent shearing occasions, that ultimately induce calcification.6,7 To additional verify our discovering on the hypertension affiliation with CAC, we discovered that larger SBP independently elevated the chance of getting a high-risk CAC rating. Our discovering on SBP supported Nielsen et al.’s research end result that uncontrolled hypertension elevated the chances of calcification by virtually two occasions.8
A subanalysis of the Ladies’s Well being Initiative (WHI) trial urged that postmenopausal ladies who had elevated DBP had decreased odds of CAC prevalence.9 Per the Multiethnic Research of Atherosclerosis knowledge within the basic inhabitants, DBP ≤60 mmHg at baseline was associated to an elevated threat of cardiovascular occasions and mortality.10 DBP is predominantly associated to coronary blood stream and has a J-curve affiliation with cardiovascular occasions.11 Our present findings matched these earlier research. The findings of our research additional verify that girls with diabetes have 1.8 occasions larger odds of getting a high-risk CAC, much like Hoff et al.12
Earlier research have evaluated the advantage of bodily exercise to the CAC scores. A research carried out by Weinberg et al. enrolling ladies aged 50 to 80 years discovered that CAC severity decreased together with elevated bodily exercise.13 One other research evaluating 26 ladies marathon runners and 28 sedentary controls discovered that girls who accomplished marathons yearly had decrease CAC and smaller calcified plaque.14 Thus, our discovering supported the inverse affiliation between bodily exercise and high-risk CAC rating.
As talked about above, the impact of hypertension, diabetes mellitus, and SBP lowered when adjusted for age. The discovering that hypertension elevated together with age was affordable and in concordance with a number of research on ladies and world populations.15,16
In our research, dyslipidaemia was not related to high-risk CAC scores. This discovering was a contradiction to different research. CAC rating within the Dutch ladies inhabitants was carefully related to hypercholesterolaemia, much like a US research.5,12 The variety of smoking ladies included on this research is perhaps too small to signify any end result. Earlier research additionally offered the same proportion of present feminine people who smoke.17,18 Due to this fact, it could possibly be interpreted that energetic smoking may not have an effect on the excessive CAC rating lead to Indonesian ladies, because the smoking prevalence in Indonesian ladies is low. We additionally discovered no affiliation between high-risk CAC rating and BMI in our cohort. Research analyzing the connections between obese/weight problems and coronary coronary heart illness, CVD, and all-cause mortality revealed contradictory findings.5,19 Our insignificant end result is perhaps as a result of each teams displaying comparable BMI distribution, comprising largely regular weight and obese ladies. The discovering must be interpreted rigorously, contemplating the likelihood that these ladies could have restricted information and consciousness of coronary heart illnesses, notably of their household historical past.20
Lastly, our research confirmed that solely one-third of ladies complained of chest ache, even with high-risk CAC. Chest ache was proven to not be related to the high-risk CAC rating. Beforehand, ladies are noticed to have extra atypical chest ache than males.21 Thus, it may be acknowledged that, even within the absence of typical chest ache signs, physicians ought to stay vigilant on the presence of different threat elements to supply further examination, similar to a CAC evaluation.
This research’s cross-sectional and single-centered nature was a big limitation. The accessible knowledge weren’t designated particularly for the present research. There was additionally regularly a paucity of information on potential confounding elements: ethnicity, socioeconomic standing, or academic stage. The end result additionally couldn’t conclude any impact of passive smoking as a result of a scarcity of information. Regardless of the limitation, our research concerned a lot of individuals and used well-measured and standardised definitions of cardiovascular threat elements.
Conclusion
In abstract, this single-centre research amongst ladies discovered {that a} historical past of hypertension, diabetes, and excessive uncontrolled SBP is perhaps used as cues for a doctor to prioritise CAC evaluation, regardless of the absence of chest ache or atypical signs. Additional potential research confirming our findings could be wanted sooner or later.
Key messages
One of many assessments for coronary atherosclerosis throughout cardiac computed tomography (CT) is coronary artery calcium (CAC) scoring
This research carried out evaluation on the determinants of high-risk coronary calcification, represented by CAC rating, amongst ladies as a step to enhance their outcomes and prognosis
In ladies, a historical past of hypertension, diabetes, and excessive uncontrolled systolic blood strain, is perhaps used as cues for physicians to prioritise CAC evaluation, regardless of the absence of chest ache or atypical signs
Conflicts of curiosity
None declared.
Funding
None.
Research approval
The Moral Committee of Siloam Hospital Surabaya had permitted this research (No. 15103/DIR-SHSB/III/2022) on 15 March 2022. As this research was retrospective and the evaluation used nameless medical-record knowledge, knowledgeable consent was waived.
Acknowledgement
The authors want to thank Gabrielle J Kembuan, Harvard Medical College, Boston, for offering language assist and proofreading the article.
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