A comparison of the Framingham risk index, coronary artery calcification, and culprit plaque morphology in sudden cardiac death.

BACKGROUND Neither clinical prediction models nor noninvasive imaging tests that detect coronary artery calcification identify all patients who experience acute coronary events. Variations in culprit plaque morphology may account for these inaccuracies. METHODS AND RESULTS We compared the 10-year Framingham risk index, histologic coronary calcification, and culprit plaque morphology in 79 consecutive adults with sudden cardiac death. There was a modest relationship between the Framingham risk index and the extent of histologic coronary calcification (r=0.35, P=0.002). Agreement in risk classification between the histologic calcification score and the Framingham risk index occurred in 50 of 79 cases (63.3%, P=0. 039). Either a focus of coronary artery calcification >/=40 micromol/L (62% of cases) or a Framingham risk index score >/= average risk for age (62% of cases) were present in 66 of 79 (83.5%) cases. Cases with plaque erosion (n=22) had significantly less coronary calcification (P=0.003) and lower Framingham risk index (P=0.001) scores than stable (n=27) or ruptured (n=30) plaques. Fourteen of 22 (63.6%) cases of plaque erosion were classified as low risk by both the Framingham risk index and the histologic calcification score. CONCLUSIONS The prediction of sudden cardiac death using the Framingham risk index and the measurement of coronary calcification are distinct methods of assessing risk for sudden cardiac death. Excessive reliance on either method alone will produce errors in risk classification, particularly for patients at risk of plaque erosion, but their combination may be complementary.

[1]  S M Grundy,et al.  Primary prevention of coronary heart disease: guidance from Framingham: a statement for healthcare professionals from the AHA Task Force on Risk Reduction. American Heart Association. , 1998, Circulation.

[2]  W. Janowitz,et al.  Differences in prevalence and extent of coronary artery calcium detected by ultrafast computed tomography in asymptomatic men and women. , 1993, The American journal of cardiology.

[3]  W. Roberts,et al.  Morphologic comparison of frequency and types of acute lesions in the major epicardial coronary arteries in unstable angina pectoris, sudden coronary death and acute myocardial infarction. , 1991, Journal of the American College of Cardiology.

[4]  P. Macfarlane,et al.  Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia , 1995 .

[5]  J. Rumberger Electron beam CT and coronary calcium score. , 1998, Circulation.

[6]  J. Strong,et al.  Lipoproteins and apolipoproteins in postmortem serum. , 1988, Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc.

[7]  W. Edwards,et al.  Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology. , 1998, Journal of the American College of Cardiology.

[8]  L E Ginzton,et al.  Coronary calcium does not accurately predict near-term future coronary events in high-risk adults. , 1999, Circulation.

[9]  P. Macfarlane,et al.  Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. , 1995, The New England journal of medicine.

[10]  H. Mcgill,et al.  Determinants of atherosclerosis in the young , 1998 .

[11]  Relationship of atherosclerosis in young men to serum lipoprotein cholesterol concentrations and smoking. A preliminary report from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. , 1990, JAMA.

[12]  D. Levy,et al.  Prediction of coronary heart disease using risk factor categories. , 1998, Circulation.

[13]  R. Virmani,et al.  Effect of hypertension and cardiac hypertrophy on coronary artery morphology in sudden cardiac death. , 1996, Circulation.

[14]  Y. Arad,et al.  Predictive value of electron beam computed tomography of the coronary arteries. 19-month follow-up of 1173 asymptomatic subjects. , 1996, Circulation.

[15]  A. Becker,et al.  Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology. , 1994, Circulation.

[16]  R. Virmani,et al.  Coronary plaque erosion without rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. , 1996, Circulation.

[17]  D. Rader,et al.  Electron beam computed tomographic coronary calcium scanning: a review and guidelines for use in asymptomatic persons. , 1999, Mayo Clinic proceedings.

[18]  R. Virmani,et al.  Coronary risk factors and plaque morphology in men with coronary disease who died suddenly. , 1997, The New England journal of medicine.

[19]  J. Strong,et al.  Relation of glycohemoglobin and adiposity to atherosclerosis in youth. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. , 1995, Arteriosclerosis, thrombosis, and vascular biology.

[20]  J. Rumberger,et al.  Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area. A histopathologic correlative study. , 1995, Circulation.

[21]  V. Fuster,et al.  Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications. A statement for health professionals from the American Heart Association. Writing Group. , 1996, Circulation.

[22]  S B Hulley,et al.  Overall and coronary heart disease mortality rates in relation to major risk factors in 325,348 men screened for the MRFIT. Multiple Risk Factor Intervention Trial. , 1986, American heart journal.

[23]  R. Detrano,et al.  Electron beam computed tomographic coronary calcium as a predictor of coronary events: comparison of two protocols. , 1997, Circulation.

[24]  Y. Arad,et al.  Comparison of electron beam computed tomography scanning and conventional risk factor assessment for the prediction of angiographic coronary artery disease. , 1998, Journal of the American College of Cardiology.

[25]  D. Grönemeyer,et al.  Coronary artery calcium in acute coronary syndromes: a comparative study of electron-beam computed tomography, coronary angiography, and intracoronary ultrasound in survivors of acute myocardial infarction and unstable angina. , 1997, Circulation.

[26]  H. Krumholz,et al.  Guide to primary prevention of cardiovascular diseases. A statement for healthcare professionals from the Task Force on Risk Reduction. American Heart Association Science Advisory and Coordinating Committee. , 1997, Circulation.

[27]  R. Krauss,et al.  A prospective study of triglyceride level, low-density lipoprotein particle diameter, and risk of myocardial infarction. , 1996, JAMA.

[28]  J. Neaton,et al.  Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). , 1986, JAMA.

[29]  A. Gotto,et al.  Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. , 1998, JAMA.

[30]  M J Davies,et al.  Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death. , 1984, The New England journal of medicine.

[31]  L. Weinert,et al.  Echocardiographic detection of regional diastolic dysfunction in patients with coronary artery disease and normal wall motion , 1998 .

[32]  R. Detrano Predictive value of electron beam computed tomography. , 1997, Circulation.

[33]  S. Shapiro,et al.  The risk of myocardial infarction after quitting smoking in men under 55 years of age. , 1985, The New England journal of medicine.

[34]  J. Hoeg Evaluating coronary heart disease risk. Tiles in the mosaic. , 1997, JAMA.