Subclinical Atherosclerosis Can Be Identified in Adults with Coarctation of the Aorta

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Coarctation of the aorta (CoA) increases the risk of morbidity and mortality, with coronary artery disease considered the leading culprit. Reduced systemic arterial compliance may persist or worsen after repair, and hypertension and residual lesions may also contribute.

Coronary artery calcium (CAC) has been validated as an independent predictor of coronary artery disease in several specialized populations. A Massachusetts General Hospital team led by Ami B. Bhatt, MD, director of the Adult Congenital Heart Disease Program, reports in The American Journal of Cardiology that CAC scores derived from computed tomography (CT) images are useful in patients with CoA.

A Retrospective Study

Dr. Bhatt's group reviewed the records of 131 patients with CoA who underwent coronary CT angiography or chest CT between 2004 and 2017. Each patient was matched by age and gender with two control subjects chosen from an emergency department database who underwent coronary CT angiography for chest pain evaluation.

Researchers blinded to diagnosis and outcome graded the images as follows:

• Coronary CT angiography—quantitative CAC scores. Patients had a preceding electrocardiography-gated noncontrast scan, and CAC scores were measured on these using a radiology procedure known as the Agatston method. Patients were divided into four groups based on those scores: 0, >0 and <100, ≥100 and <400, or ≥400
• Chest CT—qualitative CAC scores. The amount of calcium in an artery was rated as absent, mild, moderate or severe

Cardiovascular Risk Factors

Risk factors for atherosclerotic cardiovascular disease were common among patients with CoA, even young adults. The prevalence of systemic hypertension (77%) was significantly higher than in the control group (38%). In addition, 10% of patients had diabetes and 62% were overweight or obese.

The median 10-year risk of atherosclerotic cardiovascular disease, calculated using the 2013 American College of Cardiology/American Heart Association pooled risk equations was 8% in patients with CoA versus 5% in controls.

Quantitative CAC Scores

Excluding individuals who had a quantitative CAC score of 0, the median score was 65 for CoA patients and 32 for control subjects.

Scores ≥400 were identified in 8% of patients with CoA and 2% of the controls (P = .03). CoA patients who were ≥40 years old were significantly more likely than younger patients to have a score ≥400 (14% vs. 0%, P = .04).

Qualitative CAC Scores

Normal-appearing coronary arteries were found in 72% of CoA patients who underwent chest CT. Patients ≥40 years old were more likely than younger patients to have mild calcium burden (30% vs. 2%, P = .001), moderate calcium burden (11% vs. 0%, P = .01) or multivessel disease (27% vs. 2%, P = .001).

Recommendations

Patients with CoA remain at low absolute risk of clinical atherosclerotic events until their sixth decade, the researchers state. Even so, they urge physicians to address modifiable risk factors for atherosclerosis in all such patients. Discussions of lifestyle modification, diet and exercise are beneficial at any age.

Low-dose ionizing radiation is associated with a greater risk of cancer in adults with congenital heart disease, and the researchers recognize that many centers prefer magnetic resonance imaging to CT. Still, they say, if coronary CT angiography or chest CT is ordered for a patient with CoA (for planning of a cardiac procedure, assessment of lung pathology, contraindication to MRI or institutional preference), subclinical atherosclerosis should be assessed. This is especially true for patients ≥40 years old, given the increased incidence of subclinical atherosclerosis in that age group.

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Refer a patient to the Mass General Heart Center