Abstract

Background: There is increasing interest in predicting heart failure (HF), a major cause of morbidity and mortality that exerts a significant financial burden. The role of coronary artery calcium (CAC), an accessible and inexpensive test, in predicting long-term HF mortality amongst asymptomatic adults remains unknown. Objectives: To determine if CAC burden is associated with HF-related mortality in the primary prevention population. Methods: The study included 66,636 primary prevention patients from the Coronary Artery Calcium Consortium. Multivariable competing risks regression was used to assess the association between CAC and HF-related mortality adjusting for demographics and traditional risk factors. Results: The mean age was 54.4 years, 67% male, 89% white, and 55% had CAC >0. A total of 260 HF-related mortality events were observed during a median follow up of 12.5 years, 75.3% of which occurred among those with a baseline CAC score >100. Compared with a CAC = 0, there was a stepwise higher risk (P < 0.005) of HF mortality for CAC 1-100 (subdistribution hazard ratio [SHR]: 2.27; 95% CI: 1.3-3.99), 100-400 (SHR: 3.68; 95% CI 2.1-6.43), and >400 (SHR: 7.05; 95% CI 4.05-12.29). This increasing risk of HF mortality across higher CAC scores persisted across age groups, sex, and in the intermediate and high-risk groups as calculated by the pooled cohort equation (PCE) and the PREVENT equation. Conclusions: Higher CAC is associated with increasing incidence of long-term HF-related mortality in the primary prevention population, particularly intermediate and high-risk patients. Early preventive approaches in patients with high CAC must focus on preventing heart failure and ASCVD with lifestyle changes and medications.