Coronary vascular age comes of age
Coronary vascular age comes of age
Alberto Cuocolo 0 2
Michele Klain 0 2
Mario Petretta 0
0 Reprint requests: Alberto Cuocolo, MD, Department of Advanced Biomedical Sciences, University Federico II , Naples , Italy; J Nucl Cardiol 1071-3581/$34.00 Copyright 2017 American Society of Nuclear Cardiology
1 Department of Translational Medical Sciences, University Federico II , Naples , Italy
2 Department of Advanced Biomedical Sciences, University Federico II , Naples , Italy
The majority of cardiovascular risk estimates are
strongly influenced by chronological age and, starting
from 50 years, age turns out to be the predominant
cardiovascular risk factor.1 The foremost explanation of
this evidence is the progressive accumulation of
atherosclerotic plaques over time, and the use of
chronological age in cardiovascular risk assessment is a
surrogate for atherosclerotic burden. If the
cardiovascular risk estimate is primarily driven by age, a young
person with a significantly elevated risk factor burden is
still likely to have a low risk score. To overcome the
short-term estimate pitfalls, it has been proposed to use a
time horizon much longer than 10 years in risk
calculation, such as the 30-year risk, or even the lifetime risk,
instead of the conventional 10-year risk.2 Specific score
vascular age charts useful for the full range of absolute
risk and age have also been proposed.3
As the atherosclerotic burden of individuals with
the same chronological age can be considerably
different, due to contribution of the other traditional risk
factors,4 a technique that better measures atherosclerotic
impairment could represent a helpful clinical tool.5 Two
of the most promising procedures for the evaluation of
subclinical atherosclerosis are coronary artery calcium
(CAC) scanning by computed tomography (CT) and
carotid intima-media thickness (CIMT) assessment by
‘‘Vascular age,’’ also known as arterial age, heart
age, or cardiovascular risk age, is an emerging concept
based on the theory that the conversion of chronological
age to an age derived from vascular imaging data would
lead to a more accurate assessment of individual
cardiovascular risk. CAC score and CIMT assessment can
be used to define vascular age. In particular, CIMT
vascular age is determined by linear regression modeling
using published nomograms of CIMT percentiles or the
age at which the individual’s measurement would
represent the 50th percentile of a reference database.
Conversely, the CT approach provides a convenient
transformation of CAC score from Agatston units in
years. It has been reported that CAC and CIMT provide
similar information in the assessment of vascular age.8
On the other hand, the rational to use these tools in
cardiovascular risk prediction models is still debated.
Vascular age may contribute to a superior understanding
of long-term cardiovascular risk especially in young
adults, but despite the growing interest in the clinical
utility of this novel concept, only few data are
available.9 In particular, the impact of vascular age to predict
myocardial ischemia has not been evaluated and there is
the need to investigate the potential role of vascular age
in the prediction of stress-induced myocardial ischemia
in patients with suspected coronary artery disease.
Coronary calcium accumulation is the result of an
active process related to atherosclerosis, and thus
detection of coronary artery calcifications corresponds to
an atherosclerosis advancement report. The strong
predictive value of calcium deposit evaluation, regardless
of the risk category estimated by traditional risk scores,
has been widely demonstrated.10–12
Cuocolo et al
Coronary vascular age comes of age
The emerging idea to assign a vascular age,
according to observed CAC, shoots for taking into
account the relationship between calcium deposit
process and actual obsolescence of vascular system,
tailoring individual cardiovascular risk aside from
Prognostic data from MESA14,15 showed that the
risk associated with vascular age was a much stronger
predictor of cardiovascular events than predictions based
on chronological age. Moreover, in the same cohort,
chronological age did not provide additional information
after controlling for vascular age. Other investigations
showed that there is a significant inverse relationship
between telomere length and coronary artery
calcifications in individuals with no clinical history of CAD
suggesting a potential association of telomere length, a
marker of biological aging, with cumulative lifelong
burden of oxidative stress detected with coronary artery
Yet, vascular age would be a useful tool to
communicate test results to patients and to apply stricter
therapeutic strategies to freeze cardiovascular disease
progression in patients with an vascular age higher than
the respective chronological age. Indeed, the
communication of a given vascular age would have a superior
emotive impact improving observance of therapies and
The authors have indicated that they have no financial
conflict of interest.
1. Wilson PW , D'Agostino RB , Levy D , Belanger AM , Silbershatz H , Kannel WB . Prediction of coronary heart disease using risk factor categories . Circulation 1998 ; 97 : 1837 - 47 .
2. Karmali KN , Lloyd-Jones DM . Adding a life-course perspective to cardiovascular-risk communication . Nat Rev Cardiol 2013 ; 10 : 111 - 5 .
3. Cuende JI , Cuende N , Calaveras-Lagartos J . How to calculate vascular age with the SCORE project scales: a new method of cardiovascular risk evaluation . Eur Heart J 2010 ; 31 : 2351 - 8 .
4. Goff DC Jr, Lloyd-Jones DM , Bennett G , Coady S , D'Agostino RB Sr , Gibbons R , et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines . J Am Coll Cardiol 2014 ; 63 : 2935 - 59 .
5. Stein JH , Fraizer MC , Aeschlimann SE , Nelson-Worel J , McBride PE , Douglas PS . Vascular age: Integrating carotid intima-media thickness measurements with global coronary risk assessment . Clin Cardiol 2004 ; 27 : 388 - 92 .
6. Pletcher MJ , Greenland P . Coronary calcium scoring and cardiovascular risk: The shape of things to come . Arch Intern Med 2008 ; 168 : 1027 - 8 .
7. Coll B , Feinstein SB . Carotid intima-media thickness measurements: Techniques and clinical relevance . Curr Atheroscler Rep 2008 ; 10 : 444 - 50 .
8. Khalil Y , Mukete B , Durkin MJ , Coccia J , Matsumura ME . A comparison of assessment of coronary calcium vs carotid intima media thickness for determination of vascular age and adjustment of the Framingham Risk Score . Prev Cardiol 2010 ; 13 : 117 - 21 .
9. Groenewegen KA , den Ruijter HM , Pasterkamp G , Polak JF , Bots ML , Peters SA . Vascular age to determine cardiovascular disease risk: A systematic review of its concepts, definitions, and clinical applications . Eur J Prev Cardiol 2016 ; 23 : 264 - 74 .
10. Assante R , Zampella E , Arumugam P , Acampa W , Imbriaco M , Tout D , et al. Quantitative relationship between coronary artery calcium and myocardial blood flow by hybrid rubidium-82 PET/ CT imaging in patients with suspected coronary artery disease . J Nucl Cardiol 2017 ; 24 : 494 - 501 .
11. Chang SM , Nabi F , Xu J , Peterson LE , Achari A , Pratt CM , et al. The coronary artery calcium score and stress myocardial perfusion imaging provide independent and complementary prediction of cardiac risk . J Am Coll Cardiol 2009 ; 54 : 1872 - 82 .
12. Blaha M , Budoff MJ , Shaw LJ , Khosa F , Rumberger JA , Berman D , et al. Absence of coronary artery calcification and all-cause mortality . JACC Cardiovasc Imaging 2009 ; 2 : 692 - 700 .
13. Nappi C , Nicolai E , Daniele S , Acampa W , Gaudieri V , Assante R , et al. Long-term prognostic value of coronary artery calcium scanning, coronary computed tomographic angiography and stress myocardial perfusion imaging in patients with suspected coronary artery disease . J Nucl Cardiol 2016 . doi: 10 .1007/s12350-016- 0657-2.
14. Budoff MJ , Nasir K , McClelland RL , Detrano R , Wong N , Blumenthal RS , et al. Coronary calcium predicts events better with absolute calcium scores than age-sex-race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis) . J Am Coll Cardiol 2009 ; 53 : 345 - 52 .
15. McClelland RL , Nasir K , Budoff M , Blumenthal RS , Kronmal RA . Arterial age as a function of coronary artery calcium (from the Multi-Ethnic Study of Atherosclerosis [MESA]) . Am J Cardiol 2009 ; 103 : 59 - 63 .
16. Samani NJ , van der Harst P. Biological ageing and cardiovascular disease . Heart 2008 ; 94 : 537 - 9 .
17. De Meyer T, Rietzschel ER , De Buyzere ML , Van Criekinge W , Bekaert S. Telomere length and cardiovascular aging: the means to the ends? Ageing Res Rev 2011 ; 10 : 297 - 303 .