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A Systematic Review and Meta-analysis

Mark J. Pletcher, MD, MPH; Jeffrey A. Tice, MD; Michael Pignone, MD, MPH; Warren S. Browner, MD, MPH

Arch Intern Med. 2004;164:1285-1292.

Background  Primary prevention of coronary heart disease is most appropriate for patients at relatively high risk. Measurement of coronary artery calcium has been proposed as a way to improve risk assessment, but it is unknown whether it adds predictive information to standard risk factor assessment.

Methods  We systematically searched electronic databases for relevant articles published between January 1, 1980, and March 19, 2003, and hand searched bibliographies. We included studies that reported measuring the coronary artery calcium score by electron beam computed tomography in asymptomatic subjects and subsequent follow-up of those patients for coronary events and that presented score-specific relative risks, adjusted for established risk factors. Two abstractors verified inclusion criteria and abstracted data from each study. We estimated adjusted relative risks associated with 3 standard categories of coronary artery calcium scores (1-100, 101-400, and >400), compared with a score of 0, and used a random-effects model for meta-analysis.

Results  Meta-analysis of the 4 studies meeting inclusion criteria yielded a summary adjusted relative risk of 2.1 (95% confidence interval, 1.6-2.9) for a coronary artery calcium score of 1 to 100. Relative risk estimates for higher calcium scores were higher, ranging from 3.0 to 17.0 but varied significantly among studies. Subgroup analyses suggested that differences among studies in outcome adjudication (blinded or not), measurement of other risk factors (direct or by patient history), tomographic slice thickness (3 or 6 mm), and/or proportion of female study subjects may account for this heterogeneity.

Conclusion  The coronary artery calcium score is an independent predictor of coronary heart disease events.

From the Department of Epidemiology and Biostatistics (Drs Pletcher and Browner), Division of General Internal Medicine (Drs Pletcher and Tice), and Department of Medicine (Dr Browner), University of California, San Francisco; the Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina–Chapel Hill School of Medicine (Dr Pignone); and the Research Institute, California Pacific Medical Center (Dr Browner). The authors have no relevant financial interest in this article.

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