Asymptomatic LV dysfunction in individuals with markedly increased coronary artery calcium: baseline CMR findings from EARLY-SYNERGY
T Severijn, D Ties, G Pundziute, M Guglielmo, C Van Der Aalst, I Van Der Bilt, R L Braam, J W C Gratama, B D Westenbrink, C J M Doggen, M H Oudkerk, H De Koning, R Nijveldt, R Vliegenthart, P Van Der HarstAbstract
Background
The prevalence of asymptomatic left ventricular systolic dysfunction (ALVSD) in subjects with elevated coronary artery calcium (CAC) is unknown. Data from the EARLY-SYNERGY trial have shown a high yield of ischaemia and silent myocardial infarction (MI) on cardiac magnetic resonance imaging (CMR) in this population, but the association between CAC burden and left ventricular ejection fraction (LVEF) has not yet been specifically addressed.
Purpose
To quantify the prevalence of ALVSD, to evaluate the association between CAC burden and LVEF, and to assess the association between LVEF and myocardial ischemia and silent infarction, in individuals with CAC ≥300.
Methods
EARLY-SYNERGY is a multicentre randomised trial where asymptomatic adults with CAC ≥300, identified through population-based imaging studies, were enrolled. This cross-sectional analysis included all participants who underwent baseline perfusion stress CMR. LVEF and left ventricular volumes were quantified using standardised CMR analysis. LVEF was categorised as preserved (≥50%), mildly reduced (40–49%) and moderately-to-severely reduced (<40%). CAC was analysed in predefined strata (CACS 300–399, 400–999 and ≥1000). We assessed (1) the overall prevalence of LV dysfunction, (2) the association of LVEF and ischaemia/unrecognised MI, and (3) the association between CAC burden and LV dysfunction using logistic regression, expressed as unadjusted odds ratios.
Results
A total of 640 participants (mean age 69.6 ± 6.9 years, 24% women) with CAC ≥300 were included. Mean LVEF was 65.6% ± 8.0% and 25 participants (3.9%) had LVEF <50%, of whom 21 (3.3%) had LVEF 40-49% and 4 (0.6%) had LVEF <40%. The prevalence of any LV systolic dysfunction (LVEF <50%) increased across CAC strata from 3.1% in CAC 300–399 to 3.6% in CAC 400–999 and 5.4% in CAC ≥1000 but was not statistically significant (P for trend .31). CMR-detected ischaemia and/or unrecognised MI was present in 40% (N = 10/25) of those with LVEF < 50%, compared to 20.8% (128/615) in participants with preserved LVEF (OR 2.54, 95% CI [1.11 – 5.78]).
Conclusion
In asymptomatic individuals with CAC ≥ 300, CMR reveals a 3.9% burden of ALVSD, with no significant trend across increasing CAC categories. Presence of LV systolic dysfunction was associated with the presence of CMR-detected ischaemia and/or unrecognised infarction. These findings suggest that CAC-based screening identifies a population not only at high risk of coronary events but also at risk for future heart failure, and that combining CAC assessment with CMR may enable early detection of ALVSD and targeted prevention strategies.