DOI: 10.2337/dc23-1864 ISSN: 0149-5992

Epidemiology and Prognostic Implications of Coronary Artery Calcium in Asymptomatic Individuals With Prediabetes: A Multicohort Study

Mahmoud Al Rifai, Mouaz H. Al-Mallah, Michael J. Blaha, Jaideep Patel, John W. McEvoy, Khurram Nasir, Izza Shahid, Kershaw V. Patel, Garima Sharma, Jaume Marrugat, Helena Tizon-Marcos, Raimund Erbel, Andreas Stang, Karl-Heinz Jöckel, Nils Lehmann, Sara Schramm, Börge Schmidt, Roger S. Blumenthal, Salim S. Virani, Vijay Nambi, Miguel Cainzos-Achirica
  • Advanced and Specialized Nursing
  • Endocrinology, Diabetes and Metabolism
  • Internal Medicine


To describe the epidemiology and prognostic value of coronary artery calcium (CAC) in individuals with prediabetes.


We pooled participants free of clinical atherosclerotic cardiovascular disease (ASCVD) from four prospective cohorts: the Multi-Ethnic Study of Atherosclerosis, Heinz Nixdorf Recall Study, Framingham Heart Study, and Jackson Heart Study. Two definitions were used for prediabetes: inclusive (fasting plasma glucose [FPG] ≥100 to <126 mg/dL and hemoglobin A1c [HbA1c] ≥5.7% to <6.5%, if available, and no glucose-lowering medications) and restrictive (FPG ≥110 to <126 mg/dL and HbA1c ≥5.7% to <6.5%, if available, among participants not taking glucose-lowering medications).


The study included 13,376 participants (mean age 58 years; 54% women; 57% White; 27% Black). The proportions with CAC ≥100 were 17%, 22%, and 37% in those with euglycemia, prediabetes, and diabetes, respectively. Over a median (25th–75th percentile) follow-up time of 14.6 (interquartile range 7.8–16.4) years, individuals with prediabetes and CAC ≥100 had a higher unadjusted 10-year incidence of ASCVD (13.4%) than the overall group of those with diabetes (10.6%). In adjusted analyses, using the inclusive definition of prediabetes, compared with euglycemia, the hazard ratios (HRs) for ASCVD were 0.79 (95% CI 0.62, 1.01) for prediabetes and CAC 0, 0.70 (0.54, 0.89) for prediabetes and CAC 1–99, 1.54 (1.27, 1.88) for prediabetes and CAC ≥100, and 1.64 (1.39, 1.93) for diabetes. Using the restrictive definition, the HR for ASCVD was 1.63 (1.29, 2.06) for prediabetes and CAC ≥100.


CAC ≥100 is frequent among individuals with prediabetes and identifies a high ASCVD risk subgroup in which the adjusted ASCVD risk is similar to that in individuals with diabetes.

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