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Original Investigation
November 18, 2020

Associations Between Carotid Artery Plaque Burden, Plaque Characteristics, and Cardiovascular Events: The ARIC Carotid Magnetic Resonance Imaging Study

Author Affiliations
  • 1Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 2Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey
  • 3Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 4Michael E. DeBakey VA Medical Center, Houston, Texas
  • 5The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 6The University of Texas Health Science Center School of Public Health, Houston
  • 7Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 8Division of Geriatric Medicine, University of Mississippi Medical Center, Jackson
  • 9Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Cardiol. 2021;6(1):79-86. doi:10.1001/jamacardio.2020.5573
Key Points

Question  In an asymptomatic community-based cohort, are carotid artery plaque characteristics on magnetic resonance imaging associated with cardiovascular events when adjusted for plaque burden?

Findings  In this cohort study of 1256 participants from the Atherosclerosis Risk in Communities Carotid Magnetic Resonance Imaging substudy, magnetic resonance imaging measures of carotid artery plaque burden and characteristics were analyzed. The presence of a lipid core was independently associated with incident cardiovascular disease events when adjusted for traditional cardiovascular disease risk factors and carotid artery wall thickness.

Meaning  In this study, the presence of a lipid core was associated with incident cardiovascular disease events independent of carotid artery wall thickness in asymptomatic individuals and improved risk prediction of incident cardiovascular disease events over traditional cardiovascular risk factors.

Abstract

Importance  It remains unknown whether in an asymptomatic community-based cohort magnetic resonance imaging (MRI) measures of plaque characteristics are independently associated with incident cardiovascular disease (CVD) events when adjusted for carotid artery (CA) wall thickness, a measure of plaque burden.

Objective  To assess associations of CA MRI plaque characteristics with incident CVD events.

Design, Setting, and Participants  The Atherosclerosis Risk in Communities (ARIC) study is a prospective epidemiologic study of the incidence of CVD in 15 792 adults of which 2066 women and men were enrolled in the ARIC Carotid MRI substudy. ARIC participants were enrolled from 1987 to 1989, and the substudy was conducted between January 2004 and December 2005. Analysis began January 2017 and ended August 2020.

Exposures  Incident CVD events during a median (interquartile range [IQR]) follow-up time of 10.5 (8.1-10.9) years were assessed.

Main Outcomes and Measures  Proportional hazards Cox analyses were performed to ascertain associations between MRI variables of CA plaque burden and plaque characteristics.

Results  Of 15 792 ARIC participants, 2066 were enrolled in the substudy, of whom 1256 (701 women [55.8%]) had complete data and were eligible for incident CVD analyses. Carotid artery plaques in participants with incident CVD events (172 [13.7%]) compared with those without (1084 [86.3%]) had a higher normalized wall index (median [IQR], 0.48 [0.36-0.62] vs 0.43 [0.34-0.55]; P = .001), maximum CA wall thickness (median [IQR], 2.22 [1.37-3.52] mm vs 1.96 [1.29-2.85] mm; P = .01), maximum CA stenosis (median [IQR], 5% [0%-22%] vs 0% [0%-13%]; P < .001), and when present, a larger lipid core volume (median [IQR], 0.05 [0.02-0.11] mL vs 0.03 [0.01-0.07] mL; P = .03), respectively. The presence of a lipid core was independently associated with incident CVD events when adjusted for traditional CVD risk factors and maximum CA wall thickness (hazard ratio, 2.48 [95% CI, 1.36-4.51]; P = .003), whereas the presence of calcification was not. The frequency of intraplaque hemorrhage presence in this population of individuals free of CVD at baseline who were not recruited for carotid stenosis was too small to draw any meaningful conclusions (intraplaque hemorrhage presence: 68 of 1256 participants [5.4%]). Carotid artery lumen area and maximum stenosis, which were overall low, were independently associated with incident CVD events when adjusted for traditional CVD risk factors, as anticipated.

Conclusions and Relevance  The presence of a CA lipid core on MRI is associated with incident CVD events independent of maximum CA wall thickness in asymptomatic participants.

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