Holistic approach to the risk of coronary obstruction and myocardial ischemia detected by coronary CT angiography

Background Most cardiovascular risk models rely only on the assessment of traditional risk factors despite demonstrated environmental and socio-economic inequalities in cardiovascular disease. A holistic approach to the risk of coronary obstruction and ischemia is now required. Purpose To assess independent impacts of air and noise pollution, residential green space, socioeconomic status (SES) on non-invasively derived coronary obstruction and myocardial ischemia. Methods Consecutive patients screened by coronary computed tomography angiography (CCTA) for stable chest pain between 01/01/2019 and 31/12/2020 were included in a registry. The exposome over the last two years was assessed at patients’ residences, incorporating both environmental and socio-economic factors. Environmental exposures included PM2.5 (particulate matter <2.5 micrometres) and NO2 (nitric dioxide) concentrations, major road and airport distance, and the normalized difference vegetation index (NDVI). Socio-economic determinants encompassed neighbourhood-level low education rates, annual income, and population density. Exposomic associations with obstructive coronary artery disease (OCAD, stenosis ≥50%) and abnormal fractional flow reserve (FFRCT<80%) were analysed using propensity score-adjusted logistic regression. Subgroup analysis was performed based on Framingham low (<10%) and high (>20%) 10-year coronary heart disease risk categories. Results 2620 patients were enrolled, including 420 (16%) FFRCT analyses. OCAD was reported in 518 (20%) patients and abnormal FFRCT in 276 (11%). People with OCAD lived closer to the airport (10.841 [7.869-19.022] km vs. 12.297 [8.691-22.843] km, p<0.001). People living closer to the airport had more cardiovascular, socioeconomic risk factors: lower income and higher population density. Distance to airport decreased OCAD risk (OR 0.983, 95%CI 0.974-0.992, per 1 km) in univariable analysis. After propensity score (PS) adjustment, environmental stressors were not significantly associated with OCAD, regardless of Framingham risk categories. Only distance to major road decreased abnormal FFRCT risk (OR 0.634, 95%CI: 0.421-0.926, per 1 km) in high-risk patients after PS adjustment. Conclusions Particulate and gaseous air pollutants were not associated with OCAD or ischemia. The most vulnerable population consisted of people living close to the airport mainly throughout socio-economic inequities, while major road proximity showed a complex relationship with ischemia in patients with established CV risk factors. These findings highlight the need for a holistic approach integrating social determinants of CV health to target preventive health measures and public health interventions in the more vulnerable groups.