Coronary Artery Calcium in Individuals With Severe Mental Illness

HomeCirculation: Cardiovascular ImagingVol. 12, No. 3Coronary Artery Calcium in Individuals With Severe Mental Illness Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCoronary Artery Calcium in Individuals With Severe Mental IllnessLimited Value or Just Limited Data? Tamar S. Polonsky, MD, MSCI and Michael D. Miedema, MD, MPH Tamar S. PolonskyTamar S. Polonsky Correspondence to Tamar S. Polonsky, MD, MSCI, Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC6080, Chicago, IL 606037. Email E-mail Address: [email protected] Department of Medicine, University of Chicago Medicine, IL (T.S.P.). and Michael D. MiedemaMichael D. Miedema Minneapolis Heart Institute (M.D.M.), MN. Minneapolis Heart Institute Foundation (M.D.M.), MN. Originally published14 Mar 2019https://doi.org/10.1161/CIRCIMAGING.119.008861Circulation: Cardiovascular Imaging. 2019;12:e008861This article is a commentary on the followingCoronary Artery Calcification and Mortality Risk in Patients With Severe Mental IllnessSee Article by Kugathasan et alIt is well-established that risk assessment for atherosclerotic cardiovascular disease (ASCVD) based on traditional risk factors has limitations. A large proportion of cardiovascular events occur among adults not identified as higher risk based on their traditional risk factors alone, and many of those whose estimated 10-year risk is elevated were never destined to experience an ASCVD event. In the 2018 Guideline on the Management of Blood Cholesterol from the American College of Cardiology/American Heart Association and multiple other health organizations, there is support for use of coronary artery calcium (CAC) testing in individuals with intermediate ASCVD risk (estimated 10-year risk of 7.5% to <20%) when treatment decisions are unclear.1 For individuals with borderline ASCVD risk (estimated 10-year risk of 5% to <7.5%) and risk-enhancing factors such as chronic inflammatory conditions or a strong family history of premature ASCVD, CAC can again be considered for further risk stratification.In this issue of Circulation: Cardiovascular Imaging, Kugathasan et al2 evaluated the prognostic significance of CAC in adults with severe mental illness (SMI)—a subgroup at substantially elevated cardiovascular risk. Adults with SMI die of cardiovascular disease an average of 10 to 20 years earlier than adults without SMI.3,4 The higher cardiovascular risk involves coronary, cerebrovascular, heart failure, and arrhythmic events, with mortality rates that are 2 to 3× as high as the general population.4 The elevated cardiovascular risk is likely related to several factors, including a high burden of cardiovascular risk factors (particularly smoking), adverse lifestyle, and inadequate treatment or nonadherence to medication.5,6 CAC testing could be a useful adjunct to risk assessment in patients with SMI, given that they often develop ASCVD risk factors or experience events at young ages, when standard risk calculators may still classify them as low risk. The investigation by Kugathasan et al—one of the only studies of subclinical disease among adults with SMI to date—begins to address important clinical questions in an extremely vulnerable population.7The authors used data from a clinical database in Denmark, the Western Denmark Heart Registry, which includes 55% of the Danish population and incorporates data on cardiac computed tomography. The registry data were then linked to the Danish National Patient Registry to obtain diagnoses of SMI, including codes for schizophrenia and bipolar disorder. From 2008 to 2016, the cohort included 48 757 adults who had undergone CAC testing for clinical indications, 1.2% (n=564) of whom had a diagnosis of SMI. As with prior studies of SMI, the Danish registry showed that adults with SMI were significantly more likely to smoke, have diabetes mellitus, hypertension, and an elevated body mass index, compared with adults without SMI.6,8Kugathasan et al stratified CAC scores based on age ≤60 or >60 years and CAC score ≤100 or >100. Despite having a higher burden of risk factors, adults with SMI had a similar distribution of CAC scores as those without SMI. About 12% of younger adults had a CAC >100, and 40% of older adults had a CAC >100. The authors stated that they did not provide further description of the distribution of CAC results because of a small sample size. It would have been instructive to see the prevalence of patients with a CAC of 0, given the important prognostic implications of having no CAC. Zero CAC is associated with a low risk of incident ASCVD events over 10 years, suggesting that many patients with CAC of 0 could forgo statin therapy, although guidelines caution against withholding treatment among adults who smoke, have diabetes mellitus, or have a strong family history of premature ASCVD.1,9 Future study of cardiovascular events, specifically among adults with SMI and a CAC of 0, could help clarify to what degree CAC testing can be used to guide treatment decisions in this high-risk population.Kugathasan et al then examined the association of CAC scores with all-cause and cardiovascular mortality. Compared with adults without SMI and a CAC <100, those with SMI had a higher risk of all-cause mortality. However, the risk was similar among adults with SMI, regardless of their CAC scores. Adults with SMI and CAC ≤100 had a hazard ratio of 3.48 (1.99–6.09), and adults with CAC >100 had a hazard ratio 2.75 (1.22–6.19). There was no association between CAC and cardiovascular mortality in the SMI group. The authors concluded that CAC is not a useful prognostic tool in adults with SMI. However, an important limitation, which the authors acknowledge, is the sample size. Among adults with SMI, there were a total of only 21 deaths (6 cardiovascular), significantly limiting the ability to establish meaningful associations between CAC and mortality. It is, therefore, premature to discount the use of CAC for risk assessment in adults with SMI.It would also be helpful to understand how the patients with SMI who underwent CAC testing might differ from other patients with SMI who did not undergo CAC testing. How do they compare in their burden of cardiovascular risk factors, medication use, and healthcare utilization? Such information could clarify how generalizable the results are to the broader population of patients with SMI.Individuals with SMI represent a complex population because the psychiatric condition itself, and the subsequent treatments, may lead to increased cardiovascular risk. Adoption of healthy lifestyle behaviors and adherence to preventive pharmacotherapy is challenging. As a result, hypertension, diabetes mellitus, and dyslipidemia are not only more prevalent in individuals with SMI but are also less likely to be effectively treated.10 Psychopharmacological treatment can also worsen cardiovascular risk. Several antipsychotic and antidepressant medications lead to adverse changes in cardiovascular risk factors, such as weight gain, dyslipidemia, and diabetes mellitus.5 Studies have also shown associations of antipsychotic medication use and sudden cardiac death, which may be related to mechanisms other than atherosclerosis, such as arrhythmias.6,11In the general population, CAC has the potential to guide treatment decisions for preventive medications, including use of statins, aspirin, and antihypertensive therapy.12,13 Additional study is needed to determine whether and how it could be effectively utilized in populations with SMI, particularly whether adults with SMI could safely avoid medication if they have zero CAC. Interestingly, in a population-based study, adults with SMI who were treated with statins also had less self-harm behavior and fewer psychiatric hospitalizations, compared with periods when they were not exposed to statin therapy, even after controlling for the stability of psychiatric symptoms.14 The authors suggested potential mechanisms, including decreased neuroinflammation or synergy with antipsychotic medications. As a result, factors other than cardiovascular risk may ultimately influence decisions about preventive medications for patients with SMI.Although there are a paucity of data on the prevalence and relevance of subclinical disease among adults with SMI, prior studies have examined other strategies for risk assessment. For example, using data from the Health Improvement Network in the United Kingdom, Osborn et al15 compared cardiovascular risk prediction with the Framingham risk score to a new score that added variables relevant to adults with SMI. The revised score incorporated the use of antidepressant or antipsychotic medication, heavy alcohol use, and a social deprivation score. The revised score outperformed the Framingham risk score, with a C statistic of 0.8 versus 0.78 for the Framingham risk score. Notably, the sample size for the study was substantially larger than that of Kugathasan, including 38 824 adults with SMI and 2324 cardiovascular events. Given that a model based on traditional risk factors alone performed reasonably well, it seems highly plausible that CAC should also enhance risk prediction in studies with a large enough sample size.Assessment of ASCVD risk is a fundamental component of ASCVD prevention, and CAC is an important tool for personalized risk assessment. The study by Kugathasan et al represents a first step in improving our understanding of the prevalence of subclinical disease in adults with SMI. Further study is needed to understand the determinants of CAC in adults with SMI and how the CAC burden relates to future cardiovascular risk.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Tamar S. Polonsky, MD, MSCI, Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC6080, Chicago, IL 606037. Email [email protected]bsd.uchicago.eduReferences1. 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Circulation: Cardiovascular Imaging. 2019;12 March 2019Vol 12, Issue 3 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.119.008861PMID: 30866648 Originally publishedMarch 14, 2019 Keywordsrisk factorsEditorialshumanscalciumadultPDF download Advertisement SubjectsCardiovascular DiseaseEpidemiologyMental HealthRisk Factors