Asymptomatic, CT angiography-detected coronary artery disease associated with 8-fold increased risk for heart attack

1. Asymptomatic, CT angiography-detected coronary artery disease associated with 8-fold increased risk for heart attack 

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3027    

Editorial: https://www.acpjournals.org/doi/10.7326/M23-0533    

URL goes live when the embargo lifts 

A cohort study of more than 9,000 persons found that in asymptomatic middle-aged persons without known cardiovascular disease, subclinical, obstructive coronary atherosclerosis is associated with a more than 8-fold elevated risk for myocardial infarction. The findings are published in Annals of Internal Medicine.  

Coronary atherosclerosis is a biological process responsible for the development of myocardial infarction. These conditions together define the clinical syndrome “ischemic heart disease.” Subclinical coronary atherosclerosis precedes ischemic heart disease and may evolve at an early age, many years before clinical disease develops. For more than 50 years, obstructive coronary artery disease, defined 

as a luminal coronary stenosis of 50% or greater, has been considered a key feature of elevated risk. In the past decades, however, the extent of atherosclerosis in the coronary tree as well as specific morphologic features of the atherosclerotic plaque have been acknowledged as important risk factors. 

Researchers from the University of Copenhagen, Copenhagen, Denmark studied 9,533 asymptomatic persons aged 40 years or older without known cardiovascular disease to define characteristics of subclinical coronary atherosclerosis associated with the development of myocardial infarction. Participants were assessed using computed tomography angiography (CTA) to diagnose obstructive coronary atherosclerosis. The authors found that 54 percent of persons had no subclinical coronary atherosclerosis. Among the 46 percent of persons diagnosed with subclinical coronary atherosclerosis, 36 percent had nonobstructive disease and 10 percent had obstructive disease. Among persons diagnosed with the condition, subclinical coronary atherosclerosis was also found in 61 percent of male participants and 36 percent of women. According to the authors, identification of luminal obstructive or extensive subclinical coronary atherosclerosis provides potentially clinically relevant, incremental risk assessment in patients without suspected or known ischemic heart disease undergoing cardiac CT and/or electrocardiogram-gated chest CT for other clinical indications. 

An accompanying editorial by authors from the BHF Centre for Cardiovascular Science, University of Edinburgh highlights that this research provides an opportunity to study the contemporary natural history of coronary artery disease in the absence of intervention, where neither patient nor clinician are aware of scan findings. The authors add that the study also provides invaluable data about event rates and prevalence of asymptomatic coronary artery disease that will inform public health prevention strategies and ongoing clinical trials of targeting preventative therapies in persons screened for occult coronary artery disease.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Klaus Fuglsang Kofoed, MD, PhD, DMSc, please email Klaus.Kofoed@regionh.dk.  

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2. Inclusion of Medicare Advantage beneficiaries substantially changes hospital performance rankings  

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3165   

URL goes live when the embargo lifts  

A cross-sectional analysis of hospitals found that one in four hospitals were reclassified to lower performance groups when Medicare Advantage (MA) beneficiaries were included the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. It also raises concern that some hospitals may be unfairly penalized by the Medicare program due to potential misclassification of hospital performance. The analysis is published in Annals of Internal Medicine.  

Medicare links hospital performance on readmissions and mortality to payment solely based on outcomes among fee-for-service (FFS) beneficiaries. Whether including MA beneficiaries, who now account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.  

Researchers from the Harvard T.H. Chan School of Public Health and Beth Israel Deaconess Medical Center conducted a cross-sectional analysis of hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. They then calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia based on only FFS beneficiaries and then both FFS and MA beneficiaries. The authors found the hospitals in the top-performing group for readmissions and mortality based on FFS beneficiaries, between 21.6 and 30.2 percent were reclassified to a lower-performing group with the inclusion of MA beneficiaries. They also found that a similar percentage of low-performing hospitals were reclassified to higher-performing groups using the same criteria. According to the authors, their findings have important policy implications for federal efforts to evaluate hospital quality, particularly because MA is expected to soon be the dominant source of Medicare coverage in the United States.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Jose F. Figueroa, MD, MPH, at jfigueroa@hsph.harvard.edu. 

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