TY - JOUR
T1 - Association between hypercholesterolemia and mortality risk among patients referred for cardiac imaging test
T2 - Evidence of a “cholesterol paradox?”
AU - Rozanski, Alan
AU - Han, Donghee
AU - Blaha, Michael J.
AU - Gransar, Heidi
AU - Friedman, John
AU - Hayes, Sean
AU - Thomson, Louise E.J.
AU - Miedema, Michael D.
AU - Nasir, Khurram
AU - Budoff, Matthew J.
AU - Shaw, Leslee J.
AU - Rumberger, John A.
AU - Blumenthal, Roger S.
AU - Villines, Todd
AU - Lin, Fay
AU - Berman, Daniel S.
N1 - Funding Information:
This work was supported in part by the Dr. Miriam and Sheldon G Adelson Medical Research Foundation.
Funding Information:
This work was supported in part by the Dr. Miriam and Sheldon G Adelson Medical Research Foundation. Dr. Berman participates in software royalties for QPS software at Cedars-Sinai Medical Center. Dr. Blaha reports grants from the National Institutes of Health, U.S. Food and Drug Administration, American Heart Association, and Aetna Foundation ; grants and personal fees from Amgen; and personal fees from Sanofi, Regeneron, Novartis, Bayer, and Novo Nordisk outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Funding Information:
This work was supported in part by the Dr. Miriam and Sheldon G Adelson Medical Research Foundation. Dr. Berman participates in software royalties for QPS software at Cedars-Sinai Medical Center. Dr. Blaha reports grants from the National Institutes of Health, U.S. Food and Drug Administration, American Heart Association, and Aetna Foundation; grants and personal fees from Amgen; and personal fees from Sanofi, Regeneron, Novartis, Bayer, and Novo Nordisk outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Publisher Copyright:
© 2022
PY - 2022/9/1
Y1 - 2022/9/1
N2 - Aim: Some observational studies have observed a lower, rather than higher, mortality rate in association with hypercholesterolemia during follow-up of patients after cardiac stress testing. We aim to assess the relationship of hypercholesterolemia and other CAD risk factors to mortality across a wide spectrum of patients referred for various cardiac tests. Methods and results: We identified four cardiac cohorts: 64,357 patients undergoing coronary artery calcium (CAC) scanning, 10,814 patients undergoing coronary CT angiography (CCTA), 31,411 patients without known CAD undergoing stress/rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), and 5051 patients with known CAD undergoing stress/rest SPECT-MPI. Each cohort was followed for all-cause mortality using risk-adjusted Cox models. We pooled the hazard ratios between cohorts with a random effects model. Baseline risk varied markedly among cohorts, from an annualized mortality rate of 0.31%/year in CAC patients to 3.63%/year among SPECT-MPI patients with known CAD. Hypertension, diabetes, and smoking were each associated with increased mortality in each patient cohort (pooled hazard ratio[95% CI]: 1.38[1.33–1.44], 1.88[1.76–2.00], and 1.67[1.48–1.86], respectively). By contrast, hypercholesterolemia was associated with decreased rather than increased mortality (pooled hazard ratio[95% CI]: 0.71[0.58–0.84]). Analysis of serum lipids among 7744 patients undergoing CAC or CCTA scanning revealed an inverse relationship between LDL cholesterol and mortality. Conclusions: Among a broad spectrum of patients referred for a variety of cardiac tests and ranging from low to high clinical risk, hypercholesterolemia was not associated with increased mortality risk. Our findings suggest that hypercholesterolemia may be sensitive to confounding by other clinical factors and post-test treatment changes in patient populations.
AB - Aim: Some observational studies have observed a lower, rather than higher, mortality rate in association with hypercholesterolemia during follow-up of patients after cardiac stress testing. We aim to assess the relationship of hypercholesterolemia and other CAD risk factors to mortality across a wide spectrum of patients referred for various cardiac tests. Methods and results: We identified four cardiac cohorts: 64,357 patients undergoing coronary artery calcium (CAC) scanning, 10,814 patients undergoing coronary CT angiography (CCTA), 31,411 patients without known CAD undergoing stress/rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), and 5051 patients with known CAD undergoing stress/rest SPECT-MPI. Each cohort was followed for all-cause mortality using risk-adjusted Cox models. We pooled the hazard ratios between cohorts with a random effects model. Baseline risk varied markedly among cohorts, from an annualized mortality rate of 0.31%/year in CAC patients to 3.63%/year among SPECT-MPI patients with known CAD. Hypertension, diabetes, and smoking were each associated with increased mortality in each patient cohort (pooled hazard ratio[95% CI]: 1.38[1.33–1.44], 1.88[1.76–2.00], and 1.67[1.48–1.86], respectively). By contrast, hypercholesterolemia was associated with decreased rather than increased mortality (pooled hazard ratio[95% CI]: 0.71[0.58–0.84]). Analysis of serum lipids among 7744 patients undergoing CAC or CCTA scanning revealed an inverse relationship between LDL cholesterol and mortality. Conclusions: Among a broad spectrum of patients referred for a variety of cardiac tests and ranging from low to high clinical risk, hypercholesterolemia was not associated with increased mortality risk. Our findings suggest that hypercholesterolemia may be sensitive to confounding by other clinical factors and post-test treatment changes in patient populations.
KW - Atherosclerosis
KW - Cardiac risk factors
KW - Coronary artery disease
KW - Hypercholesterolemia
KW - Coronary Artery Disease/diagnostic imaging
KW - Myocardial Perfusion Imaging/methods
KW - Prognosis
KW - Humans
KW - Tomography, Emission-Computed, Single-Photon/methods
KW - Coronary Angiography/methods
KW - Cholesterol
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U2 - 10.1016/j.pcad.2022.10.007
DO - 10.1016/j.pcad.2022.10.007
M3 - Article
C2 - 36272449
AN - SCOPUS:85142798903
SN - 0033-0620
VL - 74
SP - 60
EP - 69
JO - Progress in Cardiovascular Diseases
JF - Progress in Cardiovascular Diseases
ER -