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Original research
Hypertension attenuates the prognostic value of coronary artery calcification scoring in low-risk patients
  1. Edd Maclean1,
  2. Joban Sehmi2,
  3. Gajen Kanaganayagam3,
  4. Edward David Nicol4,5
  1. 1 William Harvey Research Institute, Queen Mary University of London, London, UK
  2. 2 Department of Cardiology, West Hertfordshire Hospitals NHS Trust, Watford, UK
  3. 3 Imperial College London, International Centre for Circulatory Health, London, UK
  4. 4 Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  5. 5 National Heart and Lung Institute, Imperial College, London, UK
  1. Correspondence to Dr Edward David Nicol, Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NJ, UK; e.nicol{at}


Objectives In outpatients with suspected ischaemic symptoms, we investigated the impact of risk factor profile on the prognostic value of coronary artery calcium scoring (CACS) and CT coronary angiography (CTCA).

Methods 772 consecutive patients underwent CACS and CTCA; 52 patients (6.7%) with significant coronary artery lesions underwent revascularisation within 60 days and were excluded. 720 remaining patients were followed up for 38.1±17.4 months.

Results Late presentation (after 60 days) major adverse cardiovascular events (MACEs) were recorded in 27 patients (3.8%). Hypertension was strongly associated with adverse outcomes (unadjusted HR 6.5 (2.9 to 14), p<0.001), and hypertensive patients had double the prevalence of non-calcified plaque versus normotensive individuals (30.2% vs 14.3%, p<0.001). Adjusting for confounders, severe stenosis at CTCA was predictive of MACE for normotensive and hypertensive patients (HR 9.6 (2.8 to 43.1), p<0.001, and HR 6.2 (2.4 to 16.1), p<0.001, respectively). CACS alone was not predictive of MACE throughout the cohort (HR 1.001 (0.9997 to 1.001), p=0.36) and when adjusting for confounders, a cut-off of CACS>400 predicted MACE in normotensive individuals (HR 10.6 (2.41 to 49.3), p<0.001) but not in hypertensive individuals (HR 1.3 (0.5 to 3.6), p=0.56). Zero calcium score did not mitigate the risk of MACE (HR 0.84 (0.39 to 1.8), p=0.65) and 13/27 patients (48.1%) who suffered MACE had a 0 calcium score; all had hypertension.

Conclusions In low-risk patients with stable cardiovascular symptoms, CTCA provides important additive prognostic information over CACS, and CACS (including CACS>400) underestimated cardiovascular risk in patients with hypertension. This may relate to the increased prevalence of non-calcified plaque in these individuals.

  • cardiac computer tomographic (CT) imaging
  • hypertension
  • chronic coronary disease

Data availability statement

Data are available upon reasonable request.

Statistics from

Data availability statement

Data are available upon reasonable request.

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  • Contributors All authors contributed to study conception, data collection and analysis. All authors approved the final manuscript. EN is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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