To the Editors,
Inflammatory bowel disease (IBD) patients are at increased risk for atherosclerotic cardiovascular disease (ASCVD).1,2 Claxton and colleagues reported a case with IBD that developed myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) as assessed by CT coronary angiogram (CTA).3 Calcium scores and the nature of coronary plaque by CTA can predict ASCVD events in the general population.4 The role of CTA has not been studied in IBD. We did the first study to assess nature of plaque in IBD patients by CTA.
We retrospectively identified IBD patients who had undergone CTA at a single tertiary care center. Patients with chronic inflammatory disorders, HIV, malignancy, and familial hypercholesterolemia were excluded. Data regarding demographics, ASCVD traditional risk factors, and IBD disease activity and medications (nontraditional risk factors) were collected (Table 1). Primary outcomes were mean coronary artery calcium (CAC) score, clinical ASCVD risk scores (American Heart Association/American College of Cardiology 10-year risk and MESA-CAC), and plaque assessment by CTA determined by the number of coronary segments with calcified, noncalcified, or mixed plaque (segment involvement score [SIS]). Secondary outcomes were major cardiovascular events and total CV outcomes. We also compared outcomes after age stratification. (Table 1)
Table 1.
Demographics, traditional, and nontraditional risk factors for ASCVD, and primary and secondary outcomes.
| Total IBD (N = 28) |
UC (N = 9) |
CD (N = 19) |
P | |
|---|---|---|---|---|
| Age (at time of CTA), mean (SD) | 55.6 (14.5) | 58.4 (11.8) | 54.2 (15.7) | 0.5 |
| Age at IBD diagnosis, mean (SD) | 40.6 (16.2) | 50.6 (17.9) | 35.8 (13.4) | 0.02 |
| Gender, N (%) | >0.9 | |||
| Female | 20 (71.4) | 7 (77.8) | 13 (68.4) | |
| Male | 8 (28.6) | 2 (22.2) | 6 (31.6) | |
| Race | 0.7 | |||
| White | 25 (89.3) | 9 (100.0) | 16 (84.2) | |
| Black | 2 (7.1) | 0 (0.0) | 2 (10.5) | |
| Native Hawaiian or Other Pacific Islander | 1 (3.6) | 0 (0.0) | 1 (5.3) | |
| Traditional risk factors, N (%) | ||||
| BMI, N (%) | 0.3 | |||
| Normal | 7 (25.0) | 1 (11.1) | 6 (31.6) | |
| Underweight | 1 (3.6) | 1 (11.1) | 0 (0.0) | |
| Overweight/Obese | 20 (71.4) | 7 (77.8) | 13 (68.4) | |
| Family history of CVD, N (%) | 19 (67.9) | 5 (55.6) | 14 (73.7) | 0.4 |
| HTN, N (%) | 14 (50.0) | 7 (77.8) | 7 (36.8) | 0.1 |
| DM, N (%) | 3 (10.7) | 0 (0.0) | 3 (15.8) | 0.5 |
| CKD, N (%) | 2 (7.1) | 1 (11.1) | 1 (5.3) | >0.9 |
| HLD, N (%) | 18 (64.3) | 8 (88.9) | 10 (52.6) | 0.1 |
| Smoking history, N (%) | 0.5 | |||
| Current | 2 (7.4) | 1 (11.1) | 1 (5.6) | |
| Former | 10 (37.0) | 2 (22.2) | 8 (44.4) | |
| Never | 15 (55.6) | 6 (66.7) | 9 (50.0) | |
| Alcohol use, N (%) | 0.7 | |||
| Never | 10 (35.7) | 3 (33.3) | 7 (36.8) | |
| Occasional | 14 (50.0) | 4 (44.4) | 10 (52.6) | |
| Low risk/High risk | 4 (14.3) | 2 (22.2) | 2 (10.5) | |
| Nontraditional Risk Factors, Mean (SD) or N (%) | ||||
| Prior bowel surgery, N (%) | 14 (50.0) | 4 (44.4) | 10 (52.6) | >0.9 |
| Montreal Classification: UC, N (%) | 0.01 | |||
| E1—Proctitis | 1 (9.1) | 1 (12.5) | NA | |
| E2—Left-sided | 3 (27.3) | 3 (37.5) | ||
| E3—Extensive | 4 (36.4) | 4 (50.0) | ||
| Montreal Classification: CD, N (%) | 0.005 | |||
| L1—Ileal | 5 (23.8) | NA | 5 (26.3) | |
| L1, L4—Ileal, UGI | 1 (4.8) | 1 (5.3) | ||
| L2—Colonic | 6 (28.6) | 6 (31.6) | ||
| L3—Ileocolonic | 7 (33.3) | 7 (36.8) | ||
| Disease type: CD, N (%) | 0.005 | |||
| B1—Non-stricturing, non-penetrating | 12 (57.1) | NA | 12 (57.1) | |
| B2—Stricturing | 4 (19.0) | 4 (190) | ||
| B2, B3, P—Stricturing, penetrating, or perianal | 3 (14.3) | 3 (14.3) | ||
| Age at CD diagnosis, N (%) | 0.3 | |||
| A1 - < 16 | 2 (7.1) | 0 (0.0) | 2 (11.8) | |
| A2 - 17- 40 | 13 (46.4) | 3 (33.3) | 10 (52.6) | |
| A3 - > 40 | 13 (46.4) | 6 (66.7) | 7 (36.8) | |
| Disease by imaging CT or MR within 1 year of CTA, N (%) | >0.9 | |||
| Active | 2 (33.3) | 1 (50.0) | 1 (25.0) | |
| Inactive | 4 (66.7) | 1 (50.0) | 3 (75.0) | |
| Primary Outcomes, Mean (SD) or N (%) | ||||
| CAC score, Mean (SD) | 194.0 (554.0) | 137.9 (403.2) | 220.5 (621.2) | 0.7 |
| ASCVD score, Mean (SD) | 14.4 (14.0) | 12.5 (11.7) | 15.4 (16.0) | 0.8 |
| MESA CAC score, Mean (SD) | 7.9 (8.6) | 5.4 (7.9) | 9.7 (9.2) | 0.4 |
| Age-stratified MESA CAC score, Mean (SD) | <0.05* | |||
| <65 (N = 20) | 3.6 (4.4) | 1.4 (0.3) | 4.9 (5.3) | |
| ≥65 (N = 8) | 13.8 (9.9) | 9.5 (10.4) | 18.0 (8.9) | |
| CTA Parameters | ||||
| CTA indication, N (%) | 13 (46.4) | 5 (55.6) | 8 (42.1) | 0.5 |
| Chest pain | 4 (14.3) | 0 (0.0) | 4 (21.1) | 0.1 |
| Dyspnea on exertion | 2 (22.2) | 2 (22.2) | 7 (36.8) | 0.4 |
| Abnormal stress test | 3 (33.3) | 5 (26.3) | 8 (28.6) | 0.7 |
| Other | ||||
| Age at CTA, N (%) | 0.3 | |||
| <45 years | 8 (28.6) | 1 (11.1) | 7 (36.8) | |
| 45-65 years | 12 (42.9) | 5 (55.6) | 7 (36.8) | |
| >65 years | 8 (28.6) | 3 (33.3) | 5 (26.3) | |
| Atherosclerosis in CTA, N (%) | 10 (35.7) | 3 (33.3) | 7 (36.8) | >0.9 |
| Total SISa mean (SD) | 1.8 (3.1) | 1.8 (3.7) | 1.8 (3.0) | >0.9 |
| Age-stratified SIS,a mean (SD) | ||||
| <65 (N = 20) | 0.9 (2.4) | 1.4 (0.3) | 4.9 (5.3) | <0.05* |
| ≥65 (N = 8) | 4.1 (3.7) | 3.7 (6.4) | 4.4 (1.9) | |
| Secondary outcomes, N (%) | ||||
| MACE after CTAb | 5 (17.9) | 1 (11.1) | 4 (21.1) | >0.9 |
| Total CV outcomes after CTAb | 8 (28.6) | 1 (11.1) | 7 (36.8) | 0.2 |
aSIS, Segment involvement score: total segments involved with noncalcified, calcified or mixed plaque.
bMACE after CCTA: non-fatal MI, nonfatal stroke, coronary revascularization, or CV death.
*Statistically significant.
Total CV outcomes after CTA: MACE + Heart failure + PAD + arrhythmia + mesenteric ischemia.
Nine ulcerative colitis (UC) and 19 Crohn’s disease (CD) patients went CTA. There were no significant differences in demographic, traditional, and non-traditional risk factors for ASCVD between UC and CD patients, except that UC patients were older at the time of diagnosis. (Table 1) Most patients had IBD for >10 years. All patients had inactive disease within 1 year of CTA; 35% of patients used biologics, with only 10% on active steroids; 35% of patients had a positive CTA for atherosclerosis as assessed by the presence of plaque (N = 10) and CAC >0 (CAC 1-99, N = 3; CAC >100, N = 7). There was no difference in primary and secondary outcomes between UC and CD. However, when stratified by age, MESA-CAC and total SIS were higher in the age group of IBD and CD patients 65 years and older, suggesting higher atherosclerotic risk with advanced age in this cohort (Table 1).
In this first study assessing coronary plaque in IBD patients by CTA, one-third of patients had atherosclerosis. There was no difference in the nature of plaque between UC and CD. However, older IBD and CD patients with primarily inactive disease had higher plaque burden by SIS. Assessment of coronary plaque and ASCVD risk in IBD are needed in larger prospective studies.
Contributor Information
Malek Ayoub, Department of Medicine, Washington University, St. Louis, MO, USA; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Harini Shah, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Bao Chau Nguyen, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA.
Maahum Mehdi, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Sneha Nagavally, Department of Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
April Dawson, Department of Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
Sadeer Al-Kindi, Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH, USA.
Salim Virani, Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center and Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA.
Divyanshu Mohananey, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Abhinav Sharma, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Preetika Sinh, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA.
Funding
SV: Grant support: Department of Veterans Affairs, NIH, Tahir and Jooma Family, Honorarium; AD: American Diabetes Association;11-22-JDFHD-01.
Conflicts of Interest
SV: American College of Cardiology (Associate editor for Innovations, acc.org).
References
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