Multisite atherosclerosis in subjects with metabolic syndrome and diabetes and relation to cardiovascular events: The Multi-Ethnic Study of Atherosclerosis


      • Persons with diabetes or metabolic syndrome have more atherosclerotic sites.
      • Cardiovascular disease rates are greater the number of atherosclerotic sites.
      • Those with 4 vs. 0 atherosclerotic sites have a 4–14-fold greater risk of CVD events.
      • Multisite atherosclerosis adds to CVD event prediction, except over coronary calcium.


      Background and aims

      The extent and relation of multisite atherosclerosis to cardiovascular disease (CVD) in metabolic syndrome (MetS) and diabetes (DM) are not well documented. We examined the extent of multisite atherosclerosis and its prognostic value for CVD events in MetS and DM.


      In CVD-free subjects from the Multi-Ethnic Study of Atherosclerosis, multisite atherosclerosis was measured as: (1) the number of arterial beds involved (coronary calcium>0, abdominal aortic calcium>0, carotid intima-media thickness ≥1 mm and ankle brachial index<1 or ≥1.4); (2) a composite score summing the quartile rank for each atherosclerosis measure. Hazard ratios (HRs) and c-statistics were calculated for incident CVD and coronary heart disease (CHD) over 10.6 years.


      Of 1675 individuals (mean age 64 years, 51% male), 33.4% had MetS and 15.9% had DM. The number of atherosclerotic sites was higher in those with DM (mean ± SD = 1.67 ± 1.15) and MetS (1.49 ± 1.12) versus neither MetS/DM (1.09 ± 1.09) (p < 0.0001). CVD rates per 1000 person-years ranged from 3.5, 8.2, and 10.0 in those with 0 sites positive to 35.1, 79.6 and 103.4 in those with 4 sites positive among neither DM/MetS, MetS and DM groups, respectively. HRs (95% CI) for CVD comparing those with 4 vs. 0 atherosclerotic sites were 4.0 (0.8–19.1), 4.9 (2.0–12.0), and 14.4 (3.6–57.6), respectively. C-statistics adding multisite atherosclerosis measures increased over models without the measures and with CIMT or ABI but not CAC.


      Multisite atherosclerosis is greater with MetS or DM, and predicts CVD and CHD events. Risk prediction is improved over CIMT and ABI but not CAC.

      Graphical abstract



      AAC (abdominal aortic calcium), CAC (coronary artery calcium), CHD (coronary heart disease), CIMT (carotid intimal-medial thickness), CVD (cardiovascular disease), DM (diabetes mellitus), MetS (metabolic syndrome), PCE (pooled cohort equation)
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      Linked Article

      • Coronary calcium is not all we need: Carotid plaque burden measured by ultrasound is better
        AtherosclerosisVol. 287
        • Preview
          In a paper from the Multi-Ethnic Study of Atherosclerosis, Zhao et al. [1] reported that coronary calcium scores predicted most of the risk of cardiovascular events, with little contribution of carotid intima-media thickness (IMT) and ankle-brachial index. In the accompanying editorial, Paolo Raggi stated “Coronary calcium is all we need for risk assessment, yet we do not use it often enough” [2]. He is right that assessing burden of atherosclerosis is much better for predicting risk than calculations from panels of risk factors, and that coronary calcium is much better than IMT and ankle-brachial index.
        • Full-Text
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      • Coronary calcium is all we need for risk assessment, yet we do not use it often enough
        AtherosclerosisVol. 282
        • Preview
          In an investigation published in this issue of Atherosclerosis, Zhao et al. [1] tested the hypothesis that atherosclerosis detected at multiple sites provides important prognostic information in patients with and without cardiometabolic disorders followed for an average of 10.5 years from screening. In 1675 patients enrolled in the Multi Ethnic Study of Atherosclerosis (MESA), they performed computed tomography (CT) imaging of the coronary arteries and aorta and measured their respective calcium scores.
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