Coronary Inflammation Highest in Socioeconomically Deprived Areas: ORFAN

WASHINGTON, DC—People living in areas with the highest levels of socioeconomic deprivation have more coronary inflammation identified on coronary CT angiography (CCTA) than those living in the least deprived areas, an analysis of the Oxford Risk Factors and Noninvasive Imaging (ORFAN) study shows.

Moreover, the degree of inflammation corresponds with the risk of cardiac mortality over the next several years, irrespective of socioeconomic status, Kenneth Chan, MBBS (University of Oxford, England), reported here Friday at the 2024 Society of Cardiovascular Computed Tomography (SCCT) meeting.

“This highlights the critical role of coronary inflammation as a potential therapeutic target in cardiovascular prevention,” he concluded, suggesting that it may have a role in helping to “address the inequality in the risks.”

Previously, the ORFAN investigators showed that greater coronary inflammation measured on routine CT scans with the assistance of artificial intelligence (AI) signals significantly increased risks of cardiac mortality and MACE over the next several years, even after adjustment for other cardiovascular risk factors and the presence or extent of CAD.

The current analysis focused on socioeconomic aspects, which are often underrecognized determinants of cardiovascular health, Chan told TCTMD, noting that about two-thirds of the global CVD burden lies in low- and middle-income countries. He and his colleagues explored whether coronary inflammation could further stratify risk within socioeconomic groups, with the aim of identifying patients who are at a particularly high risk for cardiac problems.

“Inflammation measured noninvasively on CT scans, which are increasingly used as the first diagnostic test for patients with chest pain, might have a role in picking up the inflammatory risk in both deprived and nondeprived cohorts, and that would help us to start preventative treatment, which might have an impact on narrowing the gap between the socioeconomic groups,” he said.

Stratifying Risk Beyond Socioeconomic Status

The ORFAN study has a goal of including about 250,000 patients undergoing CCTA as part of routine clinical care from centers around the world. That will include 200,000 from UK hospitals, and about half have been enrolled so far, Chan said. Clinical outcomes are tracked through linkage to national registries.

The current analysis focused on 33,365 patients with stable CAD who underwent CCTA in England between 2010 and 2021. The assessment of socioeconomic deprivation was based on seven domains—income, employment, education, health, living environment, barriers to housing and services, and crime—and was used to rank nearly 33,000  English regions from least to most deprived.

Over a median follow-up of 4.8 years, risk of cardiac mortality increased along with higher levels of deprivation. Compared with individuals living in the least deprived areas, those in the most deprived had an 82% greater risk of dying from a cardiac cause (HR 1.82; 95% CI 1.52-2.20).

The findings were similar when looking at premature cardiac mortality (before age 75), although the relationships with deprivation were stronger.

The investigators then explored the impact of coronary inflammation. Through AI-assisted postprocessing of the CT scans, CaRi-Heart technology (Caristo Diagnostics) detected inflammation and calculated a fat attenuation index (FAI) score for each coronary vessel.

Though the proportion of patients with obstructive coronary disease did not differ across deprivation categories, inflammation did. For the left anterior descending, left circumflex, and right coronary arteries, the FAI score was highest—indicating the greatest degree of inflammation—among the individuals living in the most deprived areas.

And having a greater number of inflamed arteries conferred even higher risks regardless of where an individual lived. In the most deprived group, having three inflamed arteries versus none carried more than a tenfold greater risk of cardiac mortality during follow-up (HR 10.5; 95% CI 7.5-14.7), a relationship that was even stronger among in the least deprived group (HR 22.2; 95% CI 14.5-33.8).

The FAI score was independently associated with cardiac mortality across all three arteries and across subgroups defined by sex, ethnicity, deprivation ranking, and the presence of obstructive CAD.

Equity in Healthcare Delivery

Delivering commentary after Chan’s presentation, Kavitha Chinnaiyan, MD (Oakland University William Beaumont School of Medicine, Royal Oak, MI), co-chair of the SCCT meeting program committee, reflected on the broader implications, noting that the use of cardiac CT continues to increase.

“Here at this threshold of this incredible opportunity that we have in increased application, the most important question we need to ask is [about] the equity of healthcare delivery,” she said. “It is not really about should we be doing more CT but [about] the judicious and appropriate use of CT, and particularly its use in populations that would most benefit from it.”

She noted that low socioeconomic status is linked to psychosocial stress, a risk factor for cardiac disease.

There are numerous questions around how best to improve the application of cardiac CT, Chinnaiyan said, adding that “as we move forward, SCCT is also reconsidering our vision and our strategy for equitable healthcare delivery and judicious use of cardiac CT.”

And she suggested that Chan’s presentation is reflective of an opportunity for expanding the reach of CCTA. “It’s so important that we have now seen the application of not just ‘Is there stenosis and should this patient go to the cath lab?’ but really a far more upstream application of this technology.”

Chan noted that integration of the FAI score into daily clinical practice is being piloted at seven UK hospitals, which will provide some insights into how this information influences clinicians’ decision-making and impacts patient outcomes.