Risk of coronary artery disease in adults with congenital heart disease: A comparison with the general population

doi:10.1016/j.ijcard.2019.11.114

International Journal of Cardiology

Volume 304, 1 April 2020, Pages 39-42

https://doi.org/10.1016/j.ijcard.2019.11.114 Get rights and content

Highlights

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Coronary artery disease risk was low in adult congenital heart disease patients.
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Coronary artery disease risk was increased compared to the general population.
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Relative risk was greater at younger age and in women.
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Relative risk was greater in those with more severe congenital heart disease.

Abstract

Background

Coronary artery disease (CAD) will increasingly determine outcome in the aging adult congenital heart disease (CHD) population. We aimed to determine sex-specific incidence of CAD in adult CHD patients throughout adulthood, compared to the general population.

Methods and results

We followed 11,723 adult CHD patients (median age 33 years; 49% male; 57% mild, 34% moderate, 9% severe CHD) from the Dutch CONCOR registry, and two age-sex-matched persons per patient from the general population for first CAD event in national registers (period 2002–2012). Incidence rates were estimated using smoothed hazard functions. CAD risk during follow-up, stratified by CHD severity, was compared using proportional subdistribution hazards regression. In ACHD patients, 103 CAD events (43 women) occurred over 60,456 person-years. Rates per 1000person-years increased from 0.3(95% confidence interval: 0.1–0.6) at age 20 to 5.8(3.7–8.9) at 70 years in female, and from 0.5(0.3–1.0) to 7.8(5.1–11.8) in male patients. Compared to the general population, relative risk was 12.0(2.5–56.3) in women and 4.6(1.7–12.1) in men aged 20 years. Relative risk declined with age, remaining significant up to age ~65 years in women and ~50 years in men. In patients with mild, moderate and severe CHD, CAD risk was 1.3(0.9–1.9), 1.6(1.0–2.5) and 2.9(1.3–6.9) times increased compared to the general population, respectively.

Conclusions

We found increased CAD risk in adult CHD patients, with greater relative risk at younger age, in women and those with more severe CHD. These results underline the importance of screening for and treatment of CAD risk factors in these patients.

Introduction

In the aging adult congenital heart disease (ACHD) population, prognosis is increasingly determined by acquired coronary artery disease (CAD) [[1], [2], [3]]. Thus, it is important to determine CAD incidence in ACHD patients. Recent population-based CHD studies reported increased incidence of ischemic heart disease in children and adults with CHD [[4], [5], [6]]. No studies have yet reported sex- and age-specific CAD incidence rates from early to late adulthood; we aimed to determine this, and CHD-severity specific cumulative CAD incidence, in ACHD patients compared to the general population.

Section snippets

Methods

The study conforms to the Declaration of Helsinki, and was approved by the ethics boards of participating centres.

Baseline characteristics

Supplemental table III shows characteristics of the ACHD patients; 6622 (56.5%), 4014 (34.2%) and 1087 (9.3%) had mild, moderate and severe CHD, respectively. Percentage males (overall: 48.8%) and median age at inclusion (overall: 32.9 years, interquartile range: 23.0–45.7) differed between mild (male: 45.5%; age: 36.1, 24.9–48.7), moderate (52.1%; 31.3, 22.3–43.6) and severe (56.9%; 23.5, 19.8–30.8) CHD (p < 0.001, all pairwise comparisons). Mean follow-up: 5.2 ± 3.1 years.

Incidence rates, compared with general population

In ACHD patients,

Discussion

We found increased CAD risk in ACHD patients compared to the general population. Small absolute risk-increases constituted considerable relative risks at young age (12.0 and 4.6 in women and men aged 20 years, respectively). CAD rates were higher in men throughout adulthood, but increased up to older age in women and remarkably lower than in the general population in older men (statistically non-significant). Cumulative CAD incidence was not significantly increased in mild, but ~2 and ~3 times

Declaration of competing interest

The authors report no relationships that could be construed as a conflict of interest.

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These risk factors for atherosclerotic disease in the non-congenital population are also associated with significant CVD/CAD risk elevation in those with CHD.7,8 Additionally, studies have shown that ACHD increases the risk and rates of CAD development.9,10 However, as demonstrated by Wang et al., it is unclear whether this association between CHD and CVD is confounded by a specific risk factor profile of CVD among CHD survivors, or whether CHD alone is an independent risk factor.11
Atherosclerotic coronary artery disease (CAD) is well-studied in acquired cardiac diseases; however, little data exist regarding outcomes of adult congenital heart disease (ACHD) with CAD. This study examined patients who underwent coronary artery bypass grafting (CABG) during repair of ACHD. This was a retrospective study of patients who underwent CABG for CAD concomitant with ACHD repair 1972-2021. Demographic information, ACHD diagnosis, surgical history, operative details, and outcomes were analyzed. Data are presented as median (interquartile range [IQR]). 157 patients were identified with a median age of 63 (IQR 17) years. Left anterior descending (LAD) was the predominant diseased artery (109 patients [69%]); of those 83 (76%) were treated with mammary artery. 90 (57.3%) patients had 1 bypass, 42 (26.7%) 2, 19 (12%) 3, and 6 (3.8%) had 4. There has been no early mortality since 1988. There was no long-term survival difference between the patients with LAD disease treated with mammary compared to vein (P = 0.68), but early mortality was higher in those treated with vein (10.3% vs 0%, P = 0.018). Late recurrent angina was found in 18 patients (12%) and recurrent CAD found in 17 patients (11%), with 16 patients (10%) requiring CAD reintervention. At most recent follow-up (7.2 [IQR 11.4] years), 101 (64.3%) patients were deceased at 10 (IQR 13.1) years after surgery. Surgical revascularization for CAD may be necessary during the treatment of ACHD, most commonly for LAD disease. Early mortality was low in recent decades. Continued surveillance for recurrent CAD is required.
Coronary artery disease in older adults with congenital heart defects: risk factors and pharmacotherapy
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¹: This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Short communicationRisk of coronary artery disease in adults with congenital heart disease: A comparison with the general population

Highlights

Abstract

Background

Methods and results

Conclusions

Introduction

Section snippets

Methods

Baseline characteristics

Incidence rates, compared with general population

Discussion

Declaration of competing interest

J. Am. Coll. Cardiol.

Am. Heart J.

Am. J. Cardiol.

Int. J. Cardiol.

J Cardiovasc Comput Tomogr

Am. J. Cardiol.

Congenital heart disease beyond the age of 60: emergence of a new population with high resource utilization, high morbidity, and high mortality

Eur. Heart J.

Substantial cardiovascular morbidity in adults with lower-complexity congenital heart disease

Circulation

Reilly M. bshazard: a flexible tool for nonparametric smoothing of the hazard function

R J

Factors associated with coronary artery disease and stroke in adults with congenital heart disease

Heart Br Card Soc

Short communication
Risk of coronary artery disease in adults with congenital heart disease: A comparison with the general population