Assessment of Coronary Artery Calcium Scoring to Guide Statin Therapy Allocation According to Risk-Enhancing Factors

Abstract

Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD. DESIGN, SETTING, AND PARTICIPANTS The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US.Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (Ն7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL. EXPOSURES Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index. MAIN OUTCOMES AND MEASURESIncident ASCVD over a median follow-up of 12.0 years. RESULTS A total of 1688 participants (mean [SD] age, 65 [6] years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067. CONCLUSIONS AND RELEVANCEIn this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhan...

Toxic Metals and Subclinical Atherosclerosis in Carotid, Femoral, and Coronary Vascular Territories: The Aragon Workers Health Study

“…12 Indeed, it has been recently suggested that coronary calcium can enhance the classification of individuals at intermediate risk of atherosclerotic CVD. 13 Therefore, a multiterritorial vascular assessment, which is being adopted by epidemiological studies on subclinical atherosclerosis, 11 provides a richer information compared with single territories assesment. 14 Using data of the AWHS (Aragon Workers Health Study), our study investigated, for the first time, the association of a panel of toxic metals (sum of inorganic arsenic, barium, cadmium, chromium, antimony, titanium, uranium, vanadium, and tungsten) as measured in urine, with a comprehensive panel of subclinical atherosclerosis measures, including atherosclerosis presence at the carotid, femoral, and coronary territories.…”

Implications of the 2019 American College of Cardiology/American Heart Association Primary Prevention Guidelines and potential value of the coronary artery calcium score among South Asians in the US: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study

“…Nevertheless, it must also be noted that 30% of them had CAC = 0. Although data on incident events are still not available in MASALA, prior analyses of Multi-Ethnic Study of Atherosclerosis (MESA) participants at intermediate risk and with up to three risk enhancing features reported low ASCVD event rates if CAC = 0 [13,14]. Moreover, analyses in MESA and other cohorts with low baseline statin use have reported low 10-year event rates also among individuals with CAC = 0 and prediabetes/metabolic syndrome, which are frequent risk factors in non-diabetic SAs [29,30].…”

“…First, as described above, the current lack of incident ASCVD data in MASALA mandates caution when extrapolating the protective prognosis associated with CAC = 0 to SA populations. Nonetheless, the favorable prognosis associated with CAC = 0 in MESA participants with other risk enhancing factors is reassuring [13,14]. Moreover, the favorable prognosis of CAC = 0 has also been confirmed in multiple other populations, including those considered at increased ASCVD risk [38].…”

“…Recent studies have shown, however, that there is marked risk heterogeneity among individuals at intermediate risk and with up to three risk enhancing factors (other than SA ethnicity). Specifically, a coronary artery calcium (CAC) score of zero is highly prevalent in these individuals, and is associated with low ASCVD event rates [13,14]. These findings suggest that even among individuals with prevalent risk enhancing features there is room for further risk assessment, potentially with tools such as CAC, for a more personalized allocation of chronic preventive statin therapy [15].…”

Value of addition of coronary artery calcium to risk scores in the prediction of major cardiovascular events in patients with type 2 diabetes

“…In these cases, the use of CACS may improve the allocation of newer therapies and identify patients at higher risk who will have greater benefit in risk reduction. However, although diabetic patients with zero calcium have good long-term prognosis, and recent findings suggest that among individuals at intermediate risk with risk-enhancing factors, cardiovascular event rates are generally lower than the recommended threshold to initiate statin therapy when the CACS is zero [ 25 ], statins should be given to diabetic patients according to current clinical guidelines until prospective studies are performed. The presence and severity of CACS was repeatedly shown to improve discrimination and reclassification of future cardiovascular risk when compared to traditional risk factors, including in patients with type 2 diabetes [ 20 , 26 , 27 ].…”