Coronary Artery Calcium Scoring for Risk Assessment in Patients With Severe Hypercholesterolemia

https://doi.org/10.1016/j.amjcard.2022.10.060Get rights and content

The American College of Cardiology and the American Heart Association guidelines recommend treatment of patients with severe hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/100 ml) with a high-intensity statin. However, atherosclerotic cardiovascular disease (ASCVD) risk, even among those with severe hypercholesterolemia, is heterogeneous, and coronary artery calcium (CAC) scoring may be used to clarify risk. We sought to evaluate CAC in patients with severe hypercholesterolemia and measure its impact on real-world statin prescriptions. We identified patients with at least 1 LDL-C ≥190 mg100 ml who had a CAC scoring in the Community Benefit of No-Charge Calcium Score Screening Program (CLARIFY) study (NCT04075162) between 2014 and 2020. We explored the CAC distribution, factors associated with CAC >0, and ASCVD risk (myocardial infarction, stroke, revascularization, death). A total of 1,904 patients (1.257 women, aged 57.8 ± 9.3 years) with severe hypercholesterolemia were included. LDL-C ranged from 190 to 524 mg100 ml (mean 215.5 ± 27 mg100 ml). A total of 864 patients (45.4%) had CAC = 0 and 1,561 (82%) had CAC <100. In patients with LDL-C ≥250 mg100 ml, 67 (36.6%) had CAC = 0. Age, male gender, smoking, diabetes, systolic blood pressure, and obesity (ps ≤0.001) were associated with CAC >0. In patients with LDL-C ≥190 mg100 ml, CAC was associated with a higher risk for ASCVD events (CAC ≥100 vs CAC <100, hazard ratio 3.57 [1.81 to 7.04], p <0.001). A higher CAC category was associated with increased statin use after CAC scoring (p <0.001). In patients with severe hypercholesterolemia, 45% had CAC = 0, which was associated with a significantly lower ASCVD risk. CAC was associated with statin prescription and cholesterol lowering. In conclusion, CAC scoring may be used to clarify ASCVD risk in this heterogeneous population with severe hypercholesterolemia.

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Methods

Patients were enrolled from the CLARIFY (Community Benefit of No-Charge Calcium Score Screening Program) study (ClinicalTrials.gov identifier: NCT04075162). The CLARIFY study enrolled 52,214 patients from 2014 to 2020, with at least 1 CV risk factor but without previous atherosclerotic CV disease, in a large health system (University Hospitals) in Cleveland, Ohio.8 CAC was offered at low charge ($99, January 2014 to December 2016) or no charge (January 2017 to current). All patients underwent

Results

Of the 52,214 patients included in the CLARIFY study, 1,904 participants (3.6%) had at least 1 measured LDL-C ≥190 mg/100 ml (1,257 women, 647 men, aged 57.8 ± 9.3 years). LDL-C ranged from 190 to 524 mg/100 ml (mean 215.5 ± 27 mg/100 ml). Overall, 864 patients (45.4%) had a CAC = 0 and 1,561 patients (82%) with CAC <100. Baseline characteristics for all patients, stratified by CAC category (0, 1 to 99, 100 to 399, 400+) are reported in Table 1. Prevalent CAC was associated with older age, male

Discussion

To the best of our knowledge, this is the largest study investigating the role of CAC in real-world cohort of patients with severe dyslipidemia. Our study demonstrates that CAC provides value in risk stratification for patients with severe hypercholesterolemia (LDL-C ≥190 mg/100 ml). CAC was linked with dose-response relation with statin prescription and cholesterol lowering in this cohort.

It was previously demonstrated that approximately 600,000 patients in the United States and between 14 and

Disclosures

The authors have no conflicts of interest to declare.

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Drs. Rajagopalan, and Al-Kindi contributed equally as co-senior authors.

Funding: None.

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