Elsevier

The American Journal of Cardiology

Volume 136, 1 December 2020, Pages 49-55
The American Journal of Cardiology

Relation of Absence of Coronary Artery Calcium to Cardiovascular Disease Mortality Risk Among Individuals Meeting Criteria for Statin Therapy According to the 2018/2019 ACC/AHA Guidelines

https://doi.org/10.1016/j.amjcard.2020.08.050Get rights and content

The 2013 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines resulted in broad recommendations for preventive statin therapy allocation in patients without known cardiovascular disease (CVD). Subsequent studies demonstrated significant heterogeneity of atherosclerotic cardiovascular disease risk across the primary prevention population. In 2018/2019, the guidelines were revised to optimize risk assessment and cholesterol management. We sought to evaluate the heterogeneity of risk in statin-recommended patients, using coronary artery calcium (CAC) according to 2018/2019 ACC/AHA guidelines in a primary prevention cohort. We evaluated 5,800 statin-naive patients aged 40 to 75 years without known coronary heart disease from the Cedars-Sinai Medical Center study cohort. All participants underwent clinical CAC scoring for risk stratification and were followed for all-cause and CVD-specific mortality. A total of 181 deaths occurred including 54 CVD deaths over a follow-up of 9.5 years. Overall, 1,939 participants would have been recommended statin therapy, 32% of whom had no detectable CAC. CAC = 0 participants had the lowest all-cause and CVD mortality rates in both statin-recommended and nonrecommended groups (0.2 and 0.4 CVD deaths per 1,000 person-years, respectively). Absence of CAC in statin-naive patients portends an approximately 12-fold lower CVD mortality (0.2% vs 2.4%) in those recommended for statin therapy compared with any CAC present. In conclusion, in a cohort of patients meeting the 2018/2019 ACC/AHA guidelines for statin therapy for primary prevention, there was a marked heterogeneity of CAC scores, with about one-third of the statin recommended population having no detectable CAC (CAC = 0) with a significantly lower CVD mortality compared with CAC>0.

Section snippets

Methods

CAC Consortium represents four participating institutions from three states within the US (California, Minnesota, and Ohio), which contributed data from 66,636 asymptomatic patients spanning years 1991 to 2010.7 This is an observational retrospective cohort study designed primarily to evaluate the association between CAC and long-term mortality. All CAC scans were clinically indicated and physician-referred in patients without a known history of coronary heart disease (CHD). Further details on

Results

The study cohort consisted of 13,972 asymptomatic patients without known CHD. Patient selection for the present analysis was determined according to the 2018/2019 ACC/AHA guidelines and is depicted in Figure 1. Of 13,972 participants, 3,853 on lipid-lowering medication at the time of baseline CAC scanning were excluded from the present analysis. Of the resulting 10,119 participants, 3,257 missing LDL-C levels were excluded from the analysis. Additional exclusions included participants with

Discussion

Our study demonstrates that CAC scoring substantially differentiates the risk for all-cause and CVD-specific mortality in patients with and without statin recommendation for primary prevention according to the 2018/2019 ACC/AHA guidelines. Overall, in a large cohort of asymptomatic patients who underwent CAC scanning for the evaluation of subclinical atherosclerosis, the all-cause, and CVD-specific mortality rates were much higher in the statin recommended population compared with the

Declaration of Competing Interest

The authors report no conflicts of interest to disclose relevant to the content of this manuscript.

Author contribution

Tanuja Rajan: Conceptualization, data curation, formal analysis, investigation, methodology, visualization, validation, interpretation of data, writing – original draft, Writing- review and editing. Alan Rozanski: Conceptualization, data curation, formal analysis, investigation, methodology, visualization, validation, interpretation of data, writing – original draft, Writing- review and editing, Supervision. Miguel Cainzos-Achirica: Writing – original draft, writing- review and editing. Gowtham

References (21)

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1

Tanuja Rajan and Alan Rozanski contributed equally to this work as co-first authors

2

Khurram Nasir and Daniel Berman contributed equally to this work as co-senior authors

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