Author + information
- Received April 28, 2015
- Revision received July 20, 2015
- Accepted July 20, 2015
- Published online October 13, 2015.
- Khurram Nasir, MD, MPH∗,†,‡,§∗ (, )
- Marcio S. Bittencourt, MD, MPH‖,¶,#,
- Michael J. Blaha, MD, MPH‡,
- Ron Blankstein, MD¶,
- Arthur S. Agatson, MD∗,
- Juan J. Rivera, MD, MHS∗∗,
- Michael D. Miedema, MD, MPH††,
- Christopher T. Sibley, MD‡‡,
- Leslee J. Shaw, PhD§§,
- Roger S. Blumenthal, MD‡,
- Matthew J. Budoff, MD‖‖ and
- Harlan M. Krumholz, MD, SM¶¶,##∗∗∗
- ∗Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida
- †Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
- ‡The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
- §Department of Epidemiology, Robert Stempel College of Public Health and Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- ‖Center for Clinical and Epidemiological Research and Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil
- ¶Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- #Preventive Medicine Centre, Hospital Israelita Albert Einstein, São Paulo, Brazil
- ∗∗Mount Sinai Hospital, Miami Beach, Florida
- ††Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
- ‡‡Knight Cardiovascular Institute, Oregon Health & Science University, Portland Oregon
- §§Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, Georgia
- ‖‖Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- ¶¶Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- ##Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- ∗∗∗Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- ↵∗Reprint requests and correspondence:
Dr. Khurram Nasir, Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, 1500 San Remo Avenue, Suite 340, Coral Gables, Florida 33139.
Background The American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy.
Objectives This study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not.
Methods MESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis.
Results The study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years.
Conclusions Significant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy.
This research was supported by contracts N01-HC-95159 through N01-HC-95169 from the National Heart, Lung, and Blood Institute. Dr. Nasir is on the advisory board for Quest Diagnostic; and is a consultant for Regeneron. Dr. Budoff is on the speakers bureau for General Electric. Dr. Krumholz is the recipient of research agreements from Medtronic, Inc. and Johnson & Johnson (Janssen), through Yale University, to develop methods of clinical trial data sharing; and is chair of a cardiac scientific advisory board for UnitedHealth. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 28, 2015.
- Revision received July 20, 2015.
- Accepted July 20, 2015.
- American College of Cardiology Foundation