The 2013 ACC/AHA cardiovascular prevention guidelines improve alignment of statin therapy with coronary atherosclerosis as detected by coronary computed tomography angiography

Abstract

The recently released 2013 ACC/AHA guidelines for management of blood cholesterol have substantially increased the number of adults who are eligible for preventive statin therapy. We sought to determine whether eligibility for statin therapy as determined by the 2013 ACC/AHA guideline recommendation is better aligned with the actual presence of coronary artery disease (CAD) as detected by coronary CT angiography (CCTA) when compared to prior guidelines including the 2004 NCEP ATP III and 2011 ESC/EAS guidelines. In this secondary analysis of the prospective observational ROMICAT I (Rule Out Myocardial Infarction with Computer Assisted Tomography) cohort study, we included all men and women aged 40-79 years presenting with acute chest pain but not diagnosed with acute coronary syndrome nor on admission statin. Based on risk factor assessment and lipid data, we determined guideline-based eligibility for statin therapy by the 2013 ACC/AHA, the 2004 NCEP ATP III, and the 2011 ESC/EAS guidelines. We determined the presence and severity of CAD as detected by CCTA. The 2013 ACC/AHA algorithm identified nearly twice as many individuals as eligible for statins (n = 77/189; 41%) as compared to the 2004 ATP III criteria: (n = 41/189; 22%), (p < .0001) In addition, the 2013 ACC/AHA guidelines were more sensitive for treatment of CCTA-detected CAD than the 2004 ATP III guidelines [53.4% (42.5-64.1) vs 27.3% (18.3-37.8), p < .001] and the 2011 ESC/EAE guidelines [53.4% (42.5-64.1) vs 34.1% (24.3-45.0), p < .001]. However, the specificity of these guidelines was modestly reduced compared to the 2004 ATP III guidelines [70.3 (60.4-79.0) vs 83.2 (74.4-89.9), p < .001] and the 2011 ESC/EAE guidelines [70.3 (60.4-79.0) vs 86.1 (77.8-92.2), p < .001], suggesting increased treatment of subjects without CCTA-detected CAD. Overall, the 2013 ACC/AHA guidelines are more sensitive to identify patients who have CAD detected by CCTA eligible for statin therapy as compared with prior guidelines, with an acceptable trade-off in specificity for recommending statin therapy in those without CAD.

Keywords: Atherosclerosis; Computed tomography; Guidelines; Prevention; Statin.

Figure 1. Study Flow Diagram

The original ROMICAT I (Rule out Myocardial Infarction with Computer-Assisted Tomography) consisted of 368 low-intermediate risk patients presenting with symptoms suggestive of acute coronary syndrome (ACS) to the ED. Patients with ACS, incomplete risk factor data, and patients that were already on statin therapy were excluded to generate the “primary prevention” cohort of patients (n=189).

Figure 2

2013 ACC/AHA versus 2004 ATP III Guidelines on Statin Recommendation across strata of presence and extent of coronary atherosclerosis as detected by CCTA in 189 patients without prior statin use presenting with acute chest pain in whom an acute coronary syndrome was excluded.

Figure 3

Schematic depicting the proportion of subjects eligible for statin therapy per the 2004 ATP III Guidelines, the 2013 ACC/AHA Guidelines, the 2013 ACC/AHA Guidelines using a 5.0% threshold, and the 2011 European Prevention Guidelines across strata of the presence and extent of coronary atherosclerosis as detected by CCTA in 189 patients without prior statin use presenting with acute chest pain in whom an acute coronary syndrome was excluded.