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Observational Study
. 2018 Dec 25;72(25):3233-3242.
doi: 10.1016/j.jacc.2018.09.051.

Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring

Joshua D Mitchell  1 , Nicole Fergestrom  2 , Brian F Gage  3 , Robert Paisley  4 , Patrick Moon  5 , Eric Novak  6 , Michael Cheezum  7 , Leslee J Shaw  8 , Todd C Villines  9
Affiliations
Observational Study

Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring

Joshua D Mitchell et al. J Am Coll Cardiol. .

Abstract

Background: Compared with traditional risk factors, coronary artery calcium (CAC) scores improve prognostic accuracy for atherosclerotic cardiovascular disease (ASCVD) outcomes. However, the relative impact of statins on ASCVD outcomes stratified by CAC scores is unknown.

Objectives: The authors sought to determine whether CAC can identify patients most likely to benefit from statin treatment.

Methods: The authors identified consecutive subjects without pre-existing ASCVD or malignancy who underwent CAC scoring from 2002 to 2009 at Walter Reed Army Medical Center. The primary outcome was first major adverse cardiovascular event (MACE), a composite of acute myocardial infarction, stroke, and cardiovascular death. The effect of statin therapy on outcomes was analyzed stratified by CAC presence and severity, after adjusting for baseline comorbidities with inverse probability of treatment weights based on propensity scores.

Results: A total of 13,644 patients (mean age 50 years; 71% men) were followed for a median of 9.4 years. Comparing patients with and without statin exposure, statin therapy was associated with reduced risk of MACE in patients with CAC (adjusted subhazard ratio: 0.76; 95% confidence interval: 0.60 to 0.95; p = 0.015), but not in patients without CAC (adjusted subhazard ratio: 1.00; 95% confidence interval: 0.79 to 1.27; p = 0.99). The effect of statin use on MACE was significantly related to the severity of CAC (p < 0.0001 for interaction), with the number needed to treat to prevent 1 initial MACE outcome over 10 years ranging from 100 (CAC 1 to 100) to 12 (CAC >100).

Conclusions: In a largescale cohort without baseline ASCVD, the presence and severity of CAC identified patients most likely to benefit from statins for the primary prevention of cardiovascular diseases.

Keywords: atherosclerotic cardiovascular disease; calcium score; cardiovascular risk; primary prevention; screening.

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Figures

Online Figure 1.
Online Figure 1.
Incident MACE Rate by Statin Treatment and CAC Severity The incident MACE rate for each CAC and treatment group were derived from the CIF of MACE through 10 years. There was no difference between statin treated patients in those without CAC (p=0.94) or those with CAC 1–100 (p=0.095), but there was a significant difference in those with CAC over 100 (p<0.0001).
Online Figure 2.
Online Figure 2.
Statin Use and Hazard of MACE Stratified by ASCVD Risk Score and CAC Severity Patients were classified as low baseline ASCVD risk (<5%), intermediate risk (5–20%) or high risk (>20%) using assumed risk variables and the pooled cohort equation (PCE). MACE – major adverse cardiovascular event. CAC – coronary artery calcium.
Online Figure 3.
Online Figure 3.
Statin Use and Hazard of MACE in Patients with CAC=0 Stratified by ASCVD Risk Score Using Multiple Risk Variable Estimates Multiple Models were run calculating ASCVD risk scores with varying estimates for risk factor variables (See Figure Legend). MACE – major adverse cardiovascular event. CAC – coronary artery calcium. SBP – systolic blood pressure
Central Illustration.
Central Illustration.
Cumulative Incidence of MACE Stratified by Statin Treatment and CAC Severity. Benefit of statin therapy was significantly related to CAC group (p<0.0001 for interaction), with benefit in patients with CAC >100 but not in patients with CAC < 100. aSHR – adjusted subhazard ratio. MACE – major adverse cardiovascular event. CAC – coronary artery calcium.
Figure 1.
Figure 1.
Cumulative Incidence of MACE Stratified by Statin Treatment and CAC Presence. Patients with CAC who were prescribed a statin had a significantly reduced risk of MACE (aSHR 0.76, 95% CI 0.60–0.95, p=0.015), while patients without CAC had no associated MACE reduction (aSHR 1.00, 95% CI 0.79–1.27, p=0.99). p=0.097 for interaction between statin treatment and CAC presence. aSHR – adjusted subhazard ratio. MACE – major adverse cardiovascular event. CAC – coronary artery calcium.
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References

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