CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines

Amir A. Mahabadi; Stefan Möhlenkamp; Nils Lehmann; Hagen Kälsch; Iryna Dykun; Noreen Pundt; Susanne Moebus; Karl-Heinz Jöckel; Raimund Erbel; Heinz Nixdorf Recall Study Investigators

doi:10.1016/j.jcmg.2016.03.022

JACC: Cardiovascular Imaging

Volume 10, Issue 2, February 2017 DOI: 10.1016/j.jcmg.2016.03.022

CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines

Amir A. Mahabadi, Stefan Möhlenkamp, Nils Lehmann, Hagen Kälsch, Iryna Dykun, Noreen Pundt, Susanne Moebus, Karl-Heinz Jöckel, Raimund Erbel and Heinz Nixdorf Recall Study Investigators

Author + information

vol. 10 no. 2 143-153

DOI:

https://doi.org/10.1016/j.jcmg.2016.03.022

Published By:

JACC: Cardiovascular Imaging

Print ISSN:

1936-878X

Online ISSN:

1876-7591

History:

Received January 4, 2016
Revision received February 17, 2016
Accepted March 17, 2016
Published online February 6, 2017.

American College of Cardiology Foundation

Author Information

Amir A. Mahabadi, MD^a,^∗ (amir-abbas.mahabadi{at}uk-essen.de),
Stefan Möhlenkamp, MD^b,
Nils Lehmann, PhD^c,
Hagen Kälsch, MD^a,
Iryna Dykun, MD^a,
Noreen Pundt, PhD^c,
Susanne Moebus, PhD^c,
Karl-Heinz Jöckel, PhD^c,
Raimund Erbel, MD^c,
Heinz Nixdorf Recall Study Investigators

^aDepartment of Cardiology, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
^bKrankenhaus Bethanien, Department of Cardiology, Moers, Germany
^cInstitute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany

↵∗Address for correspondence:
Dr. Amir A. Mahabadi, West-German Heart and Vascular Center, Department of Cardiology, Hufelandstrasse 55, 45147 Essen, Germany.

Abstract

Objectives The aim of this study was to assess the difference in indication for statin therapy by European Society of Cardiology (ESC) versus American Heart Association/American College of Cardiology (AHA/ACC) guidelines and to quantify the potential additional role of coronary artery calcification (CAC) score over updated guidelines in a primary prevention cohort.

Background Recently, ESC and AHA/ACC updated the guidelines regarding statin therapy in primary prevention.

Methods In 3,745 subjects (59 ± 8 years of age, 47% men) from the population based longitudinal Heinz Nixdorf Recall cohort study without cardiovascular disease or lipid-lowering therapy at baseline CAC score was assessed between 2000 and 2003. Subjects remained unaware of their initial CAC score. Statin indication was determined according to 2012 ESC and 2013 AHA/ACC guidelines based on subjects individual baseline characteristics.

Results The frequency of statin recommendation was lower according to ESC compared to AHA/ACC guidelines (34% vs. 56%; p < 0.0001), whereas low CAC score (<100) was common in subjects with statin indication by both guidelines (59% for ESC, 62% for AHA/ACC). During 10.4 ± 2.0 years of follow-up, 131 myocardial infarctions occurred. For ESC recommendations, CAC score differentiated risk for subjects without (1.0 [95% confidence interval (CI): 0.4 to 1.5] vs. 6.5 [95% CI: 4.1 to 8.9] coronary events per 1,000 person-years for CAC 0 vs. ≥100) and with statin indication (2.6 [95% CI: 0.6 to 4.7] vs. 9.9 [95% CI: 7.3 to 12.5] per 1,000 person-years for CAC 0 vs. ≥100). Likewise, CAC score stratified proportions experiencing events subjects with statin indication according to AHA/ACC (2.7 [95% CI: 1.1 to 4.2] vs. 9.1 [95% CI: 7.0 to 11.0] per 1,000 person-years for CAC 0 vs. ≥100), whereas event rate in subjects without statin indication was low (1.1 [95% CI: 0.65 to 1.68] per 1,000 person-years).

Conclusions Current ESC and AHA/ACC guidelines lead to markedly different recommendation regarding statin therapy in a German primary prevention cohort. Quantification of CAC score in addition to the guidelines improves stratification between subjects at high versus low risk for coronary events, indicating that CAC scoring may help to match intensified risk factor modification to atherosclerotic plaque burden as well as actual risk while avoiding therapy in subjects with low coronary atherosclerosis that have low 10-year event rate.

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Footnotes

This work was supported by the Heinz Nixdorf Foundation, the German Ministry of Education and Science (BMBF), and the Deutsche Forschungsgemeinschaft (ER 155/6-1, ER 155/6-2, SI 236/8-1, and SI 236/9-1). Dr. Dykun was supported by a research grant from the German Society of Cardiology. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.