Implications of coronary artery calcium testing on risk stratification for lipid-lowering therapy according to the 2016 European Society of Cardiology recommendations: The MESA study

Eur J Prev Cardiol. 2018 Nov;25(17):1887-1898. doi: 10.1177/2047487318788930. Epub 2018 Jul 25.

Abstract

Aims: The European Society of Cardiology (ESC) guideline on cardiovascular risk assessment considers coronary artery calcium a class B indication for risk assessment. We evaluated the degree to which coronary artery calcium can change the recommendation for individuals based on a change in estimated risk.

Methods and results: We stratified 5602 MESA participants according to the ESC recommendation as: no lipid-lowering treatment recommended ( N = 2228), consider lipid-lowering treatment if uncontrolled ( N = 1686), or lipid-lowering treatment recommended ( N = 1688). We evaluated the ability of coronary artery calcium to reclassify cardiovascular risk. Among the selected sample, 54% had coronary artery calcium of zero, 25% had coronary artery calcium of 1-100 and 21% had coronary artery calcium greater than 100. In the lipid-lowering treatment recommended group 31% had coronary artery calcium of zero, while in the lipid-lowering treatment if uncontrolled group about 50% had coronary artery calcium of zero. The cardiovascular mortality rate was 1.7%/10 years in the lipid-lowering treatment if uncontrolled, and 7.0%/10 years in the lipid-lowering treatment recommended group. The absence of coronary artery calcium was associated with 1.4%/10 years in the lipid-lowering treatment if uncontrolled group and 3.0%/10 years in the lipid-lowering treatment recommended group. Compared with coronary artery calcium of zero, any coronary artery calcium was associated with significantly higher cardiovascular mortality in the lipid-lowering treatment recommended group (9.0%/10 years), whereas only coronary artery calcium greater than 100 was significantly associated with a higher cardiovascular mortality in the lipid-lowering treatment if uncontrolled group (3.2%/10 years).

Conclusion: The absence of coronary artery calcium is associated with a low incidence of cardiovascular mortality or coronary heart disease events even in individuals in whom lipid-lowering therapy is recommended. A significant proportion of individuals deemed to be candidates for lipid-lowering therapy might be reclassified to a lower risk group with the use of coronary artery calcium.

Keywords: Cardiovascular disease; coronary artery calcium; primary prevention; risk stratification.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Biomarkers / blood
  • Clinical Decision-Making
  • Coronary Angiography*
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Artery Disease / ethnology
  • Dyslipidemias / blood
  • Dyslipidemias / diagnosis
  • Dyslipidemias / drug therapy*
  • Dyslipidemias / ethnology
  • Female
  • Humans
  • Hypolipidemic Agents / therapeutic use*
  • Incidence
  • Lipids / blood*
  • Male
  • Middle Aged
  • Practice Guidelines as Topic / standards*
  • Predictive Value of Tests
  • Prognosis
  • Prospective Studies
  • Risk Assessment
  • Risk Factors
  • United States / epidemiology
  • Vascular Calcification / diagnostic imaging*
  • Vascular Calcification / ethnology

Substances

  • Biomarkers
  • Hypolipidemic Agents
  • Lipids