Abstract
Background: Recommendations for preventive statin treatment in patients with stable chest pain may be difficult as symptoms can be unspecific. It is unclear if coronary CT angiography (CTA)-detected coronary artery disease (CAD) can optimize statin prescription. Methods: In stable chest pain patients randomized to CTA in the PROMISE trial, statin eligibility was defined per 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Primary outcome was a composite of death, myocardial infarction or unstable angina over 26 months median follow-up. Hazard ratios (HR) of non-obstructive (1–69% stenosis) and obstructive (≥70% stenosis) CAD for events were determined using Cox proportional hazard models. Calculated HR were then incorporated into the ACC/AHA pooled cohort equation (PCE) to revised ASCVD risk and assess re-classification of statin eligibility. Results: Among 3986 patients (60.5 ± 8.2 years; 51% female), 72.9% (2904/3986) were statin eligible. Event rates in statin-eligible vs. ineligible patients were 3.3% vs. 2.3% (HR = 1.4 (95% CI 0.9–2.2), p = 0.142). Although the proportion of statin-eligible patients increased with CAD severity, 54% without CAD were statin eligible. Incorporating information on CAD into PCE reclassified 12.7% of patients (1.3% towards statin, 11.4% towards no statin). Similar results were found in stratified analysis of statin naïve patients (reclassification of 13.9%, 1.0% towards statin, and 12.9% towards no statin). As a result, revised ASCVD risk improved model discrimination in all patients (c-statistic: 0.59 (95 %CI 0.55–0.62) vs. 0.52 (95 %CI 0.49–0.56); p 0.001), while reducing statin use by 10.1% (62.7% vs. 72.9% statin eligible, p 0.001). Conclusion: In stable chest pain patients, integration of CAD into guideline recommendations was associated with greater accuracy to reclassify those at increased risk for incident events and a more efficient use of statins.
Highlights
Scientific evidence has been translated into recommendations for preventive statin treatment to improve cardiovascular health
We demonstrated that incorporation of this information into the atherosclerotic cardiovascular disease (ASCVD) risk calculator results in modification of ASCVD risk and favorable reclassification of statin eligibility, with improved discrimination for cardiovascular events
Use of the reclassified risk would substantially reduce overall statin prescription among those without coronary artery disease (CAD), while similar proportions of those with non-obstructive and obstructive CAD would be treated. In those without coronary CT angiography (CTA)-detected CAD, the rate of statin eligibility was reduced by 30% by incorporating this information into the pooled cohort equation (PCE), with similar overall downstream cardiovascular event rates (1.1% for statin-eligible patients using original ASCVD guideline versus 1.3% with modified statin eligibility)
Summary
Scientific evidence has been translated into recommendations for preventive statin treatment to improve cardiovascular health. In the anatomic testing arm of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial, a cohort of patients with stable chest pain, events occurred in only 3.3% [2] This is similar to event rates in primary prevention cohorts without known ASCVD [3,4,5]. Recommendations for preventive statin treatment in patients with stable chest pain may be difficult as symptoms can be unspecific It is unclear if coronary CT angiography (CTA)-detected coronary artery disease (CAD) can optimize statin prescription. Conclusion: In stable chest pain patients, integration of CAD into guideline recommendations was associated with greater accuracy to reclassify those at increased risk for incident events and a more efficient use of statins
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