Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events.
Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events.
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基于指南的他汀类药物的资格，冠状动脉钙化和心血管事件。
DOI：
10.1001/jama.2015.7515
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发表时间：
2015-07-14
期刊：
影响因子：
--
通讯作者：
Hoffmann U
中科院分区：
文献类型：
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作者：
Pursnani A;Massaro JM;D'Agostino RB Sr;O'Donnell CJ;Hoffmann U
2013年美国心脏病学会/美国心脏协会（ACC/AHA）胆固醇管理指南定义了他汀类药物治疗的新资格标准。然而，尚不清楚这种方法是否能提高心血管事件高风险成人的识别能力。为了确定ACC/AHA指南与国家胆固醇教育计划2004年成人高血胆固醇检测、评估和治疗专家小组第三次更新报告（ATP III）指南相比，是否能改善对发生心血管疾病（CVD）和/或冠状动脉钙化（CAC）的个体的识别。纵向社区队列研究，本研究的参与者来自弗雷明汉心脏研究的后代和第三代队列。参与者在2002年至2005年期间接受了CAC的多探测器计算机断层扫描，并对CVD事件进行了中位9.4年的随访。他汀类药物的资格是根据Framingham危险因素和ATP III的低密度脂蛋白阈值来确定的，而ACC/AHA则使用合并队列计算器。主要结局是CVD（心肌梗死、冠心病死亡或缺血性中风）的发生。次要结局是冠心病和CAC（以Agatston评分衡量）。在2435名未服用他汀的参与者中（平均年龄51.3 [SD， 8.6]岁，56%为女性），39%（941/2435）通过ACC/AHA符合他汀标准，而通过ATP III符合他汀标准的为14% (348/2435)（P < 0.001）。有74例CVD事件（40例非致死性心肌梗死，31例非致死性缺血性中风，3例致死性冠心病事件）。符合ACC/AHA标准的他汀类药物患者与符合ATP III标准的患者相比，发生心血管疾病的风险比增加：分别为6.8 （95% CI, 3.8-11.9）和3.1 (95% CI, 1.9-5.0) （P < 0.001）。在中度弗雷明汉风险评分的参与者中，CVD和CHD的结果相似。新接受他汀类药物治疗的参与者（n = 593 [24%]） CVD发生率为5.7%，需要治疗的人数为39至58人。与ATP III相比，CAC患者更有可能通过ACC/AHA符合他汀类药物的使用条件：CAC评分b> 0 (n = 1015): 63% vs 23%；CAC评分bbb100 (n = 376): 80% vs 32%；CAC评分bbb300 (n = 186): 85% vs 34% （P均< 0.001）。在ACC/AHA符合他汀类药物条件的受试者中，CAC评分为0为低危组（306/941 [33%]），CVD率为1.6%。在这个以社区为基础的一级预防队列中，与ATP III相比，ACC/AHA确定他汀类药物资格的指南在识别心血管疾病和亚临床冠状动脉疾病发生风险增加方面具有更高的准确性和效率，特别是在中等风险参与者中。
The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for cholesterol management defined new eligibility criteria for statin therapy. However, it is unclear whether this approach improves identification of adults at higher risk of cardiovascular events. To determine whether the ACC/AHA guidelines improve identification of individuals who develop incident cardiovascular disease (CVD) and/or have coronary artery calcification (CAC) compared with the National Cholesterol Education Program’s 2004 Updated Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) guidelines. Longitudinal community-based cohort study, with participants for this investigation drawn from the offspring and third-generation cohorts of the Framingham Heart Study. Participants underwent multidetector computed tomography for CAC between 2002 and 2005 and were followed up for a median of 9.4 years for incident CVD. Statin eligibility was determined based on Framingham risk factors and low-density lipoprotein thresholds for ATP III, whereas the pooled cohort calculator was used for ACC/AHA. The primary outcome was incident CVD (myocardial infarction, death due to coronary heart disease [CHD], or ischemic stroke). Secondary outcomes were CHD and CAC (as measured by the Agatston score). Among 2435 statin-naive participants (mean age, 51.3 [SD, 8.6] years; 56% female), 39% (941/2435) were statin eligible by ACC/AHA compared with 14% (348/2435) by ATP III (P < .001). There were 74 incident CVD events (40 nonfatal myocardial infarctions, 31 nonfatal ischemic strokes, and 3 fatal CHD events). Participants who were statin eligible by ACC/AHA had increased hazard ratios for incident CVD compared with those eligible by ATP III: 6.8 (95% CI, 3.8–11.9) vs 3.1 (95% CI, 1.9–5.0), respectively (P <.001). Similar results were seen for CVD in participants with intermediate Framingham Risk Scores and for CHD. Participants who were newly statin eligible (n = 593 [24%]) had an incident CVD rate of 5.7%, yielding a number needed to treat of 39 to 58. Participants with CAC were more likely to be statin eligible by ACC/AHA than by ATP III: CAC score >0 (n = 1015): 63% vs 23%; CAC score >100 (n = 376): 80% vs 32%; and CAC score >300 (n = 186): 85% vs 34% (all P < .001). A CAC score of 0 identified a low-risk group among ACC/AHA statin-eligible participants (306/941 [33%]) with a CVD rate of 1.6%. In this community-based primary prevention cohort, the ACC/AHA guidelines for determining statin eligibility, compared with the ATP III, were associated with greater accuracy and efficiency in identifying increased risk of incident CVD and subclinical coronary artery disease, particularly in intermediate-risk participants.