Research Article| Volume 316, P79-83, January 2021

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Prognostic value of coronary artery calcium score, area, and density among individuals on statin therapy vs. non-users: The coronary artery calcium consortium


      • Statins may increase calcification in mechanistic and imaging studies.
      • The impact of statins on coronary artery calcium (CAC) predictive value is unclear.
      • CAC scoring retains utility for risk prediction in statin users.
      • The slightly weaker relationship of CAC with outcomes in statin users may be explained by changes in CAC density.


      Background and aims

      Statins do not decrease coronary artery calcium (CAC) and may increase existing calcification or its density. Therefore, we examined the prognostic significance of CAC among statin users at the time of CAC scanning.


      We included 28,025 patients (6151 statin-users) aged 40–75 years from the CAC Consortium. Cox regression models were used to assess the association of CAC with coronary heart disease (CHD) and cardiovascular disease (CVD) mortality. Models were adjusted for traditional CVD risk factors. Additionally, we examined the predictive performance of CAC components including CAC area, volume, and density using an age- and sex-adjusted Cox regression model.


      Participants (mean age 53.9 ± 10.3 years, 65.0% male) were followed for median 11.2 years. There were 395 CVD and 182 CHD deaths. One unit increase in log CAC score was associated with increased risk of CVD mortality (hazard ratio (HR), 1.2; 95% CI = 1.1–1.3) and CHD mortality (HR, 1.2; 95% CI = 1.1–1.4)) among statin users. There was a small but significant negative interaction between CAC score and statin use for the prediction of CHD (p-value = 0.036) and CVD mortality (p-value = 0.025). The volume score and CAC area were similarly associated with outcomes in statin users and non-users. Density was associated with CVD and CHD mortality in statin naïve patients, but with neither in statin users.


      CAC scoring retains robust risk prediction in statin users, and the changing relationship of CAC density with outcomes may explain the slightly weaker relationship of CAC with outcomes in statin users.

      Graphical abstract


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      Linked Article

      • Statins and coronary artery calcium: What's the score?
        AtherosclerosisVol. 316
        • Preview
          In this issue of Atherosclerosis, Osei et al. sought to understand the prognostic value of coronary artery calcium (CAC) for predicting risk among individuals already on statin therapy [1]. Risk assessment is the bedrock of primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, observations over the last two decades consistently suggest that quantitative risk assessment with a variety of clinical risk scores is imprecise and can lead to systematic under- or overestimation of events.
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