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Impact of a coronary artery calcium-guided statin treatment protocol on cardiovascular risk at 12 months: Results from a pragmatic, randomised controlled trial

      Highlights

      • The role of coronary artery calcium (CAC) imaging to improve adherence to primary prevention interventions is controversial.
      • Intermediate risk patients were randomised to seeing their CAC image and statin treatment or remained blinded without treatment.
      • At 1-year, CAC visualization predicted lower on- or off-statin treatment LDL-C, SBP and cardiovascular risk.

      Abstract

      Background and aims

      Coronary artery calcium (CAC) may encourage patients to adhere to primary prevention recommendations. This study sought to evaluate the benefit of a CAC-guided risk-management protocol in those with a family history of premature coronary artery disease (FHCAD).

      Methods

      In this Australian multi-centre, randomized controlled trial (Coronary Artery Calcium score: Use to Guide management of Hereditary Coronary Artery Disease, CAUGHT-CAD), asymptomatic, statin-native participants at low-intermediate cardiovascular risk with FHCAD underwent CAC assessment. Those with CAC between 1 and 400 were randomized (1:1) to disclosing the CAC result to both patient and physician and commencing atorvastatin (intervention) or blinding the CAC result with risk factor education only (control). The primary endpoint of this sub-study was change in Pooled Cohort Equation (PCE) at 12 months.

      Results

      Of 1088 participants who were scanned, 450 were randomised and 214 in both groups completed 1-year follow-up. At 1 year, PCE-risk decreased by 1.0% (95% CI 0.13 to 1.81) in the CAC-disclosed group and increased by 0.43% (95%CI 0.11–0.75) in the CAC-blinded group. LDL-C decreased in the CAC-disclosed group in both those who continued (1.5 mmol/L; 95% CI 1.36 to 1.74) and discontinued statins (0.62 mmol/L; 95% CI 0.32 to 0.92) but was unchanged in the CAC-blinded group.

      Conclusion

      Participants unblinded to their CAC showed reductions in LDL irrespective of statin continuation when compared to controls at 12 months. Improvements in individual risk factors and PCE risk were also noted. CAC assessment may positively influence patients and physicians to improve risk factor control.

      Keywords

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      References

        • Yusuf S.
        • Joseph P.
        • Rangarajan S.
        • Islam S.
        • Mente A.
        • Hystad P.
        • Brauer M.
        • Kutty V.R.
        • Gupta R.
        • Wielgosz A.
        • AlHabib K.F.
        • Dans A.
        • Lopez-Jaramillo P.
        • Avezum A.
        • Lanas F.
        • Oguz A.
        • Kruger I.M.
        • Diaz R.
        • Yusoff K.
        • Mony P.
        • Chifamba J.
        • Yeates K.
        • Kelishadi R.
        • Yusufali A.
        • Khatib R.
        • Rahman O.
        • Zatonska K.
        • Iqbal R.
        • Wei L.
        • Bo H.
        • Rosengren A.
        • Kaur M.
        • Mohan V.
        • Lear S.A.
        • Teo K.K.
        • Leong D.
        • O'Donnell M.
        • McKee M.
        • Dagenais G.
        Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.
        Lancet. 2020; 395: 795-808
        • Sheridan S.L.
        • Viera A.J.
        • Krantz M.J.
        • Ice C.L.
        • Steinman L.E.
        • Peters K.E.
        • Kopin L.A.
        • Lungelow D.
        Cardiovascular health intervention R and translation network work group on global coronary heart disease R. The effect of giving global coronary risk information to adults: a systematic review.
        Arch. Intern. Med. 2010; 170: 230-239
        • Banks E.
        • Crouch S.R.
        • Korda R.J.
        • Stavreski B.
        • Page K.
        • Thurber K.A.
        • Grenfell R.
        Absolute risk of cardiovascular disease events, and blood pressure- and lipid-lowering therapy in Australia.
        Med. J. Aust. 2016; 204: 320
        • van der Weijden T.
        • Bos L.B.
        • Koelewijn-van Loon M.S.
        Primary care patients' recognition of their own risk for cardiovascular disease: implications for risk communication in practice.
        Curr. Opin. Cardiol. 2008; 23: 471-476
        • Venkataraman P.
        • Stanton T.
        • Liew D.
        • Huynh Q.
        • Nicholls S.
        • Mitchell G.K.
        • Watts G.F.
        • Tonkin A.M.
        • Marwick T.H.
        Coronary artery calcium scoring in cardiovascular risk assessment of people with family histories of early onset coronary artery disease.
        Med. J. Aust. 2020; 213: 170-177
        • Gupta A.
        • Lau E.
        • Varshney R.
        • Hulten E.A.
        • Cheezum M.
        • Bittencourt M.S.
        • Blaha M.J.
        • Wong N.D.
        • Blumenthal R.S.
        • Budoff M.J.
        • Umscheid C.A.
        • Nasir K.
        • Blankstein R.
        The identification of calcified coronary plaque is associated with initiation and continuation of pharmacological and lifestyle preventive therapies: a systematic review and meta-analysis.
        JACC Cardiovasc. Imag. 2017; 10: 833-842
        • Naslund U.
        • Ng N.
        • Lundgren A.
        • Fharm E.
        • Gronlund C.
        • Johansson H.
        • Lindahl B.
        • Lindahl B.
        • Lindvall K.
        • Nilsson S.K.
        • Nordin M.
        • Nordin S.
        • Nyman E.
        • Rocklov J.
        • Vanoli D.
        • Weinehall L.
        • Wennberg P.
        • Wester P.
        • Norberg M.
        • group Vt
        Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial.
        Lancet. 2019; 393: 133-142
        • Marwick T.H.
        • Whitmore K.
        • Nicholls S.J.
        • Stanton T.
        • Mitchell G.
        • Tonkin A.
        • Blizzard C.
        • Neil A.
        • Jones C.
        • Watts G.F.
        • Investigators C.-C.
        Rationale and design of a trial to personalize risk assessment in familial coronary artery disease.
        Am. Heart J. 2018; 199: 22-30
        • Goff Jr., D.C.
        • Lloyd-Jones D.M.
        • Bennett G.
        • Coady S.
        • D'Agostino R.B.
        • Gibbons R.
        • Greenland P.
        • Lackland D.T.
        • Levy D.
        • O'Donnell C.J.
        • Robinson J.G.
        • Schwartz J.S.
        • Shero S.T.
        • Smith Jr., S.C.
        • Sorlie P.
        • Stone N.J.
        • Wilson P.W.
        • Jordan H.S.
        • Nevo L.
        • Wnek J.
        • Anderson J.L.
        • Halperin J.L.
        • Albert N.M.
        • Bozkurt B.
        • Brindis R.G.
        • Curtis L.H.
        • DeMets D.
        • Hochman J.S.
        • Kovacs R.J.
        • Ohman E.M.
        • Pressler S.J.
        • Sellke F.W.
        • Shen W.K.
        • Smith Jr., S.C.
        Tomaselli GF and American College of Cardiology/American heart association task force on practice G. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American heart association task force on practice guidelines.
        Circulation. 2014; 129: S49-S73
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J. Gen. Intern. Med. 2001; 16: 606-613
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Lowe B.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch. Intern. Med. 2006; 166: 1092-1097
        • Devlin N.J.
        • Shah K.K.
        • Feng Y.
        • Mulhern B.
        • van Hout B.
        Valuing health-related quality of life: an EQ-5D-5L value set for England.
        Health Econ. 2018; 27: 7-22
        • Law M.R.
        • Wald N.J.
        • Rudnicka A.R.
        Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis.
        BMJ. 2003; 326: 1423
        • Medical Research Council
        • National Health
        Australian Dietary Guidelines.
        2013
        • Brown W.J.
        • Bauman A.E.
        • Bull F.C.
        • Burton N.W.
        Development of evidence-based physical activity recommendations for adults (18-64 years).
        in: Report prepared for the Australian Government Department of Health. 2013
        • Paixao A.R.
        • Berry J.D.
        • Neeland I.J.
        • Ayers C.R.
        • Rohatgi A.
        • de Lemos J.A.
        • Khera A.
        Coronary artery calcification and family history of myocardial infarction in the Dallas heart study.
        JACC Cardiovasc. Imag. 2014; 7: 679-686
        • Mitchell J.D.
        • Fergestrom N.
        • Gage B.F.
        • Paisley R.
        • Moon P.
        • Novak E.
        • Cheezum M.
        • Shaw L.J.
        • Villines T.C.
        Impact of statins on cardiovascular outcomes following coronary artery calcium scoring.
        J. Am. Coll. Cardiol. 2018; 72: 3233-3242
        • Daida H.
        • Dohi T.
        • Fukushima Y.
        • Ohmura H.
        • Miyauchi K.
        The goal of achieving atherosclerotic plaque regression with lipid-lowering therapy: insights from IVUS trials.
        J. Atherosclerosis Thromb. 2019; 26: 592-600
        • Maron D.J.
        • Mancini G.B.J.
        • Hartigan P.M.
        • Spertus J.A.
        • Sedlis S.P.
        • Kostuk W.J.
        • Berman D.S.
        • Teo K.K.
        • Weintraub W.S.
        • Boden W.E.
        • Group C.T.
        Healthy behavior, risk factor control, and survival in the COURAGE trial.
        J. Am. Coll. Cardiol. 2018; 72: 2297-2305
        • Karmali K.N.
        • Persell S.D.
        • Perel P.
        • Lloyd-Jones D.M.
        • Berendsen M.A.
        • Huffman M.D.
        Risk scoring for the primary prevention of cardiovascular disease.
        Cochrane Database Syst. Rev. 2017; 3: CD006887
        • Krogsboll L.T.
        • Jorgensen K.J.
        • Gronhoj Larsen C.
        • Gotzsche P.C.
        General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis.
        BMJ. 2012; 345e7191
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • Casey Jr., D.E.
        • Collins K.J.
        • Dennison Himmelfarb C.
        • DePalma S.M.
        • Gidding S.
        • Jamerson K.A.
        • Jones D.W.
        • MacLaughlin E.J.
        • Muntner P.
        • Ovbiagele B.
        • Smith Jr., S.C.
        • Spencer C.C.
        • Stafford R.S.
        • Taler S.J.
        • Thomas R.J.
        • Williams K.A.
        • Sr
        • Williamson J.D.
        • Wright Jr., J.T.
        ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines.
        J. Am. Coll. Cardiol. 2017; 71 (2018): e127-e248
        • Williams B.
        • Mancia G.
        • Spiering W.
        • Agabiti Rosei E.
        • Azizi M.
        • Burnier M.
        • Clement D.L.
        • Coca A.
        • de Simone G.
        • Dominiczak A.
        • Kahan T.
        • Mahfoud F.
        • Redon J.
        • Ruilope L.
        • Zanchetti A.
        • Kerins M.
        • Kjeldsen S.E.
        • Kreutz R.
        • Laurent S.
        • Lip G.Y.H.
        • McManus R.
        • Narkiewicz K.
        • Ruschitzka F.
        • Schmieder R.E.
        • Shlyakhto E.
        • Tsioufis C.
        • Aboyans V.
        • Desormais I.
        • Group E.S.C.S.D.
        ESC/ESH Guidelines for the management of arterial hypertension.
        Eur. Heart J. 2018; 39 (2018): 3021-3104
        • Damen J.A.
        • Pajouheshnia R.
        • Heus P.
        • Moons K.G.M.
        • Reitsma J.B.
        • Scholten R.
        • Hooft L.
        • Debray T.P.A.
        Performance of the Framingham risk models and pooled cohort equations for predicting 10-year risk of cardiovascular disease: a systematic review and meta-analysis.
        BMC Med. 2019; 17: 109
        • Rozanski A.
        • Gransar H.
        • Shaw L.J.
        • Kim J.
        • Miranda-Peats L.
        • Wong N.D.
        • Rana J.S.
        • Orakzai R.
        • Hayes S.W.
        • Friedman J.D.
        • Thomson L.E.
        • Polk D.
        • Min J.
        • Budoff M.J.
        • Berman D.S.
        Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial.
        J. Am. Coll. Cardiol. 2011; 57: 1622-1632
        • Popkin B.M.
        • Duffey K.
        • Gordon-Larsen P.
        Environmental influences on food choice, physical activity and energy balance.
        Physiol. Behav. 2005; 86: 603-613
        • Soureti A.
        • Hurling R.
        • Murray P.
        • van Mechelen W.
        • Cobain M.
        Evaluation of a cardiovascular disease risk assessment tool for the promotion of healthier lifestyles.
        Eur. J. Cardiovasc. Prev. Rehabil. 2010; 17: 519-523
        • Thakkar J.
        • Heeley E.L.
        • Chalmers J.
        • Chow C.K.
        Inaccurate risk perceptions contribute to treatment gaps in secondary prevention of cardiovascular disease.
        Intern. Med. J. 2016; 46: 339-346
        • Denissen S.J.
        • van der Aalst C.M.
        • Vonder M.
        • Oudkerk M.
        • de Koning H.J.
        Impact of a cardiovascular disease risk screening result on preventive behaviour in asymptomatic participants of the ROBINSCA trial.
        Eur. J. Prev. Cardiol. 2019; 26: 1313-1322
        • Johnson J.E.
        • Gulanick M.
        • Penckofer S.
        • Kouba J.
        Does knowledge of coronary artery calcium affect cardiovascular risk perception, likelihood of taking action, and health-promoting behavior change?.
        J. Cardiovasc. Nurs. 2015; 30: 15-25
        • Manuel D.G.
        • Abdulaziz K.E.
        • Perez R.
        • Beach S.
        • Bennett C.
        Personalized risk communication for personalized risk assessment: Real world assessment of knowledge and motivation for six mortality risk measures from an online life expectancy calculator.
        Inf. Health Soc. Care. 2018; 43: 42-55
        • Homko C.J.
        • Santamore W.P.
        • Zamora L.
        • Shirk G.
        • Gaughan J.
        • Cross R.
        • Kashem A.
        • Petersen S.
        • Bove A.A.
        Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease.
        J. Cardiovasc. Nurs. 2008; 23: 332-337
        • Hong J.C.
        • Blankstein R.
        • Shaw L.J.
        • Padula W.V.
        • Arrieta A.
        • Fialkow J.A.
        • Blumenthal R.S.
        • Blaha M.J.
        • Krumholz H.M.
        • Nasir K.
        Implications of coronary artery calcium testing for treatment Decisions among statin Candidates according to the ACC/AHA cholesterol management guidelines: a cost-effectiveness analysis.
        JACC Cardiovasc. Imag. 2017; 10: 938-952
        • Alliance N.V.D.P.
        Guidelines for the Management of Absolute Cardiovascular Disease Risk.
        2012: 2021
        • Grundy S.M.
        • Stone N.J.
        • Bailey A.L.
        • Beam C.
        • Birtcher K.K.
        • Blumenthal R.S.
        • Braun L.T.
        • de Ferranti S.
        • Faiella-Tommasino J.
        • Forman D.E.
        • Goldberg R.
        • Heidenreich P.A.
        • Hlatky M.A.
        • Jones D.W.
        • Lloyd-Jones D.
        • Lopez-Pajares N.
        • Ndumele C.E.
        • Orringer C.E.
        • Peralta C.A.
        • Saseen J.J.
        • Smith Jr., S.C.
        • Sperling L.
        • Virani S.S.
        • Yeboah J.
        AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines.
        Circulation. 2018; 139 (2019): e1082-e1143
        • Budoff M.J.
        • Young R.
        • Burke G.
        • Jeffrey Carr J.
        • Detrano R.C.
        • Folsom A.R.
        • Kronmal R.
        • Lima J.A.C.
        • Liu K.J.
        • McClelland R.L.
        • Michos E.
        • Post W.S.
        • Shea S.
        • Watson K.E.
        • Wong N.D.
        Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the multi-ethnic study of atherosclerosis (MESA).
        Eur. Heart J. 2018; 39: 2401-2408