title: Asymptomatic individuals with a positive family history for premature coronary artery disease and elevated coronary calcium scores benefit from statin treatment: a post hoc analysis from the St. Francis Heart Study.
abstract: OBJECTIVE
  The goal of this study was to evaluate whether individuals with a positive family history for premature coronary artery disease (CAD) and coronary calcium scoring (CCS) above the 80th percentile might benefit from preventive treatment.
  
  
  BACKGROUND
  First-degree relatives of patients with premature CAD have an increased risk for cardiovascular disease (CVD), whereas events are poorly predicted in these individuals. Surrogate markers, such as CCS, might refine risk scoring. Nevertheless, the outcome of the St. Francis Heart trial, which investigated the effect of atorvastatin 20 mg/day in asymptomatic individuals with CCS above the 80th percentile, did not reach statistical significance.
  
  
  METHODS
  We performed a post hoc analysis on the database of the St. Francis trial to assess efficacy of treatment with atorvastatin 20 mg/day in those with CCS above the 80th percentile and presence (n = 543) or absence (n = 462) of a positive family history for premature CAD. All participants received aspirin 81 mg/day. Primary outcome included coronary death, myocardial infarction, coronary revascularization, stroke, and arterial surgery.
  
  
  RESULTS
  A total of 1,005 individuals, with a mean age of 59.0 ± 5.9 years and a median absolute CCS of 370 Agatston units (interquartile range: 183 to 662) participated in the trial. After a follow-up of 4.3 (interquartile range: 3.5 to 4.5) years, 7.2% of the treated individuals with a positive family history had a cardiovascular event versus 12.5% of the placebo group (hazard ratio [HR]: 0.55; 95% confidence intervals [CI]: 0.31 to 0.97; p = 0.040). This is comparable with a number needed to treat of 18.9. In individuals without a family history, events were minimally reduced: 6.6% in the treated versus 6.8% in the placebo group (HR: 1.04; 95% CI: 0.51 to 2.13; p = 0.912).
  
  
  CONCLUSIONS
  The combination of a positive family history and CCS above the 80th percentile identifies a subgroup within the primary prevention population that receives greater benefit from statin treatment than the population at large. These results have important implications for future guidelines concerning individuals with a positive family history for premature CAD.
authors.affiliation: Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
authors.forename: Ties A
authors.initials: TA
authors.lastname: Mulders
authors.forename: Suthesh
authors.initials: S
authors.lastname: Sivapalaratnam
authors.forename: Erik S G
authors.initials: ES
authors.lastname: Stroes
authors.forename: John J P
authors.initials: JJ
authors.lastname: Kastelein
authors.forename: Alan D
authors.initials: AD
authors.lastname: Guerci
authors.forename: Sara-Joan
authors.initials: SJ
authors.lastname: Pinto-Sietsma
mesh_terms: D017668:Age of Onset; D000368:Aged; D058070:Asymptomatic Diseases; D000069059:Atorvastatin; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000235:genetics / Q000401:mortality; D005260:Female; D020022:Genetic Predisposition to Disease; D006538:Heptanoic Acids / Q000627:therapeutic use*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000517:prevention & control; D009204:Myocardial Revascularization; D009518:New York / Q000453:epidemiology; D018579:Patient Selection; D010375:Pedigree; D011322:Primary Prevention; D016016:Proportional Hazards Models; D011758:Pyrroles / Q000627:therapeutic use*; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000401:mortality / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D061205:Vascular Calcification / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000235:genetics / Q000401:mortality
chemical_list: D006538:Heptanoic Acids; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D011758:Pyrroles; D000069059:Atorvastatin