title: Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis).
abstract: BACKGROUND
  The American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy.
  
  
  OBJECTIVE
  This study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not.
  
  
  METHODS
  MESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis.
  
  
  RESULTS
  The study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years.
  
  
  CONCLUSIONS
  Significant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy.
authors.affiliation: Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Department of Epidemiology, Robert Stempel College of Public Health and Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida. Electronic address: KhurramN@baptisthealth.net.
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
authors.affiliation: Center for Clinical and Epidemiological Research and Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil; Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Preventive Medicine Centre, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors.forename: Marcio S
authors.initials: MS
authors.lastname: Bittencourt
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida.
authors.forename: Arthur S
authors.initials: AS
authors.lastname: Agatson
authors.affiliation: Mount Sinai Hospital, Miami Beach, Florida.
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Rivera
authors.affiliation: Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Miedema
authors.affiliation: Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Miemdema
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland Oregon.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Sibley
authors.affiliation: Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, Georgia.
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors.forename: Roger S
authors.initials: RS
authors.lastname: Blumenthal
authors.affiliation: Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: Section of Cardiovascular Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000572:American Heart Association; D050197:Atherosclerosis / Q000188:drug therapy; D002118:Calcium / Q000032:analysis*; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000208:ethnology; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000378:metabolism; D005006:Ethnicity; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002118:Calcium
keywords: atherosclerosis; cholesterol; hydroxymethylglutaryl-CoA reductase inhibitors; risk assessment