Johns Hopkins Ciccarone Preventive Cardiology Center, Baltimore, MD 21287, USA.
Lancet. 2011 Aug 20;378(9792):684-92. doi: 10.1016/S0140-6736(11)60784-8.
BACKGROUND: The JUPITER trial showed that some patients with LDL-cholesterol concentrations less than 3·37 mmol/L (<130 mg/dL) and high-sensitivity C-reactive protein (hsCRP) concentrations of 2 mg/L or more benefit from treatment with rosuvastatin, although absolute rates of cardiovascular events were low. In a population eligible for JUPITER, we established whether coronary artery calcium (CAC) might further stratify risk; additionally we compared hsCRP with CAC for risk prediction across the range of low and high hsCRP values. METHODS: 950 participants from the Multi-Ethnic Study of Atheroslcerosis (MESA) met all criteria for JUPITER entry. We compared coronary heart disease and cardiovascular disease event rates and multivariable-adjusted hazard ratios after stratifying by burden of CAC (scores of 0, 1-100, or >100). We calculated 5-year number needed to treat (NNT) by applying the benefit recorded in JUPITER to the event rates within each CAC strata. FINDINGS: Median follow-up was 5·8 years (IQR 5·7-5·9). 444 (47%) patients in the MESA JUPITER population had CAC scores of 0 and, in this group, rates of coronary heart disease events were 0·8 per 1000 person-years. 74% of all coronary events were in the 239 (25%) of participants with CAC scores of more than 100 (20·2 per 1000 person-years). For coronary heart disease, the predicted 5-year NNT was 549 for CAC score 0, 94 for scores 1-100, and 24 for scores greater than 100. For cardiovascular disease, the NNT was 124, 54, and 19. In the total study population, presence of CAC was associated with a hazard ratio of 4·29 (95% CI 1·99-9·25) for coronary heart disease, and of 2·57 (1·48-4·48) for cardiovascular disease. hsCRP was not associated with either disease after multivariable adjustment. INTERPRETATION: CAC seems to further stratify risk in patients eligible for JUPITER, and could be used to target subgroups of patients who are expected to derive the most, and the least, absolute benefit from statin treatment. Focusing of treatment on the subset of individuals with measurable atherosclerosis could allow for more appropriate allocation of resources. FUNDING: National Institutes of Health-National Heart, Lung, and Blood Institute.
背景：JUPITER 试验表明，一些 LDL-胆固醇浓度低于 3.37mmol/L（<130mg/dL）且高敏 C 反应蛋白（hsCRP）浓度为 2mg/L 或更高的患者受益于瑞舒伐他汀治疗，尽管心血管事件的绝对发生率较低。在符合 JUPITER 条件的人群中，我们确定冠状动脉钙（CAC）是否可以进一步分层风险；此外，我们比较了 hsCRP 与 CAC 在低 hsCRP 值和高 hsCRP 值范围内的风险预测。
方法：多民族动脉粥样硬化研究（MESA）的 950 名参与者符合 JUPITER 入组的所有标准。我们比较了 CAC 负担分层（得分 0、1-100 或>100）后冠心病和心血管疾病事件发生率和多变量调整后的危险比。我们通过将 JUPITER 中记录的益处应用于每个 CAC 层的事件率，计算了 5 年需要治疗的人数（NNT）。
结果：中位随访时间为 5.8 年（IQR 5.7-5.9）。MESA JUPITER 人群中 444 名（47%）患者的 CAC 评分为 0，在此组中，冠心病事件发生率为每 1000 人年 0.8 例。所有冠心病事件的 74%发生在 CAC 评分>100 的 239 名（25%）参与者中（每 1000 人年 20.2 例）。对于冠心病，CAC 评分为 0 的预测 5 年 NNT 为 549，评分为 1-100 的为 94，评分为>100 的为 24。对于心血管疾病，NNT 分别为 124、54 和 19。在整个研究人群中，CAC 的存在与冠心病的危险比为 4.29（95%CI 1.99-9.25），与心血管疾病的危险比为 2.57（1.48-4.48）相关。多变量调整后，hsCRP 与两种疾病均无关。
解释：CAC 似乎可以进一步分层符合 JUPITER 条件的患者的风险，并且可以用于针对预计从他汀类药物治疗中获得最大和最小绝对获益的患者亚组。将治疗重点放在可测量动脉粥样硬化的亚组上，可以更合理地分配资源。
资助：美国国立卫生研究院-国家心肺血液研究所。
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