Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
JACC Cardiovasc Imaging. 2012 Mar;5(3):252-60. doi: 10.1016/j.jcmg.2011.11.014.
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.
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.
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.
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).
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.
本研究旨在评估具有早发冠心病阳性家族史和冠状动脉钙评分（CCS）超过第 80 百分位数的个体是否可能从预防性治疗中获益。
早发冠心病患者的一级亲属患心血管疾病（CVD）的风险增加，而这些个体的事件预测效果不佳。替代标志物，如 CCS，可能会改善风险评分。然而，阿托伐他汀 20mg/天对 CCS 超过第 80 百分位数的无症状个体的 St. Francis 心脏试验的结果并未达到统计学意义。
我们对 St. Francis 试验的数据库进行了事后分析，以评估阿托伐他汀 20mg/天治疗 CCS 超过第 80 百分位数且存在（n=543）或不存在（n=462）早发冠心病阳性家族史的个体的疗效。所有参与者均接受阿司匹林 81mg/天治疗。主要结局包括冠心病死亡、心肌梗死、冠状动脉血运重建、卒中和动脉手术。
共有 1005 名平均年龄 59.0±5.9 岁、CCS 中位数为 370 个 Agatston 单位（四分位距：183 至 662）的个体参加了该试验。随访 4.3 年（四分位距：3.5 至 4.5）后，阳性家族史治疗组有 7.2%的个体发生心血管事件，而安慰剂组有 12.5%（风险比[HR]：0.55；95%置信区间[CI]：0.31 至 0.97；p=0.040）。这相当于需要治疗的人数为 18.9。在无家族史的个体中，事件减少幅度较小：治疗组为 6.6%，安慰剂组为 6.8%（HR：1.04；95%CI：0.51 至 2.13；p=0.912）。
阳性家族史和 CCS 超过第 80 百分位数的联合可确定初级预防人群中从他汀类药物治疗中获益大于总体人群的亚组。这些结果对涉及早发冠心病阳性家族史个体的未来指南具有重要意义。
