Tralhão António, Ferreira António M, Gonçalves Pedro de Araújo, Rodrigues Rita, Costa Cátia, Guerreiro Sara, Cardim Nuno, Marques Hugo
aDepartment of Cardiovascular Imaging, Hospital da Luz bCEDOC, Nova Medical School, Lisbon, Portugal.
Coron Artery Dis. 2016 Nov;27(7):573-9. doi: 10.1097/MCA.0000000000000398.
Different cardiovascular risk calculators and risk-based thresholds for initiating statin therapy are currently in use. Using coronary computed tomography angiography, we sought to compare the Pooled-Cohort Equation [atherosclerotic cardiovascular disease (ASCVD) score] with the Systematic COronary Risk Evaluation (SCORE) in the identification of patients with high coronary atherosclerotic burden.
In a single-center prospective registry of patients undergoing coronary computed tomography angiography, we identified individuals aged 40-75 years without diabetes or known cardiovascular disease. Cardiovascular risk and eligibility for statin therapy were determined individually on the basis of the two calculators and the guidelines that endorse them. Coronary atherosclerotic burden was assessed by coronary calcium score, presence of stenosis greater than or equal to 50%, and several measures of plaque severity and extension.
In the 327 patients assessed (181 men, mean age 59±9 years), the median SCORE and ASCVD values were 2.6 and 9.7%, respectively. Compared with SCORE, the ASCVD calculator showed greater discriminative power to identify patients with calcium score greater than or equal to 300 [C-statistic 0.74, 95% confidence interval (CI) 0.67-0.82 vs. 0.69, 95% CI 0.61-0.78, P=0.008] and showed a trend toward better identification of patients with obstructive stenosis (C-statistic 0.72, 95% CI 0.64-0.80 vs. 0.68, 95% CI 0.60-0.76, P=0.053). The proportion of statin-eligible patients would be higher with the SCORE-based criteria, particularly among individuals with little or no detectable coronary atherosclerosis.
The SCORE calculator seems to be less discriminative than the ASCVD equation in identifying patients with high atherosclerotic burden. Current SCORE-based criteria would assign statin therapy to a larger proportion of patients with low-risk features, which could result in a lower yield of cholesterol-reducing strategies.
目前使用着不同的心血管风险计算器以及启动他汀类药物治疗的基于风险的阈值。我们利用冠状动脉计算机断层扫描血管造影术，比较汇总队列方程（动脉粥样硬化性心血管疾病[ASCVD]评分）与系统性冠状动脉风险评估（SCORE）在识别冠状动脉粥样硬化负荷较高患者方面的差异。
在一项针对接受冠状动脉计算机断层扫描血管造影术患者的单中心前瞻性登记研究中，我们纳入了年龄在40 - 75岁、无糖尿病或已知心血管疾病的个体。根据这两种计算器及其所支持的指南，分别确定心血管风险和他汀类药物治疗的适用性。通过冠状动脉钙化评分、≥50%狭窄的存在情况以及斑块严重程度和范围的多项指标来评估冠状动脉粥样硬化负荷。
在评估的327例患者（181例男性，平均年龄59±9岁）中，SCORE和ASCVD值的中位数分别为2.6和9.7%。与SCORE相比，ASCVD计算器在识别钙化评分≥300的患者方面具有更大的辨别力[C统计量0.74，95%置信区间（CI）0.67 - 0.82对比C统计量0.69，95% CI 0.61 - 0.78，P = 0.008]，并且在识别阻塞性狭窄患者方面显示出更好识别的趋势（C统计量0.72，95% CI 0.64 - 0.80对比C统计量0.68，95% CI 0.60 - 0.76，P = 0.053）。基于SCORE标准，符合他汀类药物治疗条件的患者比例会更高，尤其是在几乎没有或没有可检测到的冠状动脉粥样硬化的个体中。
在识别具有高粥样硬化负荷的患者方面，SCORE计算器似乎比ASCVD方程的辨别力更低。当前基于SCORE的标准会将他汀类药物治疗分配给更大比例具有低风险特征的患者，这可能导致降低胆固醇策略的收益。
