Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.
Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard School of Public Health, Boston, Massachusetts3Department of Cardiology, Tufts Medical Center, Boston, Massachusetts.
JAMA Cardiol. 2017 Jun 1;2(6):644-652. doi: 10.1001/jamacardio.2017.0944.
Modern prevention guidelines substantially increase the number of individuals who are eligible for treatment with statins. Efforts to refine statin eligibility via coronary calcification have been studied in white populations but not, to our knowledge, in large African American populations.
To compare the relative accuracy of US Preventive Services Task Force (USPSTF) and American College of Cardiology/American Heart Association (ACC/AHA) recommendations in identifying African American individuals with subclinical and clinical atherosclerotic cardiovascular disease (ASCVD).
DESIGN, SETTING, AND PARTICIPANTS: In this prospective, community-based study, 2812 African American individuals aged 40 to 75 years without prevalent ASCVD underwent assessment of ASCVD risk. Of these, 1743 participants completed computed tomography.
Nonzero coronary artery calcium (CAC) score, abdominal aortic calcium score, and incident ASCVD (ie, myocardial infarction, ischemic stroke, or fatal coronary heart disease).
Of the 2812 included participants, the mean (SD) age at baseline was 55.4 (9.4) years, and 1837 (65.3%) were female. The USPSTF guidelines captured 404 of 732 African American individuals (55.2%) with a CAC score greater than 0; the ACC/AHA guidelines identified 507 individuals (69.3%) (risk difference, 14.1%; 95% CI, 11.2-17.0; P < .001). Statin recommendation under both guidelines was associated with a CAC score greater than 0 (odds ratio, 5.1; 95% CI, 4.1-6.3; P < .001). While individuals indicated for statins under both guidelines experienced 9.6 cardiovascular events per 1000 patient-years, those indicated under only ACC/AHA guidelines were at low to intermediate risk (4.1 events per 1000 patient-years). Among individuals who were statin eligible by ACC/AHA guidelines, the 10-year ASCVD incidence per 1000 person-years was 8.1 (95% CI, 5.9-11.1) in the presence of CAC and 3.1 (95% CI, 1.6-5.9) without CAC (P = .02). While statin-eligible individuals by USPSTF guidelines did not have a significantly higher 10-year ASCVD event rate in the presence of CAC, African American individuals not eligible for statins by USPSTF guidelines had a higher ASCVD event rate in the presence of CAC (2.8 per 1000 person-years; 95% CI, 1.5-5.4) relative to without CAC (0.8 per 1000 person-years; 95%, CI 0.3-1.7) (P = .03).
The USPSTF guidelines focus treatment recommendations on 38% of high-risk African American individuals at the expense of not recommending treatment in nearly 25% of African American individuals eligible for statins by ACC/AHA guidelines with vascular calcification and at low to intermediate ASCVD risk.
现代预防指南大大增加了适合使用他汀类药物治疗的个体数量。已经在白人群体中研究了通过冠状动脉钙化来改进他汀类药物适应证的方法，但据我们所知，尚未在大型非裔美国人中进行研究。
比较美国预防服务工作组（USPSTF）和美国心脏病学会/美国心脏协会（ACC/AHA）建议在识别亚临床和临床动脉粥样硬化性心血管疾病（ASCVD）的非裔美国个体中的相对准确性。
设计、地点和参与者：在这项前瞻性、基于社区的研究中，2812 名年龄在 40 至 75 岁之间、无明显 ASCVD 的非裔美国人接受了 ASCVD 风险评估。其中，1743 名参与者完成了计算机断层扫描。
非零冠状动脉钙（CAC）评分、腹主动脉钙评分和新发 ASCVD（即心肌梗死、缺血性卒中和致命性冠心病）。
在纳入的 2812 名参与者中，基线时的平均（SD）年龄为 55.4（9.4）岁，1837 名（65.3%）为女性。USPSTF 指南识别出 732 名非裔美国人中 404 名（55.2%）CAC 评分大于 0；ACC/AHA 指南识别出 507 名（69.3%）（风险差异，14.1%；95%CI，11.2-17.0；P<0.001）。根据两个指南推荐他汀类药物的患者的 CAC 评分大于 0（比值比，5.1；95%CI，4.1-6.3；P<0.001）。虽然两个指南都建议他汀类药物治疗的患者每 1000 名患者中有 9.6 例心血管事件，但仅根据 ACC/AHA 指南建议他汀类药物治疗的患者的风险较低（每 1000 名患者中有 4.1 例）。在符合 ACC/AHA 指南他汀类药物适应证的患者中，每 1000 名患者中有 10 年 ASCVD 发生率为 8.1（95%CI，5.9-11.1），而 CAC 存在时为 3.1（95%CI，1.6-5.9）（P=0.02）。虽然符合 USPSTF 指南他汀类药物适应证的患者在 CAC 存在时 ASCVD 事件发生率没有显著升高，但不符合 USPSTF 指南他汀类药物适应证的非裔美国患者在 CAC 存在时 ASCVD 事件发生率更高（每 1000 名患者中有 2.8 例；95%CI，1.5-5.4），而 CAC 不存在时为 0.8 例（每 1000 名患者中有 0.8 例；95%CI，0.3-1.7）（P=0.03）。
USPSTF 指南将治疗建议重点放在了 38%的高危非裔美国人群上，而不是根据 ACC/AHA 指南建议，对近 25%的非裔美国人群进行治疗，这些人群的血管钙化且 ASCVD 风险处于低至中危水平。
