Cardiovascular Division, Miller School of Medicine, University of Miami, FL.
Department of Applied Health Science, School of Public Health, Indiana University Bloomington, IN.
Mayo Clin Proc. 2020 Aug;95(8):1740-1749. doi: 10.1016/j.mayocp.2020.01.016. Epub 2020 Jul 6.
Allocation of statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in borderline- and intermediate-risk patients has traditionally been based on population-based global risk assessment and other clinical and laboratory characteristics. Patient-specific treatment decisions are needed to provide maximal benefit and avoid unnecessary treatment. Guideline-based lipid management proposes that coronary artery calcium scoring is reasonable to implement in patients with a 10-year risk of 5.0% to 19.9% (borderline to intermediate risk) by using the pooled cohort equations when the decision about whether to initiate statin therapy is uncertain. We report data from both observational studies and a large primary prevention randomized controlled trial that support the position that this decision is, in fact, uncertain in about half of such patients because of risk misclassification. Such misclassification can be largely avoided by more widespread implementation of coronary calcium scoring, which helps to identify those with coronary artery calcium scores of 0, a finding associated with a less than 5.0% 10-year probability of an ASCVD event. Deferral of statin therapy in such patients, in the absence of smoking, diabetes, or a family history of premature ASCVD, provides more individualized and appropriate care and avoids the expense and potential adverse effects of statin therapy in those with low potential for absolute risk reduction. A rationale is also provided for the importance of coronary artery calcium scoring in women 50 years and older, possibly in place of 1 screening mammogram in women at least 55 years of age to avoid incremental radiation exposure, on the basis of the substantially higher lifetime risk of morbidity and mortality from ASCVD than from breast cancer. In patients with borderline or intermediate ASCVD risk, coronary artery calcium scoring should be used, whenever possible, as an aid to rational statin allocation for the primary prevention of ASCVD.
他汀类药物治疗用于动脉粥样硬化性心血管疾病（ASCVD）一级预防的分配，传统上基于基于人群的总体风险评估和其他临床及实验室特征。需要根据患者具体情况制定治疗决策，以获得最大获益并避免不必要的治疗。基于指南的血脂管理建议，当是否开始他汀类药物治疗的决策不确定时，对于 10 年风险为 5.0%至 19.9%（边界到中间风险）的患者，使用汇总队列方程，进行冠状动脉钙评分是合理的。我们报告了来自观察性研究和一项大型一级预防随机对照试验的数据，这些数据支持这样的观点，即在大约一半的此类患者中，由于风险分类错误，实际上这一决策是不确定的。通过更广泛地实施冠状动脉钙评分，可以在很大程度上避免这种错误分类，这有助于识别那些冠状动脉钙评分为 0 的患者，这一发现与 ASCVD 事件的 10 年概率小于 5.0%相关。在没有吸烟、糖尿病或 ASCVD 早发家族史的情况下，对这些患者推迟他汀类药物治疗，可提供更个体化和更恰当的治疗，并避免在绝对风险降低可能性较低的患者中应用他汀类药物治疗的费用和潜在不良反应。此外，基于 ASCVD 发病率和死亡率的终生风险明显高于乳腺癌，还为年龄在 50 岁及以上的女性，在可能的情况下用冠状动脉钙评分代替至少 55 岁女性 1 次筛查性乳房 X 线摄影，以避免额外的辐射暴露，提供了重要的理由。对于具有 ASCVD 边缘或中间风险的患者，只要有可能，就应使用冠状动脉钙评分来辅助合理分配他汀类药物，以进行 ASCVD 的一级预防。
