Pursnani Amit, Taron Jana, Mayrhofer Thomas, Lu Michael T, Ferencik Maros, Ladapo Joseph A, Douglas Pamela S, Hoffmann Udo
Cardiology Division, NorthShore University Health System, Evanston, IL 60201, USA.
Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
J Clin Med. 2020 Sep 24;9(10):3076. doi: 10.3390/jcm9103076.
Recommendations for preventive statin treatment in patients with stable chest pain may be difficult as symptoms can be unspecific. It is unclear if coronary CT angiography (CTA)-detected coronary artery disease (CAD) can optimize statin prescription.
In stable chest pain patients randomized to CTA in the PROMISE trial, statin eligibility was defined per 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Primary outcome was a composite of death, myocardial infarction or unstable angina over 26 months median follow-up. Hazard ratios (HR) of non-obstructive (1-69% stenosis) and obstructive (≥70% stenosis) CAD for events were determined using Cox proportional hazard models. Calculated HR were then incorporated into the ACC/AHA pooled cohort equation (PCE) to revised ASCVD risk and assess re-classification of statin eligibility.
Among 3986 patients (60.5 ± 8.2 years; 51% female), 72.9% (2904/3986) were statin eligible. Event rates in statin-eligible vs. ineligible patients were 3.3% vs. 2.3% (HR = 1.4 (95% CI 0.9-2.2), = 0.142). Although the proportion of statin-eligible patients increased with CAD severity, 54% without CAD were statin eligible. Incorporating information on CAD into PCE reclassified 12.7% of patients (1.3% towards statin, 11.4% towards no statin). Similar results were found in stratified analysis of statin naïve patients (reclassification of 13.9%, 1.0% towards statin, and 12.9% towards no statin). As a result, revised ASCVD risk improved model discrimination in all patients (c-statistic: 0.59 (95 %CI 0.55-0.62) vs. 0.52 (95 %CI 0.49-0.56); 0.001), while reducing statin use by 10.1% (62.7% vs. 72.9% statin eligible, 0.001).
In stable chest pain patients, integration of CAD into guideline recommendations was associated with greater accuracy to reclassify those at increased risk for incident events and a more efficient use of statins.
对于稳定型胸痛患者进行他汀类预防性治疗的建议可能存在困难，因为症状可能不具有特异性。目前尚不清楚冠状动脉CT血管造影（CTA）检测到的冠状动脉疾病（CAD）是否能优化他汀类药物的处方。
在PROMISE试验中，将稳定型胸痛患者随机分为接受CTA检查组，根据2018年美国心脏病学会/美国心脏协会（ACC/AHA）指南定义他汀类药物的适用标准。主要结局是在26个月的中位随访期内死亡、心肌梗死或不稳定型心绞痛的复合终点。使用Cox比例风险模型确定非阻塞性（狭窄1%-69%）和阻塞性（狭窄≥70%）CAD事件的风险比（HR）。然后将计算出的HR纳入ACC/AHA汇总队列方程（PCE），以修订动脉粥样硬化性心血管疾病（ASCVD）风险并评估他汀类药物适用标准的重新分类。
在3986例患者（60.5±8.2岁；51%为女性）中，72.9%（2904/3986）符合他汀类药物治疗标准。符合他汀类药物治疗标准与不符合标准的患者事件发生率分别为3.3%和2.3%（HR=1.4（95%CI 0.9-2.2），P=0.142）。尽管符合他汀类药物治疗标准的患者比例随CAD严重程度增加而升高，但54%无CAD的患者也符合他汀类药物治疗标准。将CAD信息纳入PCE后，12.7%的患者重新分类（1.
