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Review
. 2017 Sep;10(9):1031-1038.
doi: 10.1016/j.jcmg.2016.10.022. Epub 2017 Mar 15.

Nonobstructive Coronary Artery Disease by Coronary CT Angiography Improves Risk Stratification and Allocation of Statin Therapy

Hamed Emami  1 , Richard A P Takx  2 , Thomas Mayrhofer  3 , Sumbal Janjua  2 , Jakob Park  2 , Amit Pursnani  2 , Ahmed Tawakol  2 , Michael T Lu  2 , Maros Ferencik  4 , Udo Hoffmann  5
Affiliations
Review

Nonobstructive Coronary Artery Disease by Coronary CT Angiography Improves Risk Stratification and Allocation of Statin Therapy

Hamed Emami et al. JACC Cardiovasc Imaging. 2017 Sep.

Abstract

Objectives: This study sought to determine prognostic value of nonobstructive coronary artery disease (CAD) for atherosclerotic cardiovascular disease (ASCVD) events and to determine whether incorporation of this information into the pooled cohort equation reclassifies recommendations for statin therapy as defined by the 2013 guidelines for cholesterol management of the American College of Cardiology and American Heart Association (ACC/AHA).

Background: Detection of nonobstructive CAD by coronary computed tomography angiography may improve risk stratification and permit individualized and more appropriate allocation of statin therapy.

Methods: This study determined the pooled hazard ratio of nonobstructive CAD for ASCVD events from published studies and incorporated this information into the ACC/AHA pooled cohort equation. The study calculated revised sex- and ethnicity-based 10-year ASCVD risk and determined boundaries corresponding to the original 7.5% risk for ASCVD events. It also assessed reclassification for statin eligibility by incorporating the results from meta-analysis to individual patients from a separate cohort.

Results: This study included 2 studies (2,295 subjects; 66% male; prevalence of nonobstructive CAD, 47%; median follow-up, 49 months; 67 ASCVD events). The hazard ratio of nonobstructive CAD for ASCVD events was 3.2 (95% confidence interval: 1.5 to 6.7). Incorporation of this information into the pooled cohort equation resulted in reclassification toward statin eligibility in individuals with nonobstructive CAD, with an original ASCVD score of 3.0% and 5.9% or higher in African-American women and men and a score of 4.4% and 4.6% or higher in Caucasian women and men, respectively. The absence of nonobstructive CAD resulted in reclassification toward statin ineligibility if the original ASCVD score was as 10.0% and 17.9% or lower in African-American women and men and 13.7% and 14.3% or lower in Caucasian women and men, respectively. Reclassification is observed in 14% of patients.

Conclusions: Detection of nonobstructive CAD by coronary computed tomography angiography improves risk stratification and permits individualized and more appropriate allocation of statin therapy across sex and ethnicity groups.

Keywords: 2013 American College of Cardiology and American Heart Association prevention guidelines; coronary artery disease; prognosis; risk factors.

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Figures

Figure 1
Figure 1
Literature search and selection of eligible studies
Figure 2
Figure 2
Risk estimates of ASCVD events for presence of non-obstructive CAD
Figure 3
Figure 3
Reclassification thresholds (including 95% confidence intervals) of original ASCVD risk calculator to determine statin eligibility based on coronary CTA findings
Figure 4
Figure 4
Application of original and modified ASCVD risk calculators in primary prevention patient population
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