ARTICLE: Using Trial Eligibility to Personalize Statin Therapy Appears No More Accurate Than a Coin Flip in Determining High-Risk Status*

AUTHORS: Roger S. Blumenthal, M. Imran Aslam, William McEvoy

JOURNAL: JACC Cardiovasc Imaging. 2017 Jun 9. pii: S1936-878X(17)30403-5. doi: 10.1016/j.jcmg.2017.02.019. [Epub ahead of print]

Is it possible that around one-half of middle-aged adults estimated to be at high enough atherosclerotic cardiovascular disease (ASCVD) risk to warrant statin therapy using conventional risk equations or clinical trial results actually have very low “real-world” risk as predicted by a zero coronary artery calcium (CAC) score? Are we exposing such individuals to long-term pharmacologic therapy to prevent the consequences of a disease that they are unlikely to get? Such an illogical scenario could be thought of as akin to giving metformin to all adults over age 40 regardless of their glycemic status.

Middle-aged and older adults with a CAC score of zero have excellent survival with 10-year cardiovascular event rates of approximately 1% (1), and zero CAC is present in 40% to 50% of those with conventional indications for statin therapy (based either on primary prevention trials or risk equation thresholds) (2,3). Thus, the use of conventional trial or risk-based allocation of statin therapy could be thought of as equivalent to the coin toss at the beginning of overtime in Super Bowl LI to decide which team would have possession of the ball and control of their own fate. In essence, there is an approximately 50:50 chance that any middle-aged adult with a statin indication has zero CAC.

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