Asymptomatic Individuals With a Positive Family History for Premature Coronary Artery Disease and Elevated Coronary Calcium Scores Benefit From Statin Treatment: A Post Hoc Analysis From the St. Francis Heart Study

Study Questions:

Do individuals with a positive family history for premature coronary artery disease (CAD) and coronary calcium scoring (CCS) above the 80th percentile benefit from preventive treatment?

Methods:

A post-hoc analysis was conducted using the database of the St. Francis Heart trial to assess efficacy of atorvastatin 20 mg/day in those with CCS above the 80th percentile and presence (n = 543) or absence (n = 462) of a positive family history for premature CAD. All participants received aspirin 81 mg/day. The primary outcome included coronary death, myocardial infarction, coronary revascularization, stroke, and arterial surgery.

Results:

A total of 1,005 individuals, with a mean age of 59.0 ± 5.9 years and a median absolute CCS of 370 Agatston units (interquartile range [IQ], 183-662) participated in the trial. After a follow-up of 4.3 (IQ 3.5-4.5) years, 7.2% of the treated individuals with a positive family history had a cardiovascular event versus 12.5% of the placebo group (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.31-0.97; p = 0.040). This is comparable with a number needed to treat of 18.9. In individuals without a family history, events were minimally reduced: 6.6% in the treated versus 6.8% in the placebo group (HR, 1.04; 95% CI, 0.51-2.13; p = 0.912).

Conclusions:

The combination of a positive family history and CCS above the 80th percentile identifies a subgroup within the primary prevention population that receives greater benefit from statin treatment than the population at large. These results have important implications for future guidelines concerning individuals with a positive family history for premature CAD.

Perspective:

Family history of premature CAD was not found to be helpful in several epidemiological studies, including the Framingham study. This was thought to be due to the inaccuracy of the diagnosis of coronary disease and its manifestations. With the advent of revascularization and improved health care information, family history provided by first- and second-degree relatives is likely to be very useful, as seen in this study.

Clinical Topics: Dyslipidemia, Prevention, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Pyrroles, Coronary Artery Disease, Myocardial Infarction, Stroke, Follow-Up Studies, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Confidence Intervals, Heptanoic Acids, Primary Prevention, Calcium


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