Guideline-Based Statin Eligibility and Cardiovascular Events

Study Questions:

Does the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for treatment of blood cholesterol improve identification of individuals who develop incident cardiovascular disease (CVD) and/or have coronary artery calcification (CAC), compared with the 2004 Updated Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) guidelines?


The study was conducted in participants within the offspring and third-generation cohorts of the Framingham Heart Study (FRS) who underwent multidetector computed tomography for CAC between 2002 and 2005 and were followed up for a median of 9.4 years for incident CVD. Statin eligibility was determined based on Framingham risk factors and low-density lipoprotein cholesterol (LDL-C) thresholds for ATP III, and the pooled cohort calculator (≥7.5% 10-year risk) was used for ACC/AHA.


Among 2,435 statin-naïve participants (mean age, 51.3 [8.6] years; 56% female), 39% (941/2,435) were statin eligible by ACC/AHA compared with 14% (348/2,435) by ATP III (p < 0.001). There were 74 incident CVD events (40 nonfatal myocardial infarctions, 31 nonfatal ischemic strokes, and three fatal coronary heart disease [CHD] events). Participants who were statin eligible by ACC/AHA had increased hazard ratios for incident CVD compared with those eligible by ATP III: 6.8 vs. 3.1 (p < 0.001). Similar results were seen for CVD in participants with intermediate FRS and for CHD. Participants who were newly statin eligible (n = 593 [24%]) had an incident CVD rate of 5.7%, yielding a number needed to treat of 39-58. Participants with CAC were more likely to be statin eligible by ACC/AHA than by ATP III at each strata of CAC score: >0, >100, and >300 (all p < 0.001). A CAC score of 0 identified a low-risk group among ACC/AHA statin-eligible participants (306/941 [33%]) with a CVD rate of 1.6%.


In this community-based primary prevention cohort, the ACC/AHA guideline for determining statin eligibility, compared with the ATP III, was associated with greater accuracy and efficiency in identifying increased risk of incident CVD and subclinical coronary artery disease, particularly in intermediate-risk participants.


Concerns have been expressed that the new guidelines would increase the number of adults ages 40-75 years eligible for statins from 43 million (ATP III) to 56 million (ACC/AHA). While true, the authors of this study estimated that between 41,000 and 63,000 incident CVD events would be prevented over a 10-year period by adopting the new guideline. Whether using the ATP III or ACC/AHA guideline, about one third of the statin-eligible patients had a zero CAC score, which was associated with a 16/1,000 10-year event rate.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and Coronary Artery Disease, Interventions and Imaging, Computed Tomography, Nuclear Imaging

Keywords: Adenosine Triphosphate, Cholesterol, Cholesterol, LDL, Coronary Artery Disease, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipoproteins, LDL, Multidetector Computed Tomography, Myocardial Infarction, Primary Prevention, Risk, Risk Factors, Stroke, Vascular Calcification

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