Intensive LDL-C Lowering and Atherosclerosis Progression

Study Questions:

What is the relationship between temporal changes in coronary plaque volume and the intensity of lipid-lowering treatments, as measured with coronary computed tomography angiography (CTA)?

Methods:

A multicenter, observational study was conducted in 147 patients who underwent serial coronary CTA with a scan period of more than 2 years apart (median 3.2 years [2.4-4.8 years]), with laboratory data available within 1 month of the baseline and follow-up coronary CTA. The 147 patients had 336 vessels with measurable plaque. Three blinded observers performed quantitative assessment of coronary plaques. Patients who achieved a low-density lipoprotein cholesterol (LDL-C) with a cut off value <70 mg/dl at follow-up were compared with those who did not.

Results:

At baseline, 60% of patients were asymptomatic and 28% had atypical chest pain, which were similar at follow-up. Mean age was 62 years, 57% were male, 65% had hypertension, 20% were smokers, 5% had a history of percutaneous coronary intervention, and 5% a stroke. Using National Cholesterol Education Program Adult Treatment Program III risk, 55% were low, 32% intermediate, and 13% high risk. Forty patients were not started on statins, 55 were initiated or had an increased dose, and 41 remained on the same dose. At follow-up, the LDL-C was 57 mg/dl in the group with LDL-C <70 mg/dl and 104 mg/dl when ≥70 mg/dl. A greater percent of on-treatment LDL-C <70 mg/dl was seen in diabetics and with an increasing number of risk factors. The mean annual plaque volume progression rate was 3.63 ± 5.83%. Patients with LDL-C <70 mg/dl displayed a significant attenuation in plaque progression as compared with those with follow-up LDL-C levels ≥70 mg/dl (12.7 ± 38.2 mm3 vs. 44.2 ± 73.6 mm3, respectively; p = 0.014). In multivariate analysis, the only factor significantly influencing plaque progression per year was follow-up LDL-C levels ≥70 mg/dl (beta 0.195; p = 0.021).

Conclusions:

An LDL-C target of <70 mg/dl appeared to significantly attenuate plaque volume progression based on noninvasive quantitative assessment by coronary CTA.

Perspective:

This was an observational study with irregular use of statins in persons with CAD and poorly defined indications for the second coronary CTA. That coronary CTA can be used to measure change in plaque volume over a relatively short period of time in a modest number of patients may be important for the evaluation of novel anti-atherosclerotic therapies.

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

Keywords: Angiography, Atherosclerosis, Chest Pain, Cholesterol, Cholesterol, LDL, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Percutaneous Coronary Intervention, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Stroke, Tomography, Tomography, X-Ray Computed


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