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Subclinical Atherosclerosis, Statin Eligibility in African Americans
Study Questions:
Do current preventive recommendations accurately identify African Americans with subclinical and clinical atherosclerotic cardiovascular disease (ASCVD)?
Methods:
Data from the Jackson Heart Study, a prospective community-based study of 5,306 African American adults residing in Jackson, MS, were used for the present analysis. Those ages 40-75 years who were not on statin therapy, were free of CVD, and were not missing variables used to calculate ASCVD risk were included. Assessment of ASCVD risk was calculated from the US Preventive Services Task Force (USPSTF) and the American College of Cardiology/American Heart Association (ACC/AHA) recommendations. The primary outcomes of interest were nonzero coronary artery calcium (CAC) score, abdominal aortic calcium score, and incident ASCVD (i.e., myocardial infarction, ischemic stroke, or fatal coronary heart disease).
Results:
From the total cohort, statin eligibility was calculated in 2,812 participants from visit 1 (2000-2004). A total of 1,743 participants completed computed tomography (CT) scans. The mean age of participants at baseline was 55.4 years, and 65.3% (n = 1,837) were female. The USPSTF guidelines captured 404 of 732 African American individuals (55.2%) with a CAC score >0; the ACC/AHA guidelines identified 507 individuals (69.3%) (risk difference, 14.1%; 95% confidence interval [CI], 11.2-17.0; p < 0.001). Statin recommendation under both guidelines was associated with a CAC score >0 (odds ratio, 5.1; 95% CI, 4.1-6.3; p < 0.001). Adults who had indications for statin therapy from both guidelines had a 9.6 per 1,000 patient-year CV event rate. Adults indicated for statins under only ACC/AHA guidelines were at low to intermediate risk (4.1 events per 1,000 patient-years). Among individuals who were statin eligible by ACC/AHA guidelines, the 10-year ASCVD incidence per 1,000 person-years was 8.1 (95% CI, 5.9-11.1) in the presence of CAC and 3.1 (95% CI, 1.6-5.9) without CAC (p = 0.02). While statin-eligible individuals by USPSTF guidelines did not have a significantly higher 10-year ASCVD event rate in the presence of CAC, African American individuals not eligible for statins by USPSTF guidelines had a higher ASCVD event rate in the presence of CAC (2.8 per 1,000 person-years; 95% CI, 1.5-5.4) relative to without CAC (0.8 per 1,000 person-years; 95%, CI, 0.3-1.7; p = 0.03).
Conclusions:
The authors concluded that the USPSTF guidelines focus treatment recommendations on 38% of high-risk African American individuals at the expense of not recommending treatment in nearly 25% of African American individuals eligible for statins by ACC/AHA guidelines with vascular calcification and at low to intermediate ASCVD risk.
Perspective:
These data support the use of the ACC/AHA guidelines for identifying African American adults likely to have vascular calcification, and thus, who may benefit from statin therapy.
Keywords: ACC17, ACC Annual Scientific Session, African Americans, Atherosclerosis, Cardiac Imaging Techniques, Coronary Artery Disease, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Plaque, Atherosclerotic, Primary Prevention, Stroke, Tomography, Tomography, X-Ray Computed, Vascular Calcification
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