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Available online 3 September 2021
Impact of lipid-lowering therapies on cardiovascular outcomes according to coronary artery calcium score. A systematic review and meta-analysis
Impacto de las terapias hipolipemiantes en los resultados cardiovasculares según la puntuación de calcio coronario. Revisión sistemática y metanálisis
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Guglielmo Gallonea,
Corresponding author
guglielmo.gallone@gmail.com

Corresponding author: Division of Cardiology, Città della Salute e della Scienza, Corso Bramante 88/90, 10126 Torino, Italy.
, Edoardo Eliaa, Francesco Brunoa, Filippo Angelinia, Luca Franchina, Pier Paolo Bocchinoa, Francesco Pirolia, Umberto Annonea, Andrea Montabonea, Giorgio Marengoa, Maurizio Bertainaa, Ovidio De Filippoa, Luca Baldettib, Anna Palmisanoc, Alessandro Serafinid, Antonio Espositoc, Alessandro Depaolid, Fabrizio D’ascenzoa, Paolo Foniod, Gaetano Maria De Ferraria
a Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Torino, Italy
b Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
c Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
d Department of Radiology, Città della Salute e della Scienza, Torino, Italy
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Tables (3)
Table 1. General characteristics of the included studies
Table 2. Baseline characteristics of the study populations overall and stratified by lipid-lowering therapy status
Table 3. Odds ratios (95% confidence intervals) for ASCVD occurrence categorized by CAC strata
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Abstract
Introduction and objectives

Coronary artery calcium (CAC) score improves the accuracy of risk stratification for atherosclerotic cardiovascular disease (ASCVD) events compared with traditional cardiovascular risk factors. We evaluated the interaction of coronary atherosclerotic burden as determined by the CAC score with the prognostic benefit of lipid-lowering therapies in the primary prevention setting.

Methods

We reviewed the MEDLINE, EMBASE, and Cochrane databases for studies including individuals without a previous ASCVD event who underwent CAC score assessment and for whom lipid-lowering therapy status stratified by CAC values was available. The primary outcome was ASCVD. The pooled effect of lipid-lowering therapy on outcomes stratified by CAC groups (0, 1-100,> 100) was evaluated using a random effects model.

Results

Five studies (1 randomized, 2 prospective cohort, 2 retrospective) were included encompassing 35 640 individuals (female 38.1%) with a median age of 62.2 [range, 49.6-68.9] years, low-density lipoprotein cholesterol level of 128 (114-146) mg/dL, and follow-up of 4.3 (2.3-11.1) years. ASCVD occurrence increased steadily across growing CAC strata, both in patients with and without lipid-lowering therapy. Comparing patients with (34.9%) and without (65.1%) treatment exposure, lipid-lowering therapy was associated with reduced occurrence of ASCVD in patients with CAC> 100 (OR, 0.70; 95%CI, 0.53-0.92), but not in patients with CAC 1-100 or CAC 0. Results were consistent when only adjusted data were pooled.

Conclusions

Among individuals without a previous ASCVD, a CAC score> 100 identifies individuals most likely to benefit from lipid-lowering therapy, while undetectable CAC suggests no treatment benefit.

Keywords:
Coronary artery calcium score
Primary prevention
Lipid lowering therapy
Atherosclerotic cardiovascular disease
Meta-analysis
Abbreviations:
ASCVD
CAC
Resumen
Introducción y objetivos

La puntuación de calcio coronario (CAC) mejora la precisión de la estratificación del riesgo de enfermedad cardiovascular ateroesclerótica (ECVA) en comparación con los factores de riesgo cardiovascular tradicionales. Se evaluó la interacción de la carga ateroesclerótica coronaria determinada por la puntuación de CAC con el beneficio pronóstico de los tratamientos hipolipemiantes en el contexto de la prevención primaria.

Métodos

Se revisaron las bases de datos MEDLINE, EMBASE y Cochrane en busca de estudios que incluyeran a individuos sin ECVA previa y con datos sobre la puntuación de CAC y el tratamiento hipolipemiante según los valores de CAC. El objetivo primario fue la aparición de ECVA. Se evaluó el efecto del tratamiento hipolipemiante agrupado y estratificado por grupos de CAC (0, 1-100 y> 100) mediante un modelo de efectos aleatorios.

Resultados

Se incluyeron 5 estudios (1 aleatorizado, 2 de cohortes prospectivas y 2 retrospectivas) que incluyeron a 35.640 individuos (el 38,1% mujeres) con medias de edad de 62,2 (intervalo, 49,6-68,9) años, colesterol unido a lipoproteínas de baja densidad de 128 (114-146) mg/dl y seguimiento de 4,3 (2,3-11,1) años. La aparición de la ECVA aumentó de manera constante junto con los estratos de CAC en los pacientes tanto con como sin tratamiento hipolipemiante. Al comparar a los pacientes con (34,9%) y sin (65,1%) exposición al tratamiento hipolipemiante, este se asoció con menos aparición de ECVA en los pacientes con CAC> 100 (OR=0,70; IC95%, 0,53-0,92), pero no en aquellos con CAC de 1-100 o 0. Los resultados concordaron al agrupar los datos ajustados.

Conclusiones

Entre los individuos sin ECVA previa, una puntuación de CAC> 100 identifica a los sujetos con mayor probabilidad de beneficiarse del tratamiento hipolipemiante, mientras que un CAC indetectable indica ausencia de beneficio.

Palabras clave:
Puntuación de calcio coronario
Prevención primaria
Tratamiento hipolipemiante
Enfermedad cardiovascular ateroesclerótica
Metanálisis

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