MedicalResearch.com Interview with:
Joseph Yeboah MD, MS M.B.Ch.B.
Maya Angelou Center for Health Equity
Epidemiology & Prevention
Heart and Vascular Center of Excellence
Wake Forest University School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Dr. Yeboah: In 2013 the American College of Cardiology/American Heart Association introduced a new way of atherosclerotic cardiovascular disease (ASCVD) risk assessment. The document also recommended the use of additional risk markers including coronary artery calcium (CAC), ankle brachial index, high sensitivity C-reactive protein, family history of ASCVD, to refine ASCVD risk assessment for primary prevention. The goal of this study was to assess the utility of these recommended additional risk markers for primary ASCVD risk assessment in the most ethnically diverse prospective cohort in the USA. We found that among the additional risk markers considered in this analysis, only coronary artery calcium modestly improved primary ASCVD risk assessment.
Medical Research: What should clinicians and patients take away from your report?
Dr. Yeboah: I think physicians and patients should know that most of the recommended additional risk markers may not improve ASCVD risk assessment over and beyond the ASCVD risk estimator provided by the ACC/AHA.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Yeboah: ASCVD remains a leading cause of morbidity and mortality in the developed world including the USA. Primary prevention is the best approach for reducing this mortality and morbidity. Statins are effective for primary prevention of ASCVD but also has significant side effects. The present way of identifying asymptomatic people for statin therapy to reduce primary ASCVD events introduced by the ACC/AHA is not perfect and ends up treating a lot of individuals unnecessarily. So the ACC/AHA cholesterol guidelines also recommend the use of additional risk markers to help refine the ASCVD risk assessment in asymptomatic community dwelling individuals. Several lines of evidence including this report shows that coronary artery calcium may be best for refining primary ASCVD risk assessment. However, it is unclear whether individuals identified as high risk by CAC benefits from statin therapy. Physicians and patients are aware of these observational studies showing superiority of CAC for refining ASCVD risk assessment. Therefore even though CAC scoring is not covered by most insurance, most patients are willing to pay out of pocket to obtain it for their physicians to make statin eligibility decisions based on the results. In addition to the cost, CAC also exposes patients/individuals to a small but non trivial amount of radiation. If statin therapy is not beneficial in individuals with significant coronary artery calcium as inferred from observational studies, then this should be one of the public health concerns of our time given the significant number of patients on the drug. The NIH should put this debate and public health concern to rest by funding a large randomized clinical trial investigating the effects of statins on asymptomatic individuals classified as high risk by either CAC alone or by the addition of CAC to current ASCVD risk estimator.