The American College of Cardiology and the American Heart Association guidelines recommend
treatment of patients with severe hypercholesterolemia (low-density lipoprotein cholesterol
[LDL-C] ≥190 mg/100 ml) with a high-intensity statin. However, atherosclerotic cardiovascular
disease (ASCVD) risk, even among those with severe hypercholesterolemia, is heterogeneous,
and coronary artery calcium (CAC) scoring may be used to clarify risk. We sought to
evaluate CAC in patients with severe hypercholesterolemia and measure its impact on
real-world statin prescriptions. We identified patients with at least 1 LDL-C ≥190
mg100 ml who had a CAC scoring in the Community Benefit of No-Charge Calcium Score
Screening Program (CLARIFY) study (NCT04075162) between 2014 and 2020. We explored
the CAC distribution, factors associated with CAC >0, and ASCVD risk (myocardial infarction,
stroke, revascularization, death). A total of 1,904 patients (1.257 women, aged 57.8
± 9.3 years) with severe hypercholesterolemia were included. LDL-C ranged from 190
to 524 mg100 ml (mean 215.5 ± 27 mg100 ml). A total of 864 patients (45.4%) had CAC = 0
and 1,561 (82%) had CAC <100. In patients with LDL-C ≥250 mg100 ml, 67 (36.6%) had
CAC = 0. Age, male gender, smoking, diabetes, systolic blood pressure, and obesity
(ps ≤0.001) were associated with CAC >0. In patients with LDL-C ≥190 mg100 ml, CAC
was associated with a higher risk for ASCVD events (CAC ≥100 vs CAC <100, hazard ratio
3.57 [1.81 to 7.04], p <0.001). A higher CAC category was associated with increased
statin use after CAC scoring (p <0.001). In patients with severe hypercholesterolemia,
45% had CAC = 0, which was associated with a significantly lower ASCVD risk. CAC was
associated with statin prescription and cholesterol lowering. In conclusion, CAC scoring
may be used to clarify ASCVD risk in this heterogeneous population with severe hypercholesterolemia.
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References
- Genetic identification of familial hypercholesterolemia within a single U.S. health care system.Science. 2016; 354: aaf7000
- Familial hypercholesterolemias: prevalence, genetics, diagnosis and screening recommendations from the National Lipid Association Expert Panel on Familial Hypercholesterolemia.J Clin Lipidol. 2011; 5: S9-S17
- Use of low-density lipoprotein cholesterol gene score to distinguish patients with polygenic and monogenic familial hypercholesterolaemia: a case-control study.Lancet. 2013; 381: 1293-1301
- 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2019; 140: e596-e646
- Vascular calcification: pathobiology of a multifaceted disease.Circulation. 2008; 117: 2938-2948
- Coronary artery calcium and cardiovascular events in patients with familial hypercholesterolemia receiving standard lipid-lowering therapy.JACC Cardiovasc Imaging. 2019; 12: 1797-1804
- Clinical significance of zero coronary artery calcium in individuals with LDL cholesterol ≥190 mg/dL: the Multi-Ethnic Study of Atherosclerosis.Atherosclerosis. 2020; 292: 224-229
- No-charge coronary artery calcium screening for cardiovascular risk assessment.J Am Coll Cardiol. 2020; 76: 1259-1262
- Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society.Eur Heart J. 2013; 34 (3478a–390a)
- Large-Scale screening for monogenic and clinically defined familial hypercholesterolemia in Iceland.Arterioscler Thromb Vasc Biol. 2021; 41: 2616-2628
- Absence of coronary artery calcification in middle-aged familial hypercholesterolemia patients without atherosclerotic cardiovascular disease.JACC Cardiovasc Imaging. 2020; 13: 1090-1092
- Predicting cardiovascular events in familial hypercholesterolemia: the SAFEHEART registry (Spanish familial hypercholesterolemia cohort study).Circulation. 2017; 135: 2133-2144
- The added value of coronary calcium score in predicting cardiovascular events in familial hypercholesterolemia.JACC Cardiovasc Imaging. 2021; 14: 2414-2424
- Gender differences in coronary heart disease.Neth Heart J. 2010; 18: 598-602
- Coronary computed tomographic angiography findings and their therapeutic implications in asymptomatic patients with familial hypercholesterolemia. Lessons from the SAFEHEART study.J Clin Lipidol. 2018; 12: 948-957
- Accelerated subclinical coronary atherosclerosis in patients with familial hypercholesterolemia.Atherosclerosis. 2011; 219: 721-727
- An age-matched computed tomography angiographic study of coronary atherosclerotic plaques in patients with familial hypercholesterolaemia.Atherosclerosis. 2020; 298: 52-57
Article info
Publication history
Published online: December 21, 2022
Received in revised form:
October 14,
2022
Received:
July 13,
2022
Footnotes
Drs. Rajagopalan, and Al-Kindi contributed equally as co-senior authors.
Funding: None.
Identification
Copyright
© 2022 Published by Elsevier Inc.
