Article

Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin, vitamin C, and vitamin E - The St. Francis Heart Study Randomized Clinical Trial

Department of Research, St. Francis Hospital, Roslyn, New York 11576, USA.
Journal of the American College of Cardiology (Impact Factor: 15.34). 07/2005; 46(1):166-72. DOI: 10.1016/j.jacc.2005.02.089
Source: PubMed

ABSTRACT We sought to determine whether lipid-lowering therapy and antioxidants retard the progression of coronary calcification and prevent atherosclerotic cardiovascular disease (ASCVD) events.
The electron beam computed tomography-derived coronary calcium score predicts coronary disease events. Small, uncontrolled studies suggest that vigorous lipid-lowering therapy slows progression of coronary calcification and prevents coronary artery disease events, but controlled, scientific demonstration of these effects is lacking.
We conducted a double-blind, placebo-controlled randomized clinical trial of atorvastatin 20 mg daily, vitamin C 1 g daily, and vitamin E (alpha-tocopherol) 1,000 U daily, versus matching placebos in 1,005 asymptomatic, apparently healthy men and women age 50 to 70 years with coronary calcium scores at or above the 80th percentile for age and gender. All study participants also received aspirin 81 mg daily. Mean duration of treatment was 4.3 years.
Treatment reduced total cholesterol by 26.5% to 30.4% (p < 0.0001), low-density lipoprotein cholesterol by 39.1% to 43.4% (p < 0.0001), and triglycerides by 11.2% to 17.0% (p < or = 0.02) but had no effect (p = 0.80) on progression of coronary calcium score (Agatston method). Treatment also failed to significantly reduce the primary end point, a composite of all ASCVD events (6.9% vs. 9.9%, p = 0.08). Event rates were related to baseline calcium score (pre-specified analysis) and may have been reduced in a subgroup of participants with baseline calcium score >400 (8.7% vs. 15.0%, p = 0.046 [not a pre-specified analysis]).
Treatment with alpha-tocopherol, vitamin C, and low doses of atorvastatin (20 mg once daily) did not affect the progression of coronary calcification. Treatment may have reduced ASCVD events, especially in subjects with calcium scores >400, but these effects did not achieve conventional levels of statistical significance.

0 Followers
 · 
218 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Coronary CT angiography (CCTA) is used in the emergency department to rule out acute coronary syndrome in low-intermediate risk patients. We evaluated the potential of CCTA to tailor aspirin (ASA) and statin therapy in acute chest pain patients. We included all patients in the ROMICAT I trial who underwent CCTA before admission. Results of CCTA were blinded to caretakers. We documented ASA and statin therapy at admission and discharge and determined change in medications during hospitalization, agreement of discharge medications with contemporaneous guidelines, and agreement with the presence and severity of coronary artery disease (CAD) as determined by CCTA. We included 368 patients (53 ± 12 years; 61% male). Baseline medical therapy at presentation included 27% on ASA and 24% on statin. Most patients who qualified for secondary prevention were on ASA and statin therapy at discharge (95% and 80%, respectively), whereas among those qualifying for primary prevention therapy, only 59% of patients were on aspirin and 33% were on statin at discharge. Excluding secondary prevention patients, among those with CCTA-detected CAD, only 66/131 (50%) were on ASA at discharge and only 53/131 (40%) were on statin. Conversely, in those without CCTA-detected CAD, 54/156 (35%) were on ASA and 20/151 (13%) were on statin at discharge. There are significant discrepancies between discharge prescription of statin and ASA with the presence and extent of CAD. CCTA presents an efficient opportunity to tailor medical therapy to CAD in patients undergoing CCTA as part of their acute chest pain evaluation. Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.
    Journal of Cardiovascular Computed Tomography 02/2015; DOI:10.1016/j.jcct.2015.02.006 · 4.51 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Oxidant stress in the cardiovascular system may occur when antioxidant capacity is insufficient to reduce reactive oxygen species and other free radicals. Oxidant stress has been linked to the pathogenesis of atherosclerosis and incident coronary artery disease. As a result of this connection, early observational studies focused on dietary antioxidants, such as β-carotene, α-tocopherol, and ascorbic acid, and demonstrated an inverse relationship between intake of these antioxidants and major adverse cardiovascular events. These findings supported a number of randomized trials on the use of selected antioxidants as primary or secondary prevention strategies to decrease cardiac risk; however, many of these studies reported disappointing results with little or no observed risk reduction in antioxidant-treated patients. Several plausible explanations for these findings have been suggested, including incorrect antioxidant choice or dose, synthetic versus dietary antioxidants as the intervention, and patient selection, all of which will be important to consider when designing future clinical trials. This review will focus on the contemporary evidence that is the basis for our current understanding of the role of antioxidants in cardiovascular disease prevention.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND Cardio-vascular diseases (CVD) remain the most frequent cause of mortality in our population. Risk prediction models, such as the SCORE (Systematic COronary Risk Evaluation), allow the stratification of individuals in risk categories and to adapt the preventive management accordingly. The accuracy of SCORE could be improved by incorporating markers of subclinical atherosclerosis, particularly in individuals classified at intermediate risk. METHODS A rapid literature review was performed on the predictive increments (net reclassification index), clinical effectiveness and cost-effectiveness of noninvasive markers of subclinical atherosclerosis in asymptomatic individuals. RESULTS Coronary artery calcium score provided the highest incremental predictive value, with a net reclassification index ranging from 22% to 66% in individuals classified at intermediate risk. The added value of the anklebrachial index, aortic pulse wave velocity and carotid plaque in risk reclassification was lower than for coronary calcium, at around 15%. The clinical benefit of integrating these 4 markers to SCORE was not formally assessed in studies. Economic evaluations were only identified for one marker: coronary artery calcium. The studies showed highly unstable results, sensitive to a number of assumptions, and in particularly to those relating to the price and efficacy of preventive treatments. CONCLUSION In the absence of high quality studies on the clinical effectiveness of measuring atherosclerosis markers beyond the traditional cardiovascular risk markers, and the consequent uncertainty surrounding their cost effectiveness, the utilization of these markers is not recommended. Improving the predictive value of SCORE by the addition of easy to collect information in first-line consultation (e.g. BMI, sedentarity) is a priority.

Preview

Download
2 Downloads
Available from