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.

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    ABSTRACT: Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient’s risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (
    Current Cardiovascular Imaging Reports 04/2015; 8(6). DOI:10.1007/s12410-015-9334-0
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    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.
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    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


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