Friday, 29 March, 2024
HomeGuidelinesNew guidelines not recommending statins for African Americans

New guidelines not recommending statins for African Americans

Approximately one in four African American individuals recommended for statin therapy under guidelines from the American College of Cardiology and American Heart Association are no longer recommended for statin therapy under guidelines from the US Preventive Services Task Force (USPSTF), according to a study being released to coincide with its presentation at the American College of Cardiology’s 66th Annual Scientific Sessions.

Modern prevention guidelines substantially increase the number of individuals who are eligible for treatment with statins.

Efforts to refine statin eligibility via coronary calcification have been studied in white populations but not, to the authors’ knowledge, in large African American populations. Dr Venkatesh L Murthy, of the University of Michigan, Ann Arbor, and colleagues compared the relative accuracy of the USPSTF and American College of Cardiology/American Heart Association (ACC/AHA) recommendations in identifying African American individuals with subclinical and clinical atherosclerotic (plaque build-up within arteries) cardiovascular disease (ASCVD). African Americans are at disproportionately high risk for ASCVD.

The study included 2,812 African American individuals, ages 40 to 75 years, without prevalent ASCVD, who underwent assessment of ASCVD risk. Of these, 1,743 participants completed computed tomography, and coronary artery calcium (CAC) and abdominal aortic calcium scores were determined.

Among the findings central to prevention efforts: Approximately 1 in 4 African American individuals recommended for statin therapy under ACC/AHA guidelines are no longer recommended for statin therapy under USPSTF guidelines; individuals only eligible for statins under ACC/AHA guidelines experienced a low to intermediate event rate, suggesting decreased sensitivity of the USPSTF recommendations in identifying participants at risk of ASCVD; consequently, USPSTF guidelines focus treatment on a smaller high-risk group (38% of high-risk African American individuals) at the expense of missing significant numbers of African American individuals with vascular calcification.

While those who were eligible for statins by both USPSTF and ACC/AHA guidelines had a similar risk of incident ASCVD (heart attack, ischemic stroke, or fatal coronary heart disease) compared with non-eligible participants, the addition of CAC scoring improved risk stratification above guideline recommendations, suggesting that CAC has the potential to personalise recommendation for statin therapy by both guideline recommendations.
“Despite debate over the potential cost, risk calibration, and metabolic health implications of increasing statin use, these results support a guideline-based approach to statin recommendation, leveraging targeted imaging (or other surrogate atherosclerotic measures) in African American individuals to further personalise statin-based prevention programs,” the authors write.

Abstract
Importance: Modern prevention guidelines substantially increase the number of individuals who are eligible for treatment with statins. Efforts to refine statin eligibility via coronary calcification have been studied in white populations but not, to our knowledge, in large African American populations.
Objective: To compare the relative accuracy of US Preventive Services Task Force (USPSTF) and American College of Cardiology/American Heart Association (ACC/AHA) recommendations in identifying African American individuals with subclinical and clinical atherosclerotic cardiovascular disease (ASCVD).
Design, Setting, and Participants: In this prospective, community-based study, 2812 African American individuals aged 40 to 75 years without prevalent ASCVD underwent assessment of ASCVD risk. Of these, 1743 participants completed computed tomography.
Main Outcomes and Measures: Nonzero coronary artery calcium (CAC) score, abdominal aortic calcium score, and incident ASCVD (ie, myocardial infarction, ischemic stroke, or fatal coronary heart disease).
Results: Of the 2812 included participants, the mean (SD) age at baseline was 55.4 (9.4) years, and 1837 (65.3%) were female. The USPSTF guidelines captured 404 of 732 African American individuals (55.2%) with a CAC score greater than 0; the ACC/AHA guidelines identified 507 individuals (69.3%) (risk difference, 14.1%; 95% CI, 11.2-17.0; P < .001). Statin recommendation under both guidelines was associated with a CAC score greater than 0 (odds ratio, 5.1; 95% CI, 4.1-6.3; P < .001). While individuals indicated for statins under both guidelines experienced 9.6 cardiovascular events per 1000 patient-years, those indicated under only ACC/AHA guidelines were at low to intermediate risk (4.1 events per 1000 patient-years). Among individuals who were statin eligible by ACC/AHA guidelines, the 10-year ASCVD incidence per 1000 person-years was 8.1 (95% CI, 5.9-11.1) in the presence of CAC and 3.1 (95% CI, 1.6-5.9) without CAC (P = .02). While statin-eligible individuals by USPSTF guidelines did not have a significantly higher 10-year ASCVD event rate in the presence of CAC, African American individuals not eligible for statins by USPSTF guidelines had a higher ASCVD event rate in the presence of CAC (2.8 per 1000 person-years; 95% CI, 1.5-5.4) relative to without CAC (0.8 per 1000 person-years; 95%, CI 0.3-1.7) (P = .03).
Conclusions and Relevance: The USPSTF guidelines focus treatment recommendations on 38% of high-risk African American individuals at the expense of not recommending treatment in nearly 25% of African American individuals eligible for statins by ACC/AHA guidelines with vascular calcification and at low to intermediate ASCVD risk.

Authors
Ravi V Shah; Aferdita Spahillari; Stanford Mwasongwe; J Jeffrey Carr; James G Terry; Robert J Mentz; Daniel Addison; Udo Hoffmann; Jared Reis; Jane E Freedman; Joao AC Lima; Adolfo Correa; Venkatesh L Murthy

[link url="http://media.jamanetwork.com/news-item/guidelines-differ-on-recommendations-of-statin-treatment-for-african-americans/"]JAMA material[/link]
[link url="http://jamanetwork.com/journals/jamacardiology/fullarticle/2612836"]JAMA Cardiology abstract[/link]

MedicalBrief — our free weekly e-newsletter

We'd appreciate as much information as possible, however only an email address is required.