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Aspirin and Statin Therapy for Nonobstructive Coronary Artery Disease: Five-year Outcomes from the CONFIRM Registry
Praveen Indraratna1, Christopher Naoum1, Sagit Ben Zekry1
1Department of Radiology, University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6 (P.I., S.B.Z., P.B., S.S., J.A.L.); Department of Cardiology, Concord Hospital, Sydney, Australia (C.N.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif (H.G., D.S.B.); Department of Cardiology, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany (S.A.); Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Tex (M.H.A.); Department of Radiology, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy (D.A., G.P.); Department of Medicine, Los Angeles Biomedical Research Institute, Los Angeles, Calif (M.J.B.); Department of Radiology, Cardiovascular Imaging Center, SDN IRCCS, Naples, Italy (F.C.); Department of Cardiology, Tennessee Heart and Vascular Institute, Henderson, Tenn (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea (H.J.C.); Department of Cardiology, William Beaumont Hospital, Royal Oak, Mich (K.C., G.L.R.); Department of Medicine and Radiology, University of Ottawa, Ottawa, Canada (B.J.W.C.); Department of Radiology, Miami Cardiac and Vascular Institute, Miami, Fla (R.C.C.); Department of Cardiology, Capitol Cardiology Associates, Albany, NY (A.D.); Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany (M.H.); Department of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany (J.H.); Department of Nuclear Medicine, University Hospital, University of Zurich, Zurich, Switzerland (P.A.K.); Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea (Y.J.K.); Department of Radiology, Area Vasta 1/ASUR Marche, Fano, Italy (E.M.); Unit of Cardiovascular Imaging, Hospital da Luz, Lisbon, Portugal (H.M., P.d.A.G.); Department of Cardiology, Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (R.R.); Department of Medicine, University of Virginia Health System, Charlottesville, Va (T.C.V.); Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY (F.Y.L., L.J.S.); Department of Cardiology, Mount Sinai Hospital, New York, NY (J.N.); and Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.J.B.).
Insights
For individuals with nonobstructive coronary artery disease (CAD), statin use was linked to better outcomes, while aspirin showed no benefit. Neither medication improved results for those without plaque.
Area of Science:
- Cardiovascular Medicine
- Radiology
- Clinical Trials
Background:
- Nonobstructive coronary artery disease (CAD) affects a significant portion of the population undergoing coronary CT angiography.
- The clinical impact of aspirin and statin use in patients with nonobstructive CAD remains incompletely understood.
- Previous studies have primarily focused on patients with obstructive CAD.
Purpose of the Study:
- To investigate the association of baseline aspirin and statin use with mortality, major adverse cardiovascular events (MACE), and myocardial infarction (MI) in patients without significant coronary stenosis.
- To differentiate the effects of aspirin and statins in patients with nonobstructive CAD versus those without any detectable plaque.
Main Methods:
- Analysis of 5-year data from the Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (CONFIRM).
- Inclusion of 6386 participants with no detectable plaque or nonobstructive CAD (1%-49% stenosis); exclusion of patients with obstructive CAD (≥50% stenosis).
- Utilized Cox proportional hazard models for unadjusted and risk-adjusted analyses, with shared frailty to model hospital sites.
Main Results:
- Nonobstructive CAD was associated with a higher risk of all-cause mortality compared to no detectable plaque (10.6% vs 4.8%).
- In patients with nonobstructive CAD, baseline statin use was associated with a significantly lower rate of MACE (HR, 0.59; P = .007).
- Neither aspirin nor statin use demonstrated a significant benefit in reducing MACE, mortality, or MI in participants with no detectable plaque.
Conclusions:
- Baseline statin use, but not aspirin, is associated with improved clinical outcomes in patients with nonobstructive CAD.
- Neither aspirin nor statins provided clinical benefits for individuals without detectable coronary plaque.
- These findings highlight the importance of considering medication use in risk stratification and management strategies for patients with nonobstructive CAD.
Purpose:
In this cohort study, 5-year data from the Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (ie, CONFIRM) were examined to identify associations of baseline aspirin and statin use with mortality, major adverse cardiovascular events (MACE), and myocardial infarction (MI) in individuals without substantial (≥50%) stenosis.
Materials And Methods:
In this prospective cohort study, all participants in the registry underwent coronary CT angiography and were classified as having no detectable coronary plaque or having nonobstructive coronary artery disease (CAD) (1%-49% stenosis). Participants with obstructive (≥50%) stenosis were excluded from analysis. The study commenced in June 2003 and was completed in March 2016. All unadjusted and risk-adjusted analyses utilized the Cox proportional hazard model with hospital sites modeled using shared frailty.
Results:
A total of 6386 participants with no detectable plaque or with nonobstructive CAD were included (mean age, 56.0 years ± 13.3 [SD], 52% men). The mean follow-up period was 5.66 years ± 1.10. Nonobstructive CAD (n = 2815, 44% of all participants included in the study) was associated with a greater risk of all-cause mortality (10.6% [298 of 2815] vs 4.8% [170 of 3571], P < .001) compared to those without CAD (n = 3571, 56%). Baseline aspirin and statin use was documented for 1415 and 1429 participants, respectively, with nonobstructive CAD, and for 1560 and 1565 participants without detectable plaque, respectively. In individuals with nonobstructive CAD, baseline aspirin use was not associated with a reduction in MACE (10.9% [102 of 936] vs 14.7% [52 of 355], P = .06), all-cause mortality (9.6% [95 of 991] vs 10.9% [46 of 424], P = .468), or MI (4.4% [41 of 936] vs 6.2% [22 of 355], P = .18). On multivariate risk-adjusted analysis, baseline statin use was associated with a lower rate of MACE (hazard ratio, 0.59; 95% CI: 0.40, 0.87; P = .007). Neither therapy improved clinical outcomes for participants with no detectable plaque.
Conclusion:
In participants with nonobstructive CAD, baseline use of statins, but not of aspirin, was associated with improved clinical outcomes. Neither therapy was associated with benefit in participants without plaque.Keywords: Aspirin, Statin, Coronary Artery Disease, CT Angiography, Nonobstructive Coronary Artery DiseaseClinical trial registration no. NCT01443637 Supplemental material is available for this article. © RSNA, 2022See also the commentary by Canan and Navar in this issue.
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