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Eligibility for lipid-lowering therapy when applying systemic coronary risk estimation 2 according to guidelines on
Ali Yari1, Peter Ueda2, Pia Lundman1
1Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88 Stockholm, Sweden.
Insights
Many healthy individuals eligible for lipid-lowering therapy (LLT) based on cardiovascular disease (CVD) risk scores. A significant portion eligible for LLT showed no signs of atherosclerosis, highlighting potential over-treatment concerns.
Area of Science:
- Cardiology
- Preventive Medicine
- Public Health
Background:
- Cardiovascular disease (CVD) remains a leading cause of mortality worldwide.
- Accurate risk stratification is crucial for effective primary prevention strategies.
- Lipid-lowering therapy (LLT) is a key intervention for reducing CVD risk.
Purpose of the Study:
- To determine the proportion of apparently healthy individuals eligible for LLT using the SCORE2 risk equation.
- To assess the prevalence of subclinical atherosclerosis among those eligible for LLT.
- To compare LLT eligibility using the SCORE2 equation versus the SCORE2 chart.
Main Methods:
- The Swedish Cardiopulmonary Bioimage Study included individuals aged 50-64 years.
- Exclusion criteria: prior atherosclerotic CVD, diabetes mellitus, or chronic kidney disease.
- 10-year CVD risk estimated using SCORE2 equation and chart; LLT eligibility based on 2021 ESC guidelines; coronary atherosclerosis assessed by CCTA.
Main Results:
- Among 26,570 participants, 36% had high/very high 10-year CVD risk per SCORE2 equation.
- 35% of the total population were eligible for LLT, with 99% of high-risk individuals exceeding LDL cholesterol goals.
- Of those eligible for LLT, 38% (SCORE2 equation) to 44% (SCORE2 chart) showed no coronary atherosclerosis on CCTA.
Conclusions:
- A substantial proportion (35%) of apparently healthy individuals are eligible for LLT based on SCORE2 risk assessment.
- A significant number of eligible individuals lack objective evidence of atherosclerosis, suggesting potential for overtreatment.
- The SCORE2 chart identifies more individuals as eligible for LLT compared to the SCORE2 equation.
Aims:
To estimate the proportion eligible for lipid-lowering therapy (LLT) when using the systemic coronary risk estimation 2 (SCORE2) on apparently healthy individuals.
Methods And Results:
Individuals aged 50-64 years were randomly invited to The Swedish Cardiopulmonary Bioimage Study (n = 30 154). Participants with previous atherosclerotic cardiovascular disease (CVD), diabetes mellitus, or chronic kidney disease were excluded. The 10-year risk of CVD was estimated using the SCORE2 equation and the multicell chart. Eligibility for LLT was estimated according to the 2021 European Society of Cardiology CVD prevention guidelines. Presence of coronary atherosclerosis was determined using coronary computed tomography angiography (CCTA). Among 26 570 apparently healthy individuals, 32% had high and 4% had very high 10-year CVD risk, according to the SCORE2 equation. Among high- and very-high-risk individuals, 99% had low-density lipoprotein cholesterol levels above guideline goals making 35% of the total population eligible for LLT. Of those eligible, undergoing imaging, 38% had no signs of coronary atherosclerosis according to CCTA. Using the SCORE2 chart, 52% of the population were eligible for LLT, of which 44% had no signs of coronary atherosclerosis. In those with high or very high risk, ongoing LLT was reported in 7% and another 11% received LLT within 6 months after study participation.
Conclusion:
Nearly all apparently healthy individuals with high and very high CVD risk, or 35% of the total population, were eligible for LLT according to guidelines, and a large proportion had no signs of atherosclerosis. Compared with the SCORE2 equation, the SCORE2 chart resulted in more individuals being eligible for LLT.
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