Who needs a statin? New study compares prescribing recommendations based on traditional risk factors vs. coronary artery calcium scoring

(Press-News.org) A new study by researchers at Intermountain Health in Salt Lake City aims to determine the best method to screen and evaluate patients who are at risk of developing coronary heart disease and which patients would benefit from taking a statin medication to lower cholesterol.

Currently, cardiologists determine a patient’s need for a statin based on traditional risk factors, using the Pooled Cohort Equation (PCE), which calculates coronary risk by assessing the risk factors of age, sex, total and HDL cholesterol levels, blood pressure, and whether someone has diabetes and is a smoker.

However, a new approach to determining risk and selecting a statin is the use of the coronary artery calcium (CAC) score which is determined by taking a low-radiation dose image of the heart using computed tomography (CT) to look for calcium deposits in plaques in the heart’s coronary arteries.

Which approach is more effective? The new study aims to find out. 

“Our study is now fully enrolled with over 5,600 patients, and in this abstract for the American College of Cardiology, we wanted to look at baseline characteristics and differences in statin prescribing recommendations,” said Jeffrey L. Anderson MD, principal investigator of the study and distinguished clinical and cardiovascular research physician at Intermountain Health.

“The question is: Can we do a better job in selecting people who need a statin for primary coronary risk reduction by using the coronary artery calcium score, rather than just putting coronary risk factors into an equation – that is, is it more effective to use direct imaging evidence of plaque burden or a risk probability. That’s what we’re aiming to find out,” he said.

The new study was presented on March 29 at the American College of Cardiology’s Annual Scientific Sessions meeting in Chicago.

The research is part of CorCal Outcomes, a large, randomized clinical trial at Intermountain Health that is comparing the Pooled Cohort Equation versus coronary artery calcium score guidance to initiate a statin prescription for primary prevention of coronary heart disease.

Since 2019, Intermountain heart researchers have enrolled 5,615 patients into the study, with patients having an average age of 64.1 years old, and 51.3% of the study subjects being women. 

“This CorCal Outcomes study has been a system-wide, eight-year effort to complete enrollment,” said Dr. Anderson.

Intermountain patients at risk of coronary disease were invited to enroll in the study, and those agreeing to participate were randomized into two groups: those assessed using the Pooled Cohort Equation or by a coronary artery calcium score.

The results of scoring by their assigned risk assessment tool were sent in letters to their personal physicians, including whether a statin was recommended based on a high-risk score.

Patients in the two groups in the study were found to have very similar baseline characteristics. However, researchers found that the rate of statin medication recommendations were different.

The study is expected to conclude in early 2026, at which time a comparison of outcomes, including deaths, heart attacks, strokes, and revascularizations during up to 7 years, and an average of over 4 years, of follow-up will be made.

A recommendation to start a statin was made much more often based on the Pooled Cohort Equation. In the PCE group, 50.7% of patients were recommended a statin, with another 21.7% to be considered for one. In contrast in the CAC group, only 22.3% of patients were recommended a statin. 

This large difference in statin recommendations appears to be explained by the strong influence of older age in recommending a statin by the Pooled Cohort Equation and, in contrast, the frequent finding of a zero or low CAC score in many older patients, leading to a no-statin recommendation in them.

Knowing which score is most effective is important, said Dr. Anderson, so that physicians can get the statin drugs to the right people, and not prescribe statins to those who don’t need it.

This is especially important considering that statins entail costs and can have side effects, including muscle aches and an increased risk of diabetes.

“We know there’s a huge difference in prescribing recommendations, and next year we are anxious to see the impact of these differences on outcomes. These findings can have a huge impact on how we practice preventive medicine in the future and how many and whom we put on a statin or other lipid-lowering drugs,” said Dr. Anderson.

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