• Galectin-3 Joins Zero CAC as Negative Risk Factor for ASCVD

    Study supports moving away from the statins-for-all approach in older age

    A finding of no subclinical atherosclerosis on imaging should be good enough to say that an older patient has low cardiovascular risk and therefore doesn't need statins or other preventive therapies, a study found.

    A coronary artery calcium (CAC) score of zero or not more than 10 was the strongest negative predictor, with a diagnostic likelihood ratio (DLR) of 0.20 for both for coronary heart, indicating 80% lower risk than expected from the traditional risk factor calculations. DLRs for cardiovascular disease overall were 0.41 and 0.48, respectively.

    Next most powerful among the "negative risk markers" that could downgrade qualification for statins was a galectin-3 level less than the 25th percentile (DLR 0.44 for coronary disease and 0.43 for CVD overall).

    Absence of carotid plaque on ultrasound had DLRs of 0.39 and 0.65, respectively, according to a group led by Martin Bødtker Mortensen, MD, PhD, of Aarhus University Hospital, Denmark, reporting in the July 9 issue of the Journal of the American College of Cardiology.

    "These results may have important implications for personalizing preventive treatment in elderly individuals and should be considered in future iterations of guidelines as a potential tool to reduce unnecessary overtreatment in the growing elderly population," the investigators said.

    "Because frailty, comorbidity, and polypharmacy are increasing concerns in elderly individuals and have been proposed to increase the risk for adverse effects, the appropriateness of treating almost all elderly individuals is questionable. Accurate identification of elderly individuals at truly low risk for ASCVD [atherosclerotic cardiovascular disease] despite advancing age is therefore gaining increasing interest."

    The study was based on a median 2.7 years of follow-up from the BioImage cohort (n=5,805), which included men ages 55 to 80 and women ages 60 to 80 without known atherosclerotic cardiovascular disease who were enrolled in 2008-2009.

    Mean age was 69 years, and women made up 56% of the group. One in three people had a CAC score of zero.

    Notably, 86% of the cohort would have qualified for statin therapy under the 2018 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines because of 10-year atherosclerotic cardiovascular disease risk crossing the 7.5% threshold by the Pooled Cohort Equations.

    DLR assesses the value of performing a diagnostic test and, in this case, expresses how much lower the risk is than expected from traditional risk factor assessment.

    A binary net reclassification index (NRI) was calculated for zero CAC and the other negative risk markers to see how they changed sensitivity and specificity of the 7.5% risk threshold.

    The largest reclassification effect was observed for zero CAC (NRI 0.23) and CAC≤10 (NRI 0.28), followed by galectin-3 under the 25th percentile (NRI 0.14) and absence of carotid plaque (NRI 0.08).

    Low galectin-3 as a moderately strong negative risk factor for coronary heart disease and ASCVD is "a finding that is novel, highly interesting, and deserving of further study," wrote Michael Blaha, MD, PhD, of the Johns Hopkins Health System in Baltimore, and colleagues in an accompanying editorial.

    The researchers acknowledged the low event rates and relatively short follow-up in their dataset.

    "The primary takeaway is that atherosclerosis imaging tests are perhaps the strongest negative risk factors in cardiovascular medicine today. The results are clinically actionable and should shape our approach to these tests in clinical practice," Blaha's group concluded.

    "Fortunately, clinical guidelines have taken notice of this emerging consensus," they said, citing a section in the 2018 ACC/AHA guideline describing negative risk factors such as zero CAC and stating that intensive statin therapy is of less value in such patients.

     

    The BioImage study was funded in collaboration by Abbott, AstraZeneca, Merck, Philips, and Takeda.

    Bødtker Mortensen and Blaha disclosed no relevant conflicts.

    Source:

    Journal of the American College of Cardiology

    Source Reference: Mortensen MB, et al "Negative risk markers for cardiovascular events in the elderly" J Am Coll Cardiol 2019; DOI: 10.1016/j.jacc.2019.04.049.

    Journal of the American College of Cardiology

    Source Reference: Blaha MJ, et al "Coronary artery calcium scores of zero and establishing the concept of negative risk factors" J Am Coll Cardiol 2019; DOI: 10.1016/j.jacc.2019.05.032.

     

    Read the original article on Medpage Today: Galectin-3 Joins Zero CAC as Negative Risk Factor for ASCVD

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