Korean Circ J.  2008 Sep;38(9):483-490. 10.4070/kcj.2008.38.9.483.

Comparison of Primary Prevention Strategies for Coronary Heart Disease in Asymptomatic Individuals: The National Cholesterol Education Program-Adult Treatment Panel III Guideline Versus the Screening for Heart Attack Prevention and Education Guideline

• Cho Y
• Yoon YE
• Kim JH
• Park JB
• Park HE
• Lee W
• Choi EK
• Chun EJ
• Choi SI
• Choi DJ
• Chang HJ

• KMID: 1776349
• DOI: http://doi.org/10.4070/kcj.2008.38.9.483

Abstract

BACKGROUND AND OBJECTIVES
The National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP) III guideline has been widely accepted for the primary prevention of coronary heart disease (CHD). The coronary artery calcium score (CACS) has recently been recognized as an excellent predictor of CHD events, and a primary prevention strategy based on the CACS [the Screening for Heart Attack Prevention and Education (SHAPE) guideline] has been proposed. The purpose of this study was to explore how the guidelines function for asymptomatic South Korean individuals. SUBJECTS AND METHODS: We consecutively enrolled 2,079 asymptomatic subjects (age range for men: 45-75 years, age range for women: 55-75 years) who underwent CACS and coronary CT angiography (CCTA) as a part of a health check-up. We analyzed the differences of the target population for CHD prevention according to the 2 guidelines and we compared them in terms of the presence of occult CHD. RESULTS: Four-hundred eighteen (20%) individuals were recommended for pharmacotherapy according to the NCEP-ATP III and 371 (18%) were recommended for pharmacotherapy according to the SHAPE guideline (Cohen's kappa=0.36). According to the SHAPE guideline, more individuals with significant stenosis noted on the CCTA were categorized into the high or very high risk group (50% vs. 24%, respectively, p<0.001) and recommended for pharmacotherapy (53% vs. 28%%, respectively, p<0.001). However, 57 (43%) individuals with significant stenosis on the CCTA were not suitable for pharmacotherapy according to either the NCEP-ATP III or the SHAPE guideline. CONCLUSION: Comparing the NCEP-ATP III and the SHAPE guidelines, there were considerable differences for primary prevention in the target population. Although SHAPE might provide more accurate stratification in terms of the presence of occult CHD, a more precise risk stratification algorithm needs to be implemented for this population.

Keyword

Coronary artery disease; Primary prevention; Guideline

MeSH Terms

Angiography
Calcium
Cholesterol
Constriction, Pathologic
Coronary Artery Disease
Coronary Disease
Coronary Vessels
Health Services Needs and Demand
Heart
Mass Screening
Primary Prevention
Calcium
Cholesterol

Figure

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  Fig. 1 Venn Diagram illustrating the population qualifying for pharmacotherapy according to NCEP-ATP III or SHAPE guideline. Data are expressed as number (% of total participants). *Individuals qualifying for pharmacotherapy according to NCEP-ATP III guideline, †According to SHAPE guideline, ‡Individuals not qualifying for pharmacotherapy according to neither guidelines, §Significant stenosis was defined as more than 50% luminal narrowing on MDCT. NCEP-ATP: National Cholesterol Education Program- Adult Treatment Panel, SHAPE: Screening for Heart Attack Prevention and Education.

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  Fig. 2 Risk stratification for coronary heart disease across the severity of subclinical coronary atherosclerosis detected by MDCT. Individuals were categorized into each risk groups according to NCEP-ATP III guideline (A), and SHAPE guideline (B). *Significant stenosis was defined as more than 50% luminal narrowing on MDCT. MDCT: multi-detector computed tomography, NCEP-ATP: National Chole-Sterol Education Program-Adult Treatment Panel, SHAPE: Screening for Heart Attack Prevention and Education.

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  Fig. 3 Receiver operating characteristics curves for the presence of the plaque with significant stenosis. Significant stenosis was defined as more than 50% luminal narrowing on MDCT. NCEP-ATP III: NCEP-ATP III risk stratification (AUC, 0.64; 95% confidence interval, 0.59-0.68). SHAPE: SHAPE risk stratification (AUC, 0.84; 95% confidence interval, 0.78-0.88). AUC: area under the curve, MDCT: multi-detector computed tomography, NCEP-ATP: National Cholesterol Education Program-Adult Treat-Ment Panel, SHAPE: Screening for Heart Attack Prevention and Education.

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  Fig. 4 Proportion of individuals qualifying for pharmacotherapy according to NCEP-ATP III or SHAPE guideline across the severity of subclinical coronary atherosclerosis detected by MDCT. *Significant stenosis was defined as more than 50% luminal narrowing on MDCT, †p was calculated for McNemar test, ‡Numbers are percentage of individuals qualifying for pharmacotherapy according to each guideline. MDCT: multi-detector computed tomography, NCEP-ATP: National Cholesterol Education Program-Adult Treatment Panel, SHAPE: Screening for Heart Attack Prevention and Education.

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