The edition · Cardiology
Calcium scoring earns its place only in the borderline band, and statins after 70 prevent events without extending disability-free life
MESA data show adding a coronary calcium score to PREVENT adds little overall but sorts borderline-risk patients sharply. STAREE gives a placebo-controlled answer on statins for primary prevention after 70.
The edition in brief
In 6,098 MESA participants, adding coronary artery calcium (CAC) to the PREVENT atherosclerotic cardiovascular disease equations raised the C statistic by only 0.02, but within the borderline 3% to under 5% band, ten-year event rates ran from 1.9% with CAC of zero to 14.3% with CAC of 300 or more. In STAREE, 9,971 Australians aged 70 and over without cardiovascular disease, diabetes or dementia were randomised to atorvastatin 40 mg or placebo; over 5.9 years major cardiovascular events fell (HR 0.70, 0.61 to 0.82) but the co-primary endpoint of death, dementia or persistent disability did not (HR 0.94, 0.84 to 1.05). In 482 patients with unexplained breathlessness, standard exercise echocardiography detected only 55 to 60% of invasively proven HFpEF; adding resting left atrial compliance with separate rule-in and rule-out cut points halved the share needing invasive testing. A tertiary-centre cohort of 9,826 adults with congenital heart disease found smoking, sleep apnoea, depression and coronary disease each associated with higher late mortality. A meta-analysis of 31 testosterone trials found lower LDL but a signal for more arrhythmias (OR 1.58). Only STAREE is randomised outcome evidence; the rest is diagnostic, observational or surrogate.
A calcium score adds little across the board, but sorts borderline-risk patients sharply
Use a calcium score to settle borderline PREVENT risk, not as a routine test, because that is where it changes the estimate.
Exercise echo alone misses about four in ten cases of HFpEF
Do not let a normal exercise echo close the question of HFpEF; add left atrial strain where available and refer the indeterminate for invasive testing.
In adults with congenital heart disease, ordinary risk factors now carry a large share of late deaths
Screen adults with congenital heart disease for smoking, sleep apnoea, depression and coronary risk as routinely as you review the lesion.
Testosterone lowered LDL in trials but carried an arrhythmia signal
Treat testosterone as rhythm-neutral at best: watch for arrhythmia in men taking it, and do not prescribe it for lipid benefit.
Check lipoprotein(a) once in every adult's lifetime
Measure lipoprotein(a) once, and use a high value to tip borderline prevention decisions and to test relatives.
Atorvastatin after 70 cut cardiovascular events by 30% but did not extend disability-free survival
Offer atorvastatin for primary prevention after 70 to reduce cardiovascular events, and tell patients it did not lengthen disability-free life.
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