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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 κ=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.
Figures and Tables
 | Fig. 1Venn 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. 2Risk 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. 3Receiver 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. 4Proportion 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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Table 1
Baseline characteristics of the study population
Data are expressed as number (%) and mean±SD. BMI: body mass index, WC: waist circumference, SBP: systolic blood pressure, DBP: diastolic blood pressure, F/Hx: family history, CHD: coronary heart disease, FBS: fasting blood sugar, LDL-C: low density lipoprotein-cholesterol, HDL-C: high density lipoprotein-cholesterol, BUN: blood urea nitrogen, CRP: C-reactive protein, CACS: coronary artery calcium score
Table 2
Relationship of SHAPE risk stratification with NCEP-ATP III risk stratification
Data are expressed as number of individuals (% of total participants). Individuals classified as very high risk (CACS>400) were combined with those categorized as high risk (CACS 100-399) in SHAPE risk stratification. *Individuals were classified as low-risk (0-1 risk factor), moderate-risk (≥2 risk factors but <10% risk of CHD at 10 years), moderately high-risk (≥2 risk factors and 10% to 20% risk of CHD in 10 years), or high-risk (≥2 risk factors and >20% risk of CHD in 10 years). SHAPE: Screening for Heart Attack Prevention and Education, NCEP-ATP: National Cholesterol Education Program-Adult Treatment Panel, CACS: coronary artery calcium score, CHD: coronary heart disease
Table 3
Proportion of individuals qualifying pharmacotherapy according to each guideline and extent of agreement across the risk categories
Data are expressed as number of individuals (% of individuals categorized into the same risk group). Individuals classified as very high risk (CACS>400) were combined with those categorized as high risk (CACS 100-399) in SHAPE risk stratification. SHAPE: Screening for Heart Attack Prevention and Education, NCEP-ATP: National Cholesterol Education Program-Adult Treatment Panel, CACS: coronary artery calcium score, N/A: not applicable
Table 4
Risk stratification and proportion of individuals qualifying pharmacotherapy according to each guideline in individuals with exclusively non-calcified plaque as a manifestation of CAD
Data are expressed as number (%). *Occlusive plaque was defined as more than 50% luminal narrowing on maximum intensity projection images or multi-planar reconstruction images. CAD: coronary arterial disease, NCEP-ATP: National Cholesterol Education Program-Adult Treatment Panel, SHAPE: Screening for Heart Attack Prevention and Education
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