澳大利亚贝克心脏和糖尿病研究所Thomas H. Marwick研究小组发现，冠状动脉钙化积分与治疗联合对家族性冠状动脉疾病斑块进展的影响（一项随机临床试验）。2025年3月5日出版的《美国医学会杂志》发表了这项成果。

重要性:冠状动脉钙（CAC）评分提供了预后信息，特别是在冠状动脉疾病（CAD）中度风险的患者中。然而，将CAC评分与一级预防策略相结合的益处尚未在随机试验中得到检验。

目的:评估CAC评分与预防策略相结合是否可用于限制具有早发性CAD家族史的中危患者的斑块进展。

设计、设置和参与者：在澳大利亚7家医院进行的前瞻性、随机、开放盲法终点临床试验(2013年至2020年；最后一次随访日期为2021年6月5日)。从社区中招募年龄在40 - 70岁之间、有冠心病发病年龄小于60岁的一级亲属或发病年龄小于50岁的二级亲属的无症状人群。

干预措施:中度风险参与者进行CAC评分。CAC评分大于0但小于400的患者接受冠状动脉计算机断层血管造影（CCTA），并随机分为CAC评分告知预防组或常规护理组。

主要成果和措施：随访3年获得CCTA，由独立核心实验室测量斑块体积。主要终点是总斑块体积，并进一步分析钙化和非钙化斑块体积。

结果:这项研究包括365名参与者(平均[SD]年龄，58岁；57.5%的男性);CAC评分告知组179例，常规护理组186例。与常规治疗相比，CAC评分告知组的总血压持续下降(平均[SD]，-3[31]mg/dL vs-56[38]mg/dL；P<.001)和LDL（平均[ST]，-2[31]vs-51[36]mg/dL，P<.001）持续降低，这与合并队列方程风险计算的降低有关(平均[SD]， 2.1% [2.9%] vs 0.5% [2.9%]；P<.001)。在斑块总积方面，常规护理组的斑块进展大于CAC评分告知的参与者(平均[SD]， 24.9 [37.7] mm3 vs 15.4 [30.9] mm3；P = 0.009)，非钙化斑块体积(平均[SD]， 15.7 [32.2] mm3 vs 5.6 [28.5] mm3；P = 0.002)，纤维脂肪和坏死核心斑块体积(平均[SD]， 4.5 [25.8] mm3 vs . 0.8 [12.6] mm3；P =0.02)。这些斑块体积的变化独立于其他危险因素，包括基线斑块体积、血压和血脂。

研究结果表明，在有冠心病家族史的中等风险患者中，CAC评分与一级预防策略相结合，与常规护理相比，可降低致动脉粥样硬化性脂质，减缓斑块进展。这些数据支持使用CAC评分来辅助中危患者的强化预防策略。

附：英文原文

Title: Effects of Combining Coronary Calcium Score With Treatment on Plaque Progression in Familial Coronary Artery Disease: A Randomized Clinical Trial

Author: Nitesh Nerlekar, Sheran A. Vasanthakumar, Kristyn Whitmore, Cheng Hwee Soh, Jasmine Chan, Vinay Goel, Jacqueline Ryan, Catherine Jones, Tony Stanton, Geoffrey Mitchell, Andrew Tonkin, Gerald F. Watts, Stephen J. Nicholls, Thomas H. Marwick, Coronary Artery Calcium Score, Faraz Pathan, Kazuaki Negishi, Arun Abraham, David Playford, Kristen Fragnito, Julie Butters, Jordan Andrews, Giuseppe Di Giovanni, Sarah McLennan, Jasmine Prichard, Joanne Harris, Omar Farouque, Louise Brown, Philip Roberts-Thomson, Garry Jennings, Petr Otahal

Issue&Volume: 2025-03-05

Abstract: Importance  Coronary artery calcium (CAC) scoring provides prognostic information, especially in patients at intermediate risk for coronary artery disease (CAD). However, the benefit of combining CAC score with a primary prevention strategy has not been tested in a randomized trial.

Objective  To assess whether combining the CAC score with a prevention strategy can be used to limit plaque progression in intermediate-risk patients with a family history of premature CAD.

Design, Setting, and Participants  Prospective, randomized, open-blinded end point clinical trial in 7 hospitals across Australia (between 2013 and 2020; the last date of follow-up was June 5, 2021). Asymptomatic people aged 40 to 70 years with a first-degree relative with CAD onset at younger than 60 years old or second-degree relative with onset at younger than 50 years old were recruited from the community.

Interventions  Intermediate-risk participants underwent CAC scoring. Those with a CAC score greater than 0 but less than 400 underwent coronary computed tomography angiography (CCTA) and were randomized to CAC score–informed prevention or usual care.

Main Outcomes and Measures  Follow-up CCTA was obtained at 3 years, with plaque volume measured by an independent core laboratory. The primary outcome was total plaque volume, with further analysis for calcified and noncalcified plaque volume.

Results  This study included 365 participants (mean [SD] age, 58 [6] years; 57.5% male); 179 in the CAC score–informed and 186 in the usual care groups. Compared with usual care, the CAC score–informed group showed a sustained reduction in total (mean [SD], 3 [31] mg/dL vs 56 [38] mg/dL; P<.001) and LDL (mean [SD], 2 [31] vs 51 [36] mg/dL; P<.001) cholesterol levels at 3 years, which was associated with a reduction in pooled cohort equation risk calculation (mean [SD], 2.1% [2.9%] vs 0.5% [2.9%]; P<.001). Plaque progression was greater in usual care than CAC score–informed participants for total plaque volume (mean [SD], 24.9 [37.7] mm3 vs 15.4 [30.9] mm3; P=.009), noncalcified plaque volume (mean [SD], 15.7 [32.2] mm3 vs 5.6 [28.5] mm3; P=.002), and fibrofatty and necrotic core plaque volume (mean [SD], 4.5 [25.8] mm3 vs 0.8 [12.6] mm3; P=.02). These plaque volume changes were independent of other risk factors including baseline plaque volume, blood pressure, and lipid profile.

Conclusions and Relevance  The combination of CAC score with a primary prevention strategy in intermediate-risk patients with a family history of CAD was associated with reduction of atherogenic lipids and slower plaque progression compared with usual care. These data support the use of CAC score to assist intensive preventive strategies in intermediate-risk patients.

DOI: 10.1001/jama.2025.0584

Source: https://jamanetwork.com/journals/jama/fullarticle/2831115