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PLoS One. 2018 Dec 12;13(12):e0207194. doi: 10.1371/journal.pone.0207194. eCollection 2018.

Usefulness of baseline statin therapy in non-obstructive coronary artery disease by coronary computed tomographic angiography: From the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) study.

Author information

Department of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea.
Department of Internal Medicine and Cardiovascular Center, Seoul National University College of Medicine, Seoul, Korea.
Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York, United States of America.
Department of Imaging, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America.
Department of Healthcare Policy and Research, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York, United States of America.
Department of Cardiology, Friedrich-Alexander-University Erlangen-Nuremburg, Germany.
King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.
Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, California, United States of America.
Cardiovascular Imaging Center, SDN IRCCS, Naples, Italy.
Tennessee Heart and Vascular Institute, Hendersonville, Tennessee, United States of America.
Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.
Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, United States of America.
Department of Medicine and Radiology, University of Ottawa, Ontario, Canada.
Department of Radiology, Miami Cardiac and Vascular Institute, Miami, Florida, United States of America.
Capitol Cardiology Associates, Albany, New York, United States of America.
Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany.
Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.
Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.
Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy.
UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal.
Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Cardiology Service, Walter Reed National Military Center, Bethesda, Maryland, United States of America.
Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, California, United States of America.



The extent to which the presence and extent of subclinical atherosclerosis by coronary computed tomography angiography influences a potential mortality benefit of statin is unknown. We evaluated the relationship between statin therapy, mortality, and subclinical atherosclerosis.


In the CONFIRM study, patients with normal or non-obstructive plaque (<50% diameter stenosis) for whom data on baseline statin use was available were included. Coronary artery calcium (CAC) was quantified using the Agatston score. The extent of non-obstructive coronary atherosclerosis was quantified using the segment involvement score (SIS). 8,016 patients were followed for a median of 2.5 years with analysis of all-cause mortality and major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, unstable angina, target vessel revascularization, and coronary artery disease-related hospitalization.


1.2% of patients experienced all-cause mortality. Patients not on baseline statin therapy had a stepwise increased risk of all-cause mortality by CAC (relative to CAC = 0; CAC 1-99: hazard ratio [HR] 1.65, CAC 100-299: HR 2.19, and CAC≥300: HR 2.98) or SIS (relative to SIS = 0; SIS 1: HR 1.62, SIS 2-3: 2.48 and SIS≥4: 2.95). Conversely, in patients on baseline statin therapy, there was no significant increase in mortality risk with increasing CAC (p value for interaction = 0.049) or SIS (p value for interaction = 0.007). The incidence of MACE was 2.1%. Similar to the all-cause mortality, the risk of MACE was increased with CAC or SIS strata in patient not on baseline statin therapy. However, this relation was not observed in patient on baseline statin therapy.


In individuals with non-obstructive coronary artery disease, increased risk of adverse events occurs with increasing CAC or SIS who are not on baseline statin therapy. Statin therapy is associated with a mitigation of risk of cardiac events in the presence of increasing atherosclerosis, with no particular threshold of disease burden.

Conflict of interest statement

Dr. James K. Min receives research support from the Dalio Institute of Cardiovascular Imaging. This study was also funded, in part, by a generous gift from the Dalio Institute of Cardiovascular Imaging (New York, NY) and the Michael Wolk Foundation (New York, NY). Dr. Min has a research agreement with GE Healthcare, serves on the scientific advisory board of Arineta, and has ownership in MDDX. Dr. Nam received research grant support from Pfizer, Medtronic and Biosensors, and served as a consultant to Saint Jude Medical. Dr. Achenbach received grant support from Siemens and Bayer Schering Pharma and has served as a consultant for Servier. Dr. Al-Mallah received support from the American Heart Association, BCBS Foundation of Michigan, and Astellas. Dr. Cademartiri received grant support from GE Healthcare and has served on the Speakers’ Bureau of Bracco and as a consultant for Servier. Dr. Maffei received grant support from GE Healthcare. Dr. Chow receives educational and research support from TeraRecon and research support from CV Diagnostix. Dr Leipsic is a consultant and has stock options in both Heartflow and Circl CVI and has received speaking fees from GE Healthcare. Dr. Hausleiter is a speaker honoraria from Abbott Vascular and Edwards LifeSciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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