STREAM Trial - Subclinical Atherosclerosis
Utility of Coronary Artery Calcification With Statin Therapy in Multimorbid Older Adults - An Ancillary Study Nested Within a Randomized Trial
Insel Gruppe AG, University Hospital Bern
500 participants
Jun 21, 2022
INTERVENTIONAL
Conditions
Summary
Statins are among the most widely used drugs. While they were found to be effective for primary and secondary prevention of cardiovascular disease (CVD) in middle-aged subjects, their benefits for primary prevention in older adults (aged ≥70 years) without CVD are uncertain, particularly for those with multimorbidity. To better target adults who may benefit from statins in primary prevention, coronary artery calcium (CAC) measurement is rapidly increasing in clinical use and is recommended for risk re-classification in some guidelines. Older patients with a high burden of subclinical atherosclerosis might benefit from continuing statins to prevent CV outcomes, but this hypothesis has not been rigorously tested in randomized clinical trials (RCTs). To address these questions, the investigators conduct a RCT in 500 multimorbid adults ≥70 years old taking statins for primary prevention who will be randomized to statin continuation vs. statin discontinuation, and measure baseline CAC to determine if the risk of a composite outcome of CV events and all-cause mortality after statin discontinuation differs among those with evidence of subclinical atherosclerosis at baseline as measured by CAC.
Eligibility
Inclusion Criteria3
- ≥70 years of age
- Multimorbid with ≥2 coexistent chronic conditions (defined by ICD-10 codes) with an estimated duration of 6 months or more based on clinical decision, besides dyslipidemia treated by statins
- Taking a statin for ≥80% of the time during the year before baseline
Exclusion Criteria19
- Secondary prevention based on previous large statin trials, defined as:
- History of myocardial infarction type 12 (NSTEMI/STEMI) OR
- History of unstable angina, defined as ACS symptomatic at rest, crescendo or new-onset angina (CCS 2 or 3) without ECG or cardiac biomarker changes (based on available documents) OR
- Stable angina pectoris with a documented ischemia on a stress test or with a significant coronary disease defined as a coronary stenosis >50% OR
- History of percutaneous coronary intervention (balloon or stent) or coronary artery bypass graft OR
- History of ischemic stroke OR
- History of Transient Ischemic Attack, defined as transient neurological deficit without diffusion restriction in MRI OR
- History of carotid revascularization (stent or bypass) OR
- History of peripheral arterial disease requiring revascularization (stent or bypass; Fontaine IV)
- Aortic disease that required a vascular repair or aortic aneurysm with a maximum diameter >5.5 cm (men) or >5.2 cm (women) based on available documents
- Diagnosis of familial hypercholesterolemia based on Dutch lipid score ≥6 based on available documents (LDL-c, Family History, Personal History)
- Elevated risk of death within 3 months after baseline, defined as:
- Hospitalized patients planned for palliative care within 24h of admission OR
- Hospitalized patients with a Palliative Performance Scale (PPS) level <30% (based on situation at least 1 month before hospitalization), this corresponds to an estimated survival of 43% after 3 months; OR
- Patients with an advanced metastatic cancer prognosis of ≤20% survival rate within 1 year after baseline (based on an online tool: https://cancersurvivalrates.com)
- Body measures exceeding the CT scanner limits (morbid obesity exceeding weight and diameter limits)
- Cardiac implants with metallic interference, such as pacemaker and mechanical heart valves
- Orthopedic hardware in the mid or lower thoracic spine
- Inability to hold breath for 10 seconds
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Interventions
Statin therapy will be stopped. Additional lipid-lowering medication lowering LDL cholesterol will also be stopped.
Locations(1)
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NCT05482399