Abstract 4358531: Selecting Statins in Primary Prevention: A Comparison by the Pooled Cohort Equation or by the Coronary Artery Calcium Score in Women and Men: The CorCal Outcomes Randomized Clinical Trial

Background: Two methods for selecting statin therapy in primary prevention patients are the pooled cohort equation (PCE), based on traditional risk factors, and coronary artery calcium (CAC), a patient-level assessment of plaque burden. In a preliminary report, a lower rate of statin recommendation was noted using CAC. How well these two methods compare in the frequency of recommending statins and in impacting outcomes is unknown. Given that women have less CAC by age and fewer traditional risk factors than men, we assessed to what extent sex influences assignment to statin therapy by these two approaches. Methods: CorCal a large, randomized trial comparing PCE and CAC to guide statin initiation in primary prevention patients. From August 2019 to April 2025, 5772 Intermountain Health non-diabetic, statin-naïve primary-prevention patients consented to study participation and were randomized 1:1 to a statin recommendation guided by either PCE or CAC. For those randomized to PCE, AHA guideline recommendations were used. In the CAC arm, patients with a LDL-C > 190 mg/dL or CAC >100 AU were prescribed a high-intensity statin, and those with a CAC 1-100 and AU>75 th percentile for age and sex were prescribed a moderate-intensity statin. Results: Age averaged 64.1±6.8 years, and 51.3% are women. Baseline demographics are shown in Tables 1 and 2. At entry, women were older and had lower blood pressure and CAC and PCE scores but higher LDL-cholesterol. Statin recommendations by sex and randomization arm are presented in Table 3. A recommendation to start a statin was made less often in women than in men in both arms. However, in both sexes, fewer received a recommendation to start a statin by CAC than by the PCE algorithm (Table 3). Conclusions: In CorCal, women are older than men but have fewer risk factors by PCE and less coronary calcium by CAC. Despite their older age, they less often were recommended to start a statin in both arms. However, a much larger difference in statin recommendation was noted by randomization arm in both sexes, with no statin recommended almost 3-fold more frequently in the CAC arm. The very low recommendation rates by CAC are driven by the low median CAC scores in our primary risk population, both in women (0 AU) and men (10 AU). The evaluation of ASCVD outcomes in CorCal, planned for 2026, will assess the impact on outcomes of these differences in statin recommendations by these two approaches both overall and by sex.