Coronary computed tomography angiography to guide lipid management in an asymptomatic community-based population: RESPECT2 randomized controlled trial

AIMS: Cardiovascular disease (CVD) risk assessment and risk-guided lipid management are cornerstones of primary prevention of atherosclerotic coronary artery disease (ACAD). However, the 10-year CVD risk is often limited by individual-level inaccuracy and poor adherence. This trial aimed to determine whether a coronary computed tomography angiography (CCTA)-guided strategy improves lipid management in asymptomatic populations. METHODS AND RESULTS: This pragmatic, open-label, assessor-blinded randomized trial was conducted in Nanjing, China. Asymptomatic community-dwelling adults aged 40-69 years with no history of CVD or prior use of lipid-lowering medication (LLM) were recruited. Participants were randomized to receive individualized LLM recommendations based either on CCTA findings (CCTA group) or on 10-year CVD risk (usual-care group). The primary outcome was the proportion of participants with regular LLM use (≥24 of preceding 30 days) at both the 6-month and 12-month follow-up visits. Of 3503 randomized participants, 3491 (1748 CCTA, 1743 usual-care) were included in the primary analysis (median [IQR] age, 55 [48-61] years; 60.2% women). Among 1516 participants undergoing CCTA, ACAD was detected in 565 (37.3%). The median follow-up was 12.5 months. Regular LLM use was higher in the CCTA group than in the usual-care group (12.5% [218/1748] vs. 8.1% [141/1743]; adjusted risk ratio, 1.57 [95% confidence interval, 1.29-1.91]; P < 0.001). During follow-up, invasive coronary procedures were more frequent in the CCTA group than in the usual-care group (29 procedures vs. 1). CONCLUSION: In asymptomatic populations, a CCTA-guided strategy modestly improved lipid management, though it increased invasive coronary procedures. Longer follow-up is needed to determine its effect on clinical events. Study Registration http://www.clinicaltrials.com; Identifier: NCT05725096.