Annette, a 61-year-old real estate professional, comes to your office and is concerned about her future risk of heart attack since her father sustained his first myocardial infarction at the age of 60. She quit smoking 10 years ago with a prior 30-pack-year history but admits to continued dietary indiscretion and a relatively sedentary lifestyle. She has a history of hypertension for which she takes lisinopril.
Her vital signs at her visit today and results of labs are:
BP: 134/82 mm Hg
Pulse: 72 beats/min
Waist circumference: 36”
Total cholesterol: 194 mg/dL
Triglycerides: 180 mg/dL
HDL-C: 48 mg/dL
LDL-C: 110 mg/dL
Her 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimate is 6.2%. You discuss the possibility of performing a coronary artery calcium score (CACS) to refine her risk estimate. She is in favor of pursuing testing and is ultimately found to have an Agatston score of 52, which is at the 82nd percentile for her age, gender, and ethnicity. She is surprised by this result and asks you for your interpretation. You respond as follows:
A. Her score is consistent with mild coronary atherosclerosis and reclassifies her ASCVD risk estimate to < 5%; statin therapy is not recommended.
B. Coronary artery calcium represents healed plaque, and as such, is associated with a benign prognosis.
C. Coronary artery calcium has its origin from dysfunctional endothelial cells with altered calcium handling.
D. She has accelerated atherosclerosis and a discussion about risks and benefits of statin therapy should ensue.
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