The decision to prescribe a statin to prevent ASCVD may require considering factors in addition to global CVD risk. A short case illustrates use of the CAC score.
The 2018 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults includes recommendations on how to refine cardiovascular risk assessment to determine the need for pharmacotherapy in primary prevention; obtaining and using a measure of coronary artery calcium is one.
Are you familiar with the cut points for shared decision making with patients? Follow the case below. What would you recommend based on Annett's score?
Patient history. 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. She admits that her food choices aren’t always the best, mostly because of her unreliable schedule—which also makes it hard to exercise regularly. She has a history of hypertension for which she takes lisinopril.
Patient global 10-year ASCVD risk. 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.
What is your interpretation of the CACS findings? 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 originates from dysfunctional endothelial cells with altered calcium handling. D. She has accelerated atherosclerosis and a discussion about risks and benefits of statin therapy should be the next step.
Interpretation of CAC Agatston score of 52, which is at the 82nd percentile for her age, gender, and ethnicity. The patient has accelerated atherosclerosis and a discussion about risks and benefits of statin therapy is the next step.
CAC score refines ASCVD risk assessment. the addition of the CACS to traditional global risk assessment significantly improves measures of discrimination and reclassification. The 2018 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults suggests that additional factors may be considered to inform treatment decisions in select individuals, including CAC. According to the guidelines, if a CACS is ≥100 Agatston units or in the ≥75th percentile for age, gender, and ethnicity, statin therapy may be recommended.
10-year ASCVD Risk with CACS. Acknowledging the significant heterogeneity in ASCVD risk that exists amongst those eligible for statin therapy, a risk calculator that integrates CACS into traditional global risk assessment has been developed and is based on the Multi-Ethnic Study of Atherosclerosis (MESA) collaboration. MESA 10-Year CHD Risk with Coronary Artery Calcification
Michael Shapiro, DO, is Fred M. Parrish Professor of Cardiology and Molecular Medicine at Wake Forest University where he is faculty in the Section of Cardiovascular Medicine. He is also director of the Center for Preventive Cardiology at Wake Forest Baptist Health.