CAC scoring valuable, can help decide CVD prevention strategies
Click Here to Manage Email Alerts
PHILADELPHIA — Coronary artery calcium scoring is a helpful tool in patients aged 40 years or older whom a decision to start therapy for primary CVD prevention is not obvious, a speaker said at the Heart in Diabetes CME conference.
Matthew Budoff, MD, FACC, FAHA, endowed chair of preventive cardiology, professor of medicine and director of cardiac CT at Harbor-UCLA Medical Center, said indications for CAC scoring include as part of a primary prevention strategy in patients at intermediate but uncertain risk, for patients who are intolerant to or reluctant to take statins, for patients being considered for nonstatin lipid-lowering therapies, for patients being considered for aspirin therapy, for low-risk patients with chest pain and as motivation for people to change their lifestyle.
“It works really well for intermediate-risk patients, it works really well for compliance, it’s going to help us with nonstatin therapy decisions where we want to be more aggressive and it’s an incredible motivator of good behavior,” Budoff said during a presentation.
However, he said, CAC scoring does not work well in people younger than 40 years — possibly younger than 50 years for women — because “we need them to have some atherosclerosis to test them; maybe dialysis and early-onset type 2 diabetes would be the exceptions. And don’t take them immediately from the calcium scanner to the cath lab.”
The Pooled Cohort Equation from the American College of Cardiology and the American Heart Association vastly overestimates CVD risk and “is, in a word, terrible,” Budoff said. By contrast, CAC scoring tracks well with 10-year CVD outcomes, with those with a score of 300 or more having the highest risk and those with a score of 0 having virtually no risk, he said.
Of all tools, adding CAC scoring to the Framingham Risk Score provided by far the greatest net reclassification improvement, he said.
CAC can also be used to guide secondary CVD prevention strategies, as a score above 300 was a secondary risk equivalent, with a similar CV risk as those post-MI, as was shown in the CONFIRM registry, Budoff said.
The EISNER trial showed that in middle-aged patients with risk factors but no CVD, performing a CAC scan led to improvements in LDL, BP, exercise and lipid-lowering therapy adherence, and led to more new medication prescriptions, compared with not doing a scan, he said.
In another study, atorvastatin improved CV outcomes compared with placebo, but the treatment effect was far greater in patients with a CAC score above 100 than in those with a low CAC score, he said, noting that statin therapy has no effect on people with a CAC score of 0.
“If I have a score of 0, I don’t treat them, and that’s what the guidelines say to do,” Budoff said. “If I have a score of 100 or above, I treat them aggressively.
“There is a 5,000-year-old concept: Superior doctors prevent the disease, mediocre doctors treat the disease before it becomes evident — that’s subclinical atherosclerosis — and inferior doctors treat the full-blown disease,” Budoff said. “We want to find the disease early so we can treat it aggressively.”
References:
- Arad Y, et al. J Am Coll Cardiol. 2005;doi:10.1016/j.jacc.2005.02.088.
- Cho I, et al. Circulation. 2012;doi:10.1161/CIRCULATIONAHA.111.081380.
- Grundy SM, et al. Circulation. 2018;doi:10.1161/CIR.0000000000000625.
- Rozanski A, et al. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2011.01.019.
Collapse
Budoff M. Session 6: ASCVD Prevention and Treatment. Presented at: Heart in Diabetes; June 24-26, 2022; Philadelphia (hybrid meeting).
Click Here to Manage Email Alerts