Adults with high CAC score at similar risk for CV events as those with established ASCVD
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Key takeaways:
- A coronary artery calcium score of more than 300 is risk equivalent to established atherosclerotic CVD.
- Intensity of therapy should be matched with intensity of risk.
Adults with a coronary artery calcium score greater than 300 are at an equivalent risk for major CV events as treated patients with established atherosclerotic CVD, supporting the use of high-dose statins in this population, data show.
There are limited data on what level of calcification, as measured with a CAC score, is associated with similar risks as those who already experienced an MI, a secondary risk equivalent, Matthew J. Budoff, MD, FACC, FAHA, endowed chair of preventive cardiology, professor of medicine and director of cardiac CT at Harbor-UCLA Medical Center, and colleagues wrote in JACC: Cardiovascular Imaging. Researchers analyzed event rates of patients with established ASVCD and compared them with the risk of people without prior ASCVD aggregated into groups with increasing calcium scores to determine which CAC scores afforded risk equivalent to a cohort with existing ASCVD.
Data were derived from Budoff MJ, et al. JACC Cardiovasc Imaging. 2023;doi:10.1016/j.jcmg.2023.03.008.
“A patient with a CAC score greater than 300 has the same CV risk as a post-MI survivor,” Budoff told Healio. “We have so many great therapies in the cardiovascular realm that can be applied to high risk-patients. Understanding who these patients are, prior to having an MI, stroke or CV death, affords clinicians great opportunity to intervene in a timely manner.”
Assessing CAC data
Budoff and colleagues compared event rates of 438 patients with established ASVCD to event rates in 4,511 people with no history of ASCVD and known calcium scores to assess at what level elevated CAC scores equate to risk associated with existing ASCVD, using data from the multinational, prospective CONFIRM registry (n = 4,949). The mean age of participants was 58 years and 56% were men.
Established ASCVD included documented history of MI, stroke or peripheral artery disease; all patients were assessed at the time of coronary CT angiography. The CAC score was then categorized into the following four groups: 0 (very low), 1 to 99 (mild), 100 to 300 (moderate), and more than 300 (severe). The primary study endpoint was a composite of major adverse CV events, which included all-cause mortality, nonfatal MI and hospitalization for unstable angina, and a separate analysis evaluated late target vessel revascularization (> 90 days).
During median follow-up of 4 years, 9% of participants experienced major adverse CV events and 5% of patients died.
Incident major adverse CV events increased with higher CAC scores, with the highest rate (20%) observed among adults with a CAC score more than 300; those with prior ASCVD also had a rate of 20%. All-cause mortality, major adverse CV events, major adverse CV events plus late revascularization and MI event rates did not differ between participants with a CAC score greater than 300 and those with established ASCVD (P > .05 for all comparisons).
Participants with a CAC score of less than 300 had substantially lower event rates, according to researchers.
Guidelines on secondary prevention evolving
The researchers noted that guidelines continue to evolve and “will need to adapt this new information on secondary prevention targets with CAC.” The findings support the algorithms of the American College of Cardiology/American Heart Association calling for the use of high-dose statins in persons with CAC scores greater than 300. Secondary prevention therapies include antiplatelet agents, diabetes therapies and advanced lipid therapies that are currently approved for secondary prevention only. More research is needed to understand when a patient transitions from primary prevention risk to a higher level of risk before any CV event, Budoff and colleagues wrote.
“The implications of understanding that a CAC score > 300 equates to secondary prevention risk will allow for more advanced therapies to be applied in these higher-risk individuals, matching the intensity of therapy with the intensity of risk,” the researchers wrote. “Awaiting myocardial infarction, stroke or cardiovascular death to qualify for advanced secondary prevention therapies is both unnecessary and Darwinian because some patients will die before qualifying for these advanced therapies.”
For more information:
Matthew J. Budoff, MD, FACC, FAHA, can be reached at mbudoff@lundquist.org.
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