My treatment approachUse of the Coronary Artery Calcium Score in Discussion of Initiation of Statin Therapy in Primary Prevention
Section snippets
Burden of ASCVD and Opportunities for Prevention
Atherosclerotic cardiovascular disease, including both coronary heart disease (CHD) and stroke, was the cause of approximately 1 in 3 deaths in the United States in 2014,1 and more than a third of ASCVD deaths occurred among individuals younger than 75 years. Yet, modifiable factors may account for approximately 90% of CHD risk.2 In their 2020 Strategic Impact Goal statement, the AHA described 7 health metrics (ie, body mass index [BMI; calculated as weight in kilograms divided by height in
2013 ACC/AHA ASCVD Risk Estimator
For nearly 2 decades, clinical decisions for lipid-lowering pharmacotherapy in primary prevention have been predicated on an initial assessment of global absolute risk. For example, the Adult Treatment Panel III guidelines relied on an estimation of 10-year CHD risk using a version of the Framingham Risk Score.6 More recently, the 2013 ACC/AHA risk assessment guidelines7 endorse risk factor screening every 4 to 6 years for those aged 20 to 79 years and application of the race- and sex-specific
Concordance and Discordance in Lipid Guidelines
Adding to the confusion, in 2016, the US Preventive Services Task Force (USPSTF) published their own recommendations for cholesterol management in primary prevention.19 The USPSTF recommended, with moderate-grade evidence, that adults aged 40 to 75 years who had an estimated 10-year ASCVD risk of 10% or higher (by the PCE) and at least one major risk factor (ie, hypertension, diabetes, dyslipidemia, or smoking) should be offered a low- to moderate-intensity statin, with a weaker endorsement for
Clinician-Patient Risk Discussion
Perhaps lost among the confusion between the various lipid guidelines, it is important to remember that the 2013 ACC/AHA lipid guidelines had advised a clinician-patient risk discussion before statin initiation.8 The clinician-patient risk discussion, which requires effective communication of the most accurate and personalized risk information, may be the ideal way to bridge the gap between guidelines. This shared decision-making conversation should address potential for ASCVD risk reduction,
Refinement of ASCVD Risk Estimation
Coronary artery calcium is measured semiautomatically by noncontrast cardiac computed tomography (CT)34 and typically quantified by the Agatston score,35 which factors in the density and area of the calcium. Coronary artery calcium is a useful surrogate measure of total coronary atherosclerotic burden36 and therefore “arterial age.”37 An elevated CAC score has been found in multiple epidemiological studies to be a robust predictor of future CHD,38 stroke,39 and ASCVD40 events as well as non-CVD
Operationalizing the Clinician-Patient Risk Discussion: 2 Case-Based Examples
In this section, we illustrate execution of the clinician-patient risk discussion in 2 cases of uncertain risk and therapeutic benefit for statin primary prevention in clinical practice. In the first case, the patient has an elevated 10-year ASCVD risk largely driven by age, despite favorable levels of modifiable risk factors including normal lipid levels. In the second case, the patient has an elevated estimated 10-year ASCVD risk, largely driven by modifiable nonlipid factors.
Putting It All Together: the ABCDE Approach
A comprehensive “ABCDE” approach71 is one way to provide a consistent and comprehensive organizational method for managing cardiovascular risk and promotion of ideal cardiovascular health,3 personalized for the individual patient. The very first step of this approach is “A: Assessment of risk” through the PCE and initiating the clinician-patient risk discussion. coronary artery calcium testing can be considered when risk is uncertain after global risk assessment. Further patient discussions
Recommendations
Risk estimation using the PCE is a helpful starting point in the clinician-patient risk discussion for preventive therapy. As part of shared decision making, guidelines support offering CAC testing for advanced risk assessment in a wide variety of circumstances when either the patient or the clinician feel uncertain about whether to initiate (or intensify) lipid-lowering therapy. Personalized risk assessment allows the opportunity to engage in a more sophisticated patient-centered risk
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Grant Support: Drs Michos and Blaha are funded by the Blumenthal Scholars Fund for Preventive Cardiology Research.
Potential Competing Interests: Dr Michos has received an honorarium from Siemens Healthcare Diagnostics for adjudicating events for a clinical trial. Dr Blaha has served on the advisory boards for Novartis AG, Amgen Inc, Sanofi/Regeneron, MedImmune, and Akcea Therapeutics; has received grant funding from Amgen Inc and the Aetna Foundation; and received an honorarium from Siemens Healthcare Diagnostics for adjudicating events in a clinical trial. Dr Blumenthal reports no disclosures.