Elsevier

Mayo Clinic Proceedings

Volume 92, Issue 12, December 2017, Pages 1831-1841
Mayo Clinic Proceedings

My treatment approach
Use of the Coronary Artery Calcium Score in Discussion of Initiation of Statin Therapy in Primary Prevention

https://doi.org/10.1016/j.mayocp.2017.10.001Get rights and content

Abstract

Clinical guidelines for instituting pharmacotherapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD), specifically lipid management and aspirin, have long been based on absolute risk. However, lipid management in the current era remains challenging to both patients and clinicians in the setting of somewhat discordant recommendations from various organizations. All guidelines endorse the use of statins for primary prevention for those at sufficient absolute risk, and treatment recommendations are generally “risk-based” rather than exclusively targeting specific low-density lipoprotein cholesterol levels. Nonetheless, guidelines differ in relation to the risk threshold for initiation and the intensity of statin treatment. The key concept of the clinician-patient risk discussion introduced in the 2013 American College of Cardiology/American Heart Association cholesterol guidelines is a process that addresses the potential for ASCVD risk reduction with statin treatment, potential for adverse treatment effects, patient preferences, encouragement of heart-healthy lifestyle, and management of other risk factors. However, operationalizing the clinician-patient risk discussion requires effective communication of the most accurate and personalized risk information. In this article, we review our treatment approach for the appropriate use of coronary artery calcium testing in the intermediate-risk patient to guide shared decision making. The decision to initiate or intensify statin therapy may be uncertain across a broad range of estimated 10-year ASCVD risk of 5% to 20%, and coronary artery calcium testing can reclassify risk upward or downward in approximately 50% of this group to inform the risk discussion. We conclude with 2 case-based examples of uncertain risk and uncertain statin therapeutic benefit to illustrate execution of the clinician-patient risk discussion.

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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  • Cited by (0)

    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.

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