The Framingham risk score has been the primary method of determining a patient’s 10-year risk of cardiovascular disease. Scores such as this take into account a patient’s specific risk factors including age, gender, systolic blood pressure, total cholesterol, high-density lipoprotein fraction, smoking status, and diabetes status. These scores have been convenient and cheap, as they can be performed quickly in a provider’s office. However, sometimes more information is needed in order to make a better decision regarding statin therapy initiation. In this article, we will discuss the use and interpretation of coronary artery calcium scoring in relation to recommending statin (podcast) drug therapy in primary prevention.
One method recommended in the 2018 AHA/ACC cholesterol management guidelines is using coronary artery calcium (CAC) scores. CAC score examinations are non-invasive procedures using a cardiac computed tomography (CT). The scan helps to measure arterial calcification as a method of determining coronary atherosclerosis.
CAC scores are recommended specifically for patients who fall into an intermediate risk category, which is an estimated 40% of patients. The examination is particularly useful for those who are older than 55 years of age. CAC scores can also benefit asymptomatic adults with a range of baseline risks. If a patient and provider are discussing the risk and benefits of initiating statin therapy but struggling to decide, it may be useful to follow further with a CAC examination.
There are multiple methods that can be used for the assessment of a CAC score once the examination is complete. The Agatston method is the most commonly used as it has been used to outline population databases. The CAC score can then be analyzed after examination using the chart below. In general, statin therapy can be added for any patient with a CAC score of 1 or greater, especially if the patient is 55 years of age or older.
Coronary Artery Calcium (CAC) Score
| CAC Score | Risk Level | Clinical Interpretation |
| 0 | No Risk | Withhold Statin Therapy (unless other strong reasoning) |
| 1-10 | Minimal Risk | Statin Therapy Possible |
| 11-100 | Mild Risk | Statin Therapy Possible |
| 101-400 | Moderate Risk | Statin Therapy is Indicated |
| >400 | High Risk | Statin Therapy is Indicated |
However, it is important to note that not all patients need a CAC score. Patients that definitively fall into the “low-risk” or “high-risk” categories of the Framingham risk assessment are less likely to benefit from the additional examination. Additionally, patients that have already been initiated on statins do not need to undergo further testing. If the provider and patient are in agreement on whether a statin is or is not indicated might also allow for cost-savings by allowing the patient to not undergo the additional examination. The exam typically costs anywhere between $100 to $400, and insurance coverage can vary. Therefore, it is important to reduce this cost if possible by ensuring that CAC scoring is going to be useful in guiding care.
In summary, CAC scores can be another tool in further stratifying patients into risk groups in order to determine whether a patient might benefit from statin therapy. Looking for more on statins? Here’s an article on which ones interact with grapefruit juice.
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References
Greenland P, Smith SC Jr, Grundy SM. Improving coronary heart disease risk assessment in asymptomatic people: role of traditional risk factors and noninvasive cardiovascular tests. Circulation. 2001;104:1863–7.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., … & Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25), e1082-e1143.
Hoover L. E. (2019). Cholesterol Management: ACC/AHA Updates Guideline. American family physician, 99(9), 589–591.
Shreya, D., Zamora, D. I., Patel, G. S., Grossmann, I., Rodriguez, K., Soni, M., … & Sange, I. (2021). Coronary Artery Calcium Score-A Reliable Indicator of Coronary Artery Disease?. Cureus, 13(12).
Soto, L. “Coronary Calcium Test Could Help Clarify Heart Disease Risk – and Control Cholesterol.” (2022) American Heart Association, 17 May 2022, Accessed at: https://www.heart.org/en/news/2018/11/13/coronary-calcium-test-could-help-clarify-heart-disease-risk-and-control-cholesterol. Accessed on: 11/22/2022.
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