Here is data from a case with ASCVD risk estimate of 6.4%, who is further advised coronary artery calcium scoring (CACS) to refine risk estimate. What would the next steps in the case be? And, how helpful is CACS as tool in primary prevention of ASCVD?

A 60-year-old gentleman comes to your clinic and is concerned about his future risk of heart attack as he has a very strong family history of ischaemic heart disease in both parents. He quit smoking 8 years ago, with a prior 30-pack-year history. He is hypertensive on lisinopril. Due to unreliable schedule, his food choices and exercise habits are not always good.

Examination

• O/E: BP: 138/86 mmHg
• Pulse: 80 beats/min
• BMI: 31.4
• Waist circumference: 37"

Laboratory results

• Total cholesterol: 196 mg/dL
• Triglycerides: 182 mg/dL
• HDL-C: 46 mg/dL
• LDL-C: 111 mg/dL

His 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimate was found to be 6.4%. Assessment of coronary artery calcium score (CACS) was advised by you to refine his risk estimate. It was performed and Agatston score was 54, which is at the 82nd percentile for his age, gender, and ethnicity. He asked for your clinical implication and interpretation.

CACS- An effective diagnostic tool

Coronary artery calcium scoring (CACS) evaluates calcified coronary atherosclerotic plaque. It is considered to be the most effective diagnostic method for refining risk estimates in persons without established ASCVD. Data produced over the last 25 years have consistently shown that the degree of the calcification of coronary arteries predicts potential heart attacks.

A number of experiments have found that CAC is extremely useful for primary prevention as a decision tool. MESA study and coronary calcium and lifestyle factors evaluation trials revealed a clear correlation between CAC and the incidence of hard cardiac events such as MI, cardiac death, and resuscitated cardiac arrest.

With the growing body of evidence demonstrating that CAC scoring highly predicts cardiovascular risk, its use in preventive cardiology has the ability to extend across all races, ages, classes and sexes.

1. We see CAC as a helpful measure to be viewed narrowly to help make better choices about preventive therapies rather than being a broad-based screening method.
2. CAC will empower the joint decision-making process with knowledge about atherosclerosis pressure and ASCVD risk in the sense of clinician-patient risk dialogue.
3. High CAC can enable clinicians in preventive health to recognise and treat patients who would gain greatly from primary prevention medical intervention rather than a false reassurance of low ASCVD risk as measured.
4. CACS practises risk identification. Importantly, the incorporation of the CACS to conventional global risk management dramatically strengthens profiling and reclassification steps.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Monish S Raut is a Consultant in Cardiothoracic Vascular Anaesthesiology. His area of expertise is perioperative management and echocardiography with numerous publications in various national and international indexed journals.