Testing: Coronary artery calcium to risk stratify in primary prevention
What the test entails
- Single Computer tomography (CT) scan of the chest using either electron beam CT (EBCT) or multidetector CT (MDCT)
- A radiologist or cardiologist evaluates the CT images and quantifies calcification of the coronary arteries (a marker of atherosclerotic plaque buildup) using the Agatston score
Evidence
A 2004 meta-analysis identified the coronary artery calcium (CAC) score as an independent risk factor for coronary artery disease events (coronary death, non-fatal MI or revascularization)
- CAC score: odds ratio (OR) for coronary heart disease event
- No calcification (0): OR 1 (reference)
- Low (1-100): OR 2.1
- Medium (101-400): OR 5.4
- High (>400): OR 10
The Multi-Ethnic Study of Atherosclerosis (MESA) population-based cohort provides the best evidence for use of the coronary artery calcium (CAC) score in risk stratification.
- In a primary prevention cohort that included patients with a low (<5%), intermediate (5-20%) and high (>20%) 10-year risk of CVD based on the Framingham risk score, the CAC score was a statistically significant predictor of coronary or total CV events, but added little extra accuracy to the Framingham risk score used alone.
- Indescriminate testing is the main limitation of these results. There is little value in obtaining a CAC score in a patient who is at low risk of a CV event based on their risk factors. Similarly, a CAC score is unlikely to reclassify a patient with a high Framingham score down into a low-risk category that doesn't warrant treatment.
- To account with the limitations of the above study, the MESA investigators evaluated the performance of the CAC score (& other novel risk markers) in a sub-cohort of 1330 patients without diabetes with an "intermediate" Framingham score (10-year risk of coronary artery disease of 5-20%) over a median follow-up period of 7.6 years.
- Addition of CAC score to the Framingham risk score correctly reclassified
- ~25% of patients from an intermediate- to high-risk group (i.e. changed their estimated 10-year risk of a coronary event from 5-20% to >20%)
- ~40% of patients from the intermediate- to low-risk group
- Addition of CAC score to the Framingham risk score correctly reclassified
Bottom line
- Patients who should NOT get CAC scoring (low likelihood of altering management)
- Low Framingham score
- High Framingham score
- Patients already receiving primary prevention therapies
- Patients who have already made a decision for/against medical therapy for primary prevention
- Patients for whom CAC scoring could be useful
- Intermediate Framingham score + patient undecided about initiating therapy, or wishing for further stratification
- High Framingham score + undecided about therapy
- Clinicians can integrate the CAC score with traditional clinical risk factors to estimate a patient's 10-year CV risk using this calculator.
Prepared by: Ricky Turgeon BSc(Pharm), ACPR, PharmD
Last updated: 9 Sept 2016