Is statin use indicated with a Coronary Artery Calcium (CAC) score of 2?

From the Guidelines

For a coronary artery calcium (CAC) score of 2, statin therapy is generally not automatically recommended based on the CAC score alone. A CAC score of 2 is considered very low risk, falling within the 0-10 range that indicates minimal calcified plaque and very low cardiovascular risk 1. Instead, the decision to start a statin should be based on your overall cardiovascular risk assessment, including factors like age, blood pressure, cholesterol levels, smoking status, diabetes, and family history.

Key Considerations

• If your 10-year atherosclerotic cardiovascular disease (ASCVD) risk is calculated to be less than 5-7.5%, statins are typically not recommended 1.
• However, if you have other risk factors or your LDL cholesterol is significantly elevated (>190 mg/dL), your doctor might still consider statin therapy 1.
• The minimal CAC score suggests that lifestyle modifications including heart-healthy diet, regular exercise, smoking cessation, and maintaining healthy weight should be your primary focus 1.

Lifestyle Modifications

• These lifestyle changes can effectively manage cardiovascular risk without medication for many people with minimal coronary calcification 1.
• A CAC score of 1 to 99 favors lifestyle improvement, according to the CSANZ guidelines 1.

Statin Therapy

• If the coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients ≥55 years of age 1.
• The 2019 ACC/AHA guideline recommends statin therapy for patients with an LDL-C level of 190 mg/dL or higher 1.
• The decision to start a statin should be based on your overall cardiovascular risk assessment, including factors like age, blood pressure, cholesterol levels, smoking status, diabetes, and family history 1.

From the Research

Statin Use with CAC Score of 2

• The decision to initiate statin therapy with a Coronary Artery Calcium (CAC) score of 2 may depend on various factors, including the patient's overall risk profile and the presence of other risk-enhancing factors 2.
• A CAC score of 0-2 is generally considered low, and the presence of risk-enhancing factors may not necessarily increase the risk of atherosclerotic cardiovascular disease (ASCVD) to a level that warrants statin therapy 2.
• However, the use of CAC scoring can help reclassify risk and guide statin therapy allocation according to risk-enhancing factors 2.
• Studies have shown that CAC scoring can be a useful tool in guiding statin therapy, particularly in individuals with intermediate risk of ASCVD 3, 4, 5.
• The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of CAC scoring to guide the allocation of statin therapy among individuals with an intermediate risk of ASCVD 2.

Considerations for Statin Therapy

• The presence of a CAC score of 2 may not necessarily require statin therapy, but it is essential to consider other risk factors, such as family history, lipid profiles, and inflammatory biomarkers 2.
• Statin therapy may be beneficial for individuals with a CAC score of 2 if they have other high-risk features, such as diabetes, hypertension, or a family history of premature ASCVD 3, 4.
• The use of CAC scoring can help identify individuals who may benefit from statin therapy, even if their traditional risk factors do not indicate a high risk of ASCVD 5.
• It is crucial to consider the individual's overall risk profile and to engage in shared decision-making with the patient to determine the best course of treatment 3, 4.

Prognostic Value of CAC Score

• The prognostic value of CAC score, area, and density among individuals on statin therapy versus non-users has been studied, and the results suggest that CAC scoring retains robust risk prediction in statin users 6.
• The changing relationship of CAC density with outcomes may explain the slightly weaker relationship of CAC with outcomes in statin users 6.
• The use of CAC scoring can provide valuable information for guiding statin therapy and monitoring disease progression in individuals with ASCVD 6.