Is a computed tomography (CT) calcium score useful for individuals aged 65 and older?

From the Guidelines

CT calcium scores can be useful for people age 65 and older, particularly when there is uncertainty about cardiovascular risk and treatment decisions regarding statin therapy are unclear. For older adults, these scans are most beneficial in reclassifying intermediate-risk patients to either higher or lower risk categories, which can guide treatment intensity 1. The test measures calcium deposits in coronary arteries, with scores ranging from zero (no detectable plaque) to over 400 (extensive atherosclerosis). In older adults, some degree of coronary calcification is common due to normal aging, so context is important when interpreting results.

Some key points to consider when using CT calcium scores in older adults include:

• The ACC/AHA guidelines suggest using CAC scores to assist risk reclassification among older patient demographics, including those aged 76 to 80 years with an LDL-C level of 70 to 189 mg/dL 1.
• A high calcium score in someone over 65 might prompt more aggressive preventive measures, including moderate to high-intensity statins and stricter blood pressure and diabetes management.
• However, the presence of calcium doesn't necessarily indicate unstable plaque that will cause immediate problems.
• For very elderly patients (over 75-80), the added value of CT calcium scores diminishes further as other health considerations often take precedence in treatment decisions 1.

In terms of specific treatment decisions, a CAC score of 0 may warrant the deferral of statin therapy in adults 76 to 80 years of age with an LDL-C level of 70 to 189 mg/dL, according to the ACC/AHA guidelines 1. However, the clinical value of CT calcium scores decreases somewhat compared to younger populations, and their use should be individualized based on patient risk factors and health status.

From the Research

CT Calcium Score Utility for People Age 65 and Older

• The utility of CT calcium scores for people age 65 and older has been explored in several studies 2, 3, 4, 5, 6.
• A study published in JAMA Cardiology in 2017 found that coronary artery calcium (CAC) score was more strongly associated with incident coronary heart disease (CHD) and stroke than age alone in adults older than 60 years 2.
• The study suggested that CAC score may be a useful alternative marker to age for discriminating between lower and higher CHD risk in older adults 2.
• Another study published in the Journal of the American College of Cardiology in 2018 found that CAC scoring was a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions 3.
• A review published in BMJ in 2021 discussed the role of CAC score in the primary prevention of cardiovascular disease, highlighting its prognostic value and potential to inform personalized shared decision making 4.
• The review also noted that a CAC score of zero may be used to de-risk individuals and inform the safe delay or avoidance of certain preventive therapies 4.

Association with Cardiovascular Risk

• Studies have consistently shown that CAC score is associated with an increased risk of cardiovascular events, including CHD and stroke 2, 5, 6.
• A study published in The American Journal of Cardiology in 2023 found that CAC score was associated with a higher risk for atherosclerotic cardiovascular disease (ASCVD) events in patients with severe hypercholesterolemia 5.
• Another study published in Hypertension in 2019 found that CAC score was useful for stratifying cardiovascular risk in adults with hypertension, including those eligible for intensive blood pressure therapy 6.

Clinical Implications

• The studies suggest that CAC score may be a useful tool for clinicians to assess cardiovascular risk in people age 65 and older 2, 3, 4, 5, 6.
• The results of these studies may inform clinical decision making, including the use of statins and other preventive therapies 2, 4, 5.
• Further research is needed to fully understand the utility of CAC score in this population and to determine its potential to improve clinical outcomes 2, 4.