What is the next step for a 60-year-old male patient with a history of hypertension, who experienced symptoms of chest pain during a stress test with no changes, and had an echocardiogram showing a high coronary calcium score of 340?

From the Guidelines

The next step for this 60-year-old male patient with hypertension, a stress test showing chest pain without ECG changes, and a coronary calcium score of 340 should be referral to a cardiologist for further evaluation and likely coronary angiography, as indicated by the CAD-RADS category which suggests moderate to severe coronary artery calcification 1.

Key Considerations

• The patient's coronary calcium score of 340 indicates significant atherosclerotic disease, which, despite the non-diagnostic stress test, raises concern for coronary artery disease that requires definitive assessment to determine if revascularization is needed or if medical therapy alone would be sufficient.
• According to the CAD-RADS 2.0 guidelines, a coronary calcium score of this magnitude would likely categorize the patient as CAD-RADS 4, which recommends further evaluation with invasive coronary angiography (ICA) or functional imaging, including CT-FFR, CTP, and stress testing, depending on the location, extent, and severity of the lesion(s), and clinical characteristics such as angina severity and the use of current guideline-directed medical therapies 1.
• The presence of symptoms during stress testing and the absence of ECG changes, combined with the elevated calcium score, supports the need for a more definitive assessment of coronary artery disease, as suggested by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.

Management Recommendations

• While awaiting specialist evaluation, the patient should be started on aspirin 81mg daily and a moderate-intensity statin such as atorvastatin 20-40mg daily to reduce the risk of cardiovascular events.
• Optimization of blood pressure control with a target below 130/80 mmHg is also crucial, as uncontrolled hypertension can exacerbate coronary artery disease.
• Lifestyle modifications including a heart-healthy diet, regular exercise, smoking cessation if applicable, and weight management should be emphasized to reduce cardiovascular risk factors.
• The cardiologist may recommend coronary CT angiography or invasive coronary angiography to directly visualize coronary stenosis and guide further management, including potential revascularization if necessary.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for the Patient

The patient's stress test results and echocardiogram showing a high coronary artery calcium score of 340 indicate a potential risk for atherosclerotic cardiovascular disease (ASCVD) [(2,3)].

• The patient's history of hypertension and symptoms of chest pain during the stress test suggest the need for further evaluation and management of their cardiovascular risk factors.
• The coronary artery calcium score of 340 is considered high and indicates the presence of atherosclerotic plaque in the coronary arteries 3.
• According to the study by 2, the decision to initiate or intensify statin therapy may be uncertain in patients with an intermediate risk of ASCVD, and coronary artery calcium testing can help reclassify risk upward or downward to inform the risk discussion.
• The study by 4 suggests that the coronary calcium score can improve risk classification in patients with chest pain, even in the absence of prior risk factor screening.

Potential Treatment Options

Based on the patient's high coronary artery calcium score and history of hypertension, potential treatment options may include:

• Initiation or intensification of statin therapy to reduce the patient's risk of ASCVD [(2,3)].
• Lifestyle modifications, such as diet and exercise, to reduce the patient's cardiovascular risk factors 2.
• Further evaluation and management of the patient's hypertension to reduce their risk of ASCVD [(2,3)].

Further Evaluation

Further evaluation of the patient's cardiovascular risk factors and ASCVD risk may be necessary to determine the best course of treatment. This may include:

• Additional diagnostic testing, such as a CT coronary angiogram, to evaluate the presence and extent of coronary artery disease 4.
• Consultation with a cardiologist or other specialist to determine the best treatment options for the patient [(2,3)].