From the Guidelines
For patients with a family history of premature Atherosclerotic Cardiovascular Disease (ASCVD), Coronary Artery Calcium (CAC) scoring is recommended as an additional cardiovascular risk assessment. This test is particularly useful for individuals who have first-degree relatives with ASCVD before age 55 in men or before age 65 in women. CAC scoring is a non-invasive test that uses computed tomography (CT) to detect and measure the amount of calcium in the coronary arteries, which is a marker of atherosclerotic plaque burden. Elevated CAC scores are associated with increased cardiovascular risk independent of other risk factors. While there are currently no specific medications approved solely for CAC reduction, identifying elevated CAC scores may influence treatment decisions, including more aggressive LDL-lowering therapy with statins, ezetimibe, or PCSK9 inhibitors. Patients with elevated CAC scores might benefit from earlier and more intensive preventive strategies, including stricter blood pressure and diabetes control. The test requires only a standard CT scan and does not need fasting. Understanding CAC status provides valuable information for risk stratification and can help guide the intensity of preventive interventions for patients with family histories of premature ASCVD, as supported by the 2020 study 1 and the 2023 guidelines 1. Key points to consider include:
- CAC scoring is a useful tool for risk stratification in patients with a family history of premature ASCVD.
- Elevated CAC scores are associated with increased cardiovascular risk.
- CAC scoring can help guide treatment decisions, including the use of statins, ezetimibe, or PCSK9 inhibitors.
- Patients with elevated CAC scores may benefit from earlier and more intensive preventive strategies. It is essential to note that the use of CAC scoring as a risk modifier is supported by recent guidelines, including the 2023 multimodality appropriate use criteria for the detection and risk assessment of chronic coronary disease 1. In addition to CAC scoring, other risk-enhancing factors, such as family history of premature ASCVD, primary hypercholesterolemia, metabolic syndrome, and chronic kidney disease, should also be considered when assessing cardiovascular risk, as outlined in the 2021 ACC expert consensus decision pathway 1. Overall, CAC scoring is a valuable tool for assessing cardiovascular risk in patients with a family history of premature ASCVD and can help guide treatment decisions to reduce the risk of future cardiovascular events.
From the Research
Additional Tests for Patients with a Family History of Premature ASCVD
- Patients with a family history of premature Atherosclerotic Cardiovascular Disease (ASCVD) are at increased cardiovascular risk and may require additional testing to assess their risk and guide management decisions.
- One additional test that may be recommended for these patients is lipoprotein(a) (Lp(a)) level measurement, as elevated Lp(a) levels have been associated with increased risk of ASCVD 2, 3.
- Lp(a) level measurement can help identify individuals with elevated Lp(a) levels, who may benefit from more aggressive lipid-lowering therapy and other preventive measures to reduce their risk of ASCVD.
- Other tests that may be recommended for patients with a family history of premature ASCVD include genetic testing for familial hypercholesterolemia (FH), as FH is a common genetic disorder associated with premature ASCVD 4.
- Coronary artery calcium (CAC) scoring may also be recommended for asymptomatic individuals with a family history of premature ASCVD, as it can help assess their atherosclerotic burden and guide management decisions 2.
Lipid-Lowering Therapy
- Patients with a family history of premature ASCVD may require more aggressive lipid-lowering therapy to reduce their risk of ASCVD.
- Statins are the first-line therapy for lipid-lowering, but additional therapies such as ezetimibe and PCSK9 inhibitors may be recommended for patients with very-high ASCVD risk or those who are not achieving adequate lipid-lowering with statin therapy alone 5, 6.
- The choice of lipid-lowering therapy will depend on the individual patient's risk factors, lipid profile, and other medical conditions, and should be guided by current clinical guidelines and recommendations.