How should asymptomatic high coronary artery calcium (CAC) scores on coronary computed tomography angiography (CTCA) with indeterminate coronary artery stenosis be managed?

From the Guidelines

Asymptomatic patients with high coronary artery calcium (CAC) scores and indeterminate coronary artery stenosis on coronary computed tomography angiography (CTCA) should be managed with high-intensity statin therapy and aspirin 81mg daily, as recommended by the most recent guidelines 1. The management approach should prioritize addressing modifiable risk factors through optimal guideline-directed medical therapy and lifestyle modification, as emphasized in recent studies 2. Key components of this approach include:

• Initiation of high-intensity statin therapy, such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily, targeting LDL <70 mg/dL, especially for patients with calcium scores >100 1
• Aspirin 81mg daily, as recommended for patients with CAC >100 1
• Lifestyle modifications, including a Mediterranean or DASH diet, regular aerobic exercise (150 minutes weekly), smoking cessation, and weight management targeting BMI <25
• Consideration of functional testing to assess for ischemia, with options including stress echocardiography, nuclear stress testing, or stress cardiac MRI, and referral for invasive coronary angiography if significant ischemia is detected Regular follow-up every 3-6 months is crucial to monitor symptoms, medication adherence, and risk factor control, aiming to prevent future cardiac events by stabilizing plaques and preventing progression to symptomatic disease 2, 1.

From the Research

Management of Asymptomatic High Coronary Artery Calcium Scores

• Asymptomatic patients with high coronary artery calcium (CAC) scores on coronary computed tomography angiography (CTCA) with indeterminate coronary artery stenosis require personalized management based on individual risk factors 3.
• A CAC score of 0 is the strongest negative predictive factor for cardiovascular disease (CVD), and a 0 score can successfully de-risk a patient, potentially avoiding unnecessary radiation exposure and treatment 4.
• Higher CAC scores correlate with worse cardiovascular prognostic outcomes, and CTCA can help strategize early interventions 3, 5.
• The decision to start treatment, such as statin and aspirin therapy, should be based on individual risk factors and CAC scores, with guidelines recommending CAC scoring for individuals with intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk and selective populations with borderline ASCVD risk 3.

Role of Coronary Computed Tomography Angiography (CTCA)

• CTCA has a high diagnostic accuracy for the detection of non-obstructive and obstructive CAD in high-risk asymptomatic patients with inconclusive or unfeasible stress test results 6.
• CTCA can detect a higher prevalence of all CAD, including non-obstructive CAD, compared to CACS alone 6.
• The combination of CACS with Systematic Coronary Risk Evaluation (SCORE) can better predict significant coronary artery stenosis than CACS alone, and CTCA can be performed in patients with high or very high SCORE risk, even with a zero CACS 7.

Risk Stratification and Treatment

• Age, sex, hypertension, and diabetes mellitus are significant predictors of stenosis, and males over 45 years old with diabetes mellitus and hypertension have a higher risk of significant coronary stenosis 4.
• Asymptomatic patients with CACSs of zero do not require CTCA, and thereby avoid unnecessary radiation exposure, while those with high CAC scores and indeterminate coronary artery stenosis may require further evaluation and treatment 4, 6.