Management of Coronary Calcifications
For patients with coronary calcifications, a comprehensive management approach is recommended that includes risk stratification, appropriate diagnostic testing, medical therapy, and consideration for revascularization in selected cases based on symptoms and risk profile.
Diagnostic Assessment
- Coronary artery calcification is a reliable marker of coronary atherosclerosis and vascular age, making it a robust predictor for risk assessment and future cardiovascular events 1
- Coronary calcium detection by computed tomography is not recommended to identify individuals with obstructive coronary artery disease (CAD) 2
- When coronary calcification findings are available from previous chest CT scans, these findings should be considered to enhance risk stratification and guide treatment of modifiable risk factors 1
- Coronary CTA is not recommended when extensive coronary calcification is present, as it makes good image quality unlikely 2
- Risk stratification is recommended based on clinical assessment and the result of the diagnostic test initially employed to make a diagnosis of CAD 2
Risk Assessment
- Resting echocardiography is recommended to quantify left ventricular function in all patients with suspected CAD 2
- Risk stratification, preferably using stress imaging or coronary CTA (if local expertise and availability permit), is recommended in patients with suspected or newly diagnosed CAD 2
- In symptomatic patients with a high-risk clinical profile, invasive coronary angiography (ICA) complemented by invasive physiological guidance (FFR) is recommended for cardiovascular risk stratification, particularly if symptoms are inadequately responding to medical treatment 2
- Invasive functional assessment must be available and used to evaluate stenoses before revascularization, unless very high grade (>90% diameter stenosis) 2
Medical Management
Lifestyle Modifications
- Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended for all patients with coronary calcifications 2
- Exercise-based cardiac rehabilitation is recommended as an effective means for patients with chronic coronary syndromes to achieve a healthy lifestyle and manage risk factors 2
- Involvement of multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) is recommended 2
Pharmacological Therapy
- Medical treatment of symptomatic patients requires one or more drugs for angina/ischemia relief in association with drugs for event prevention 2
- First-line treatment for symptom control is indicated with beta-blockers and/or calcium channel blockers to control heart rate and symptoms 2
- Short-acting nitrates are recommended for immediate relief of effort angina 2
- Statins are recommended in all patients with chronic coronary syndromes 2
- If LDL-C goals are not achieved with the maximum tolerated dose of a statin, combination with ezetimibe is recommended 2
- For patients at very high risk who do not achieve their goal on a maximum tolerated dose of statin and ezetimibe, combination with a PCSK9 inhibitor is recommended 2
Antithrombotic Therapy
- Aspirin 75-100 mg daily is recommended in patients with a previous MI or revascularization 2
- Clopidogrel 75 mg daily is recommended as an alternative to aspirin in patients with aspirin intolerance 2
- For patients who have undergone coronary stenting, aspirin 75-100 mg daily is recommended following stenting 2
- Clopidogrel 75 mg daily following appropriate loading is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type 2
Special Considerations
- Patients with diabetes mellitus often have more extensive coronary calcification and complex coronary anatomy 1
- Vasodilating beta-blockers may be preferred in patients with diabetes to avoid adverse metabolic effects 1
- Atorvastatin has been shown to significantly reduce the rate of major cardiovascular events with a relative risk reduction of 22% at higher doses (80 mg vs 10 mg) 3
- Atorvastatin 10 mg daily has demonstrated a 36% relative risk reduction in coronary events in patients with hypertension and multiple cardiovascular risk factors 3
- No cardiac events were observed in one study where coronary calcifications could be excluded, highlighting the prognostic value of calcium scoring 4
Monitoring and Follow-up
- Timely review of the patient's response to medical therapies (e.g., 2-4 weeks after drug initiation) is recommended 2
- Annual influenza vaccination is recommended for patients with chronic coronary syndromes, especially in the elderly 2
- Mobile health interventions are recommended to improve patient adherence to healthy lifestyles and medical therapy 1