What is the management approach for a patient with a CT calcium score of 330, moderate to high plaque burden, nonobstructive coronary artery disease, and shortness of breath (SOB) with high activity?

Management of Moderate Coronary Calcium Score with Nonobstructive CAD and Exertional Dyspnea

For a patient with a calcium score of 330, moderate plaque burden, and shortness of breath with high activity, you should initiate high-intensity statin therapy immediately, aggressively modify all cardiovascular risk factors, and perform functional stress testing to evaluate for inducible ischemia that may explain the exertional symptoms. 1, 2

Immediate Risk Stratification

Your patient's CAC score of 330 places them in the moderate-to-high plaque burden category (100-399 range), which is associated with significantly elevated cardiovascular risk and warrants aggressive preventive intervention. 1, 2

• CAC scores >100 are associated with event rates exceeding 7.5% over 10 years, strongly favoring statin therapy initiation 2
• A score of 330 indicates established atherosclerotic disease requiring upward risk recalibration regardless of traditional risk factors 2
• Approximately 48.5% of patients with CAC scores >400 demonstrate abnormal myocardial perfusion on functional imaging, suggesting your patient with a score of 330 has substantial risk of ischemia 1

Pharmacologic Management

Initiate high-intensity statin therapy immediately to achieve ≥50% LDL-C reduction with a target LDL-C <70 mg/dL. 1, 2

• The presence of CAC indicates established atherosclerosis with proven mortality benefit from statin treatment 2
• Consider daily low-dose aspirin therapy, as studies demonstrate improved outcomes in patients with elevated calcium scores 1
• Optimize management of hypertension, diabetes (if present), and all other modifiable cardiovascular risk factors 1

Critical pitfall: Do not defer or delay statin therapy based on patient preference when CAC score is >100, as this represents established disease requiring treatment. 2

Evaluation of Exertional Dyspnea

Perform functional stress testing (stress echocardiography, SPECT, or PET) to assess for inducible myocardial ischemia as the likely cause of shortness of breath with high activity. 3, 1

The 2024 ESC guidelines recommend functional imaging for patients with suspected chronic coronary syndrome when obstructive CAD cannot be excluded by clinical assessment alone. 3

Why Functional Testing is Essential Here:

• Your patient has symptomatic presentation (exertional dyspnea) combined with moderate-high plaque burden, making obstructive disease possible despite the CT report suggesting nonobstructive CAD 3
• Shortness of breath during activity in patients with known CAD is associated with both ischemic and non-ischemic cardiac causes 4, 5
• Functional imaging will determine if the symptoms are due to myocardial ischemia requiring revascularization versus other causes 3

Alternative Consideration - Coronary CTA:

Coronary CTA may provide incremental value in patients with CAC scores >100 to definitively assess for obstructive coronary artery disease, particularly when the degree of stenosis is uncertain. 3, 1

• The CONFIRM registry demonstrated that CCTA provides incremental predictive value in patients with CAC scores 101-400 for identifying obstructive disease 3
• CCTA can assess both plaque burden and degree of luminal stenosis, which is particularly relevant given your patient's symptomatic presentation 3
• However, extensive calcification (as suggested by CAC 330) may limit image quality 3

Clinical Decision Algorithm:

Step 1: Start high-intensity statin therapy and aspirin immediately 1, 2

Step 2: Order functional stress testing (preferred) or coronary CTA to evaluate for obstructive CAD and ischemia 3, 1

Step 3: If stress testing shows significant ischemia (>10% myocardium) or CCTA reveals obstructive disease (≥70% stenosis), refer for invasive coronary angiography with FFR guidance 3

Step 4: If testing is negative for significant ischemia, consider non-cardiac causes of exertional dyspnea (pulmonary disease, deconditioning, obesity) 6, 5

Step 5: Implement aggressive lifestyle modifications including smoking cessation, heart-healthy diet, regular exercise, and weight management 1

Important Caveats:

• Do not perform serial CAC scoring once statin therapy is initiated, as statins paradoxically increase calcium scores despite reducing atherosclerosis progression 2
• In patients with CAD presenting with shortness of breath, anxiety/depression and multiple comorbidities are associated with symptom reporting, but ischemia must be excluded first 5
• The combination of moderate plaque burden and exertional symptoms places this patient at higher risk than asymptomatic individuals with similar calcium scores 3

Follow-up Strategy:

• Regular cardiovascular risk assessment with more frequent monitoring than lower-risk patients 1
• Focus on achieving and maintaining target LDL-C levels <70 mg/dL 2
• Reassess symptoms after initiating medical therapy and completing functional evaluation 3
• If revascularization is performed, invasive physiological guidance (FFR/iwFR) is recommended to evaluate stenoses before intervention 3