From the Guidelines
Treatment of calcium buildup in coronary arteries should prioritize statin therapy for patients with a coronary artery calcium (CAC) score of 100 or higher, or in the 75th percentile or higher, as it is reasonable to initiate statin therapy in these cases. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, statin therapy is recommended for patients with a CAC score of 100 or higher, or in the 75th percentile or higher. This guideline suggests that if the CAC score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher risk conditions are absent. For patients with a CAC score of 1 to 99, statin therapy may be considered for those aged 55 years or older.
The primary goal of treatment is to slow the progression of calcium buildup and reduce the risk of cardiovascular events. Statins, such as atorvastatin (40-80mg daily), rosuvastatin (20-40mg daily), or simvastatin (20-40mg daily), are the primary medication used to lower LDL cholesterol levels and stabilize plaques. Aspirin (81-325mg daily) may also be prescribed to prevent blood clots. Additionally, lifestyle modifications, including a heart-healthy Mediterranean diet, regular aerobic exercise (150 minutes weekly), smoking cessation, weight management, blood pressure control, and diabetes management, are crucial in reducing inflammation, improving endothelial function, and decreasing oxidative stress in the arterial walls.
In cases where the CAC score is zero, the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease suggests that coronary artery calcium measurement can be a useful tool in refining risk assessment for preventive interventions, such as statin therapy 1. However, the absence of coronary artery calcium does not rule out noncalcified plaque, and clinical judgment about risk should prevail. For severe cases with significant blockage, interventional procedures like angioplasty with stenting or coronary artery bypass grafting may be necessary, but medication and lifestyle changes remain the foundation of treatment.
Key considerations in treatment include:
- CAC score: 100 or higher, or in the 75th percentile or higher, warrants statin therapy
- Age: 55 years or older may be considered for statin therapy with a CAC score of 1 to 99
- Lifestyle modifications: essential for reducing inflammation and improving endothelial function
- Aspirin therapy: may be prescribed to prevent blood clots
- Clinical judgment: essential in assessing risk and guiding treatment decisions.
From the Research
Treatment Options for Calcium Buildup in Coronary Arteries
- Intravascular lithotripsy (IVL) is a novel technology used to treat calcified coronary artery disease, which works by converting electrical energy into mechanical energy to disrupt calcium deposits 2.
- IVL has been shown to be safer than rotational atherectomy, with a lower risk of atheromatous embolization, and has better procedural and clinical success rates, acute lumen gain, and less residual stenosis 2.
- However, IVL is still underutilized due to its high cost and perceived procedural risk, and more long-term clinical data is needed to validate its safety and efficacy 2.
- Other treatment options include high-pressure balloons and rotational atherectomy devices, which have their own advantages and disadvantages 2, 3.
Importance of Accurate Evaluation and Imaging
- Accurate evaluation of patient and lesion characteristics is crucial in planning the best percutaneous coronary intervention strategy for calcified coronary artery disease 3.
- Intracoronary imaging is useful and necessary to understand calcific lesion features and define the calcific arc, length, and thickness, which can suggest the best procedure before stenting and final optimization 3.
Pathophysiology of Atherosclerosis
- Atherosclerosis is the main risk factor for cardiovascular disease, and is initiated by endothelium activation, followed by a cascade of events including accumulation of lipids, fibrous elements, and calcification 4.
- The resultant atheroma plaque can lead to cardiovascular complications, and understanding the different stages of atherosclerosis development is important for developing effective treatment strategies 4.
Role of Medications in Atherosclerosis Management
- Statins and angiotensin-converting enzyme (ACE) inhibitors are first-line therapies for the management of atherosclerosis complications, and have been shown to reduce the rate of ASCVD events in patients with hypertension and lipid disorders 5.
- The combination of an ACE-inhibitor and a statin has been consistently demonstrated to be effective in reducing the rate of ASCVD events, and is a recommended treatment strategy for patients with atherosclerosis 5.