What injections can help lower Coronary Artery Calcification (CAC) scores?

No Injectable Therapies Currently Lower CAC Scores

There are currently no FDA-approved injectable medications that reduce coronary artery calcium (CAC) scores, and no guideline-recommended injectable therapies exist for this purpose. CAC represents stable, calcified atherosclerotic plaque that does not regress with current medical therapies, including injectable medications like PCSK9 inhibitors 1.

Why Injectable Therapies Don't Lower CAC Scores

• CAC reflects chronic, stable calcification that has accumulated over years to decades and represents approximately 20% of total atherosclerotic burden 2, 3, 4
• PCSK9 inhibitors (evolocumab, alirocumab) are injectable medications that dramatically lower LDL-C and reduce cardiovascular events in patients with established cardiovascular disease, but they do not reduce CAC scores 5
• The goal of therapy is not to lower the CAC score itself, but rather to prevent progression of atherosclerosis and reduce cardiovascular events (mortality, myocardial infarction, stroke) 1

What Injectable Therapies Actually Accomplish

• PCSK9 inhibitors reduce cardiovascular events (CV death, myocardial infarction, stroke, unstable angina requiring hospitalization, or coronary revascularization) in patients with established cardiovascular disease when added to statin therapy 5
• Evolocumab dosing is either 140 mg every 2 weeks OR 420 mg once monthly administered subcutaneously for adults with established CVD or primary hyperlipidemia 5
• These medications work by lowering LDL-C, not by reversing calcification, and should be considered as adjuncts to statin therapy in high-risk patients 5

The Correct Management Approach for Elevated CAC

Primary Therapy: Oral Statins

• Moderate-to-high intensity statin therapy is the cornerstone of management for patients with CAC >0, particularly those with scores ≥100, with demonstrated 22% relative risk reduction in major cardiovascular events 1, 2, 3
• Statins are oral medications, not injectable, and remain first-line therapy regardless of CAC score 1, 2

Lifestyle Modifications

• 150 minutes of moderate-intensity exercise weekly, Mediterranean or DASH diet, smoking cessation, and weight management form the foundation of primary prevention 2, 3, 4
• Blood pressure control <130/80 mmHg and optimal lipid management with LDL-C reduction of at least 30-50% from baseline 2, 3, 4

When to Consider Injectable PCSK9 Inhibitors

• Consider PCSK9 inhibitors only when LDL-C remains elevated despite maximum tolerated statin therapy in patients with established cardiovascular disease or very high risk 5
• These are adjuncts to statins, not replacements, and do not target CAC scores directly 5

Important Caveats About CAC Score Changes

• CAC scores typically progress over time and do not regress with current therapies, including statins, PCSK9 inhibitors, or any other medications 1, 6
• One small 2004 study suggested EDTA-tetracycline combination might reduce CAC scores by 14% in responders, but this has never been validated in rigorous randomized controlled trials and is not guideline-recommended 7
• Repeat CAC scanning should not be performed sooner than 3-5 years and is not recommended for monitoring treatment response 2, 3, 4
• The presence of CAC indicates atherosclerotic burden but does not necessarily correlate with degree of stenosis or predict which plaques will rupture 1, 2, 3

Common Pitfalls to Avoid

• Do not pursue therapies aimed at lowering CAC scores as this is not a validated treatment target and no proven therapies exist for this purpose 1
• Do not use serial CAC scanning to monitor treatment efficacy, as the goal is preventing cardiovascular events, not changing the calcium score 1, 2
• Do not dismiss elevated CAC scores even if traditional risk calculators suggest low risk, as CAC >0 indicates definite atherosclerosis requiring aggressive risk factor modification 2, 3, 4