From the Guidelines
Managing intracoronary calcium requires a strategic approach that prioritizes risk assessment and personalized treatment, with recent guidelines suggesting that a coronary artery calcium (CAC) score of 100 or higher is a threshold for initiating statin therapy. According to the most recent guidelines, including the 2023 major global coronary artery calcium guidelines 1, a CAC score of 0 is associated with a low risk of cardiovascular events, and statin therapy can be withheld. In contrast, a CAC score of 100 or higher is associated with a higher risk of cardiovascular events, and statin therapy should be initiated.
Key Considerations
- The 2023 guidelines suggest that a CAC score of 1 to 99 requires individualized decision-making, taking into account other risk factors and clinical considerations 1.
- The Australia and New Zealand guidelines recommend withholding statin therapy for a CAC score of 0, and initiating statin therapy for a CAC score of 101 to 400 in individuals at high risk, and for a CAC score greater than 400 in all individuals 1.
- The MESA study found that event rates varied from 1.3% to 5.6% for a CAC score of 0, and from 13.1% to 25.6% for a CAC score greater than 300, highlighting the importance of CAC scoring in risk assessment 1.
Treatment Approach
- For individuals with a CAC score of 100 or higher, statin therapy should be initiated, regardless of other risk factors.
- For individuals with a CAC score of 1 to 99, individualized decision-making is necessary, taking into account other risk factors and clinical considerations.
- Lifestyle modifications, including a healthy diet and regular exercise, are recommended for all individuals, regardless of CAC score.
Imaging and Interventional Techniques
- Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) can be used to evaluate calcium burden, distribution, and depth.
- Balloon angioplasty with non-compliant balloons at high pressure may be sufficient for moderate calcification.
- Calcium modification techniques, such as rotational atherectomy or orbital atherectomy, may be necessary for severe calcification before stent placement.
From the Research
Approach to Managing Intracoronary Calcium
- The management of intracoronary calcium is a complex process that involves various strategies, including the use of coronary artery calcium testing to guide shared decision making 2.
- Coronary artery calcifications are challenging scenarios for interventional cardiologists, and intracoronary imaging is useful and necessary to understand calcific lesion features and plan the best percutaneous coronary intervention strategy 3.
- The decision to initiate or intensify statin therapy may be uncertain across a broad range of estimated 10-year ASCVD risk of 5% to 20%, and coronary artery calcium testing can reclassify risk upward or downward in approximately 50% of this group to inform the risk discussion 2.
Risk Assessment and Stratification
- Coronary artery calcium (CAC) score is a biomarker for advanced atherosclerotic cardiovascular disease (ASCVD) risk assessment, and it has a clear advantage over traditional and non-traditional cardiovascular risk factors 4.
- The 2013 American College of Cardiology/American Heart Association (ACC/AHA) and the 2017 Society of Cardiovascular Computed Tomography (SCCT) guidelines recommend the use of CAC in ASCVD risk assessment, and it is most likely to be informative in intermediate risk patients and other special groups 4.
- A pragmatic approach that combines the pooled cohort equations (PCE) for initial ASCVD risk stratification, followed by CAC for refining ASCVD risk assessment, is supported by current evidence 4.
Treatment Strategies
- Antiplatelet therapy is a crucial component of the management of intracoronary calcium, and the optimal duration and choice of antiplatelet therapy remain controversial 5.
- A network meta-analysis of 32 randomized controlled trials found that high- to low-potency dual-antiplatelet therapy (DAPT) and aspirin+prasugrel containing DAPT for 12 months had a significantly lower incidence of major adverse cardiovascular events at 1 year, while prasugrel and ticagrelor containing DAPT for 12 months had significantly higher rates of major bleeding 5.
- Clopidogrel monotherapy was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI), and its benefit was consistent regardless of clinical risk or relative ischemic and bleeding risks 6.