Is Coronary Artery Calcification (CAC) scoring beneficial or not indicated?

From the Guidelines

Rechecking coronary artery calcium (CAC) scoring is generally not beneficial or indicated for most patients, as it provides limited additional clinical value after an initial score has been obtained. The primary purpose of CAC scoring is to detect the presence and extent of coronary artery calcification as a marker of atherosclerotic burden and to help guide preventive therapy decisions, as stated in the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease 1. After an initial CAC score, management should focus on aggressive risk factor modification based on that score rather than monitoring for changes in calcification. CAC scores naturally increase over time, even with optimal medical therapy, and this progression doesn't necessarily correlate with clinical outcomes or need for treatment adjustment, as noted in the 2021 Journal of Internal Medicine article on coronary artery calcium scoring 1.

Additionally, repeat CAC scoring exposes patients to additional radiation without clear evidence of improved outcomes. The exceptions where repeat CAC might be considered include research settings or very specific clinical scenarios where risk assessment remains uncertain despite other evaluations, such as in patients with intermediate risk and uncertain risk decisions, as mentioned in the 2019 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. Instead of rechecking CAC, clinicians should focus on managing modifiable cardiovascular risk factors and adhering to guideline-directed preventive therapies based on the initial CAC score and overall risk assessment.

Some key points to consider when evaluating the need for repeat CAC scoring include:

• The presence of risk-enhancing factors, such as persistent cigarette smoking, diabetes, or family history of ASCVD, which may influence the decision to initiate statin therapy despite a CAC score of zero 1
• The patient's overall risk assessment, including their 10-year ASCVD risk level, which can be calculated using the ASCVD Pooled Cohort Equation or other validated tools 1
• The potential benefits and limitations of CAC scoring in specific clinical scenarios, such as in older adults or those with low burden of risk factors 1

From the Research

CAC Benefit/Not Indicated

• The use of Coronary Artery Calcium (CAC) scoring is recommended in clinical guidelines for instituting pharmacotherapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) 2.
• CAC scoring can reclassify risk upward or downward in approximately 50% of intermediate-risk patients to inform the risk discussion 2.
• The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of CAC scoring to guide the allocation of statin therapy among individuals with an intermediate risk of ASCVD 3.
• The presence of risk-enhancing factors is generally not associated with an overall ASCVD risk that is higher than the recommended treatment threshold for the initiation of statin therapy in patients with CAC scores of 0 3.
• The use of CAC scoring is associated with significant improvements in the reclassification and discrimination of incident ASCVD 3.

Personalized Medicine

• Personalized medicine is about tailoring a treatment as individualized as the disease, relying on identifying genetic, epigenomic, and clinical information 4.
• The implementation of personalized medicine has the potential to reduce financial and time expenditure, and increase quality of life and life extension of patients 4.
• Personalized medicine may increase the effectiveness of existing treatments and negate the inherent problems associated with non-personalized medicine approaches 4.
• Chronic pancreatitis is an ideal complex disorder to study to consider the pros and cons of personalized medicine, because the pancreas is such a simple organ for disease modelling, and the advantages of personalized medicine are so profound 5.

Diagnostic Testing

• Coronary Computed Tomography Angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing 6.
• CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins compared with functional stress testing 6.