#28 Coronary artery calcium scoring: The ultimate cardiovascular risk assessment

February 27, 2017 | By Matthew Watto, MD

Individualize cardiovascular risk, and optimize risk reduction using cardiac CT with coronary artery calcium (CAC) scoring. Our expert guests from The Society for Cardiovascular Computed Tomography (SCCT), Dr. Harvey Hecht, Professor of Medicine from Mount Sinai, and Dr. Matthew Budoff, Professor of Medicine from UCLA, school us on the use of this powerful tool.

Special thanks to Dr. Emilio Fentanes from the SCCT for setting up this interview.

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Clinical Pearls:

1. CAC scores detect atherosclerosis, NOT stenosis.
2. CAC score of zero gives most patients a 10 year warranty
3. Check CAC score if risk between 5-20% risk (low to intermediate risk) on Framingham, or the ASCVD Pooled cohort equation
4. Certain insurers now covering CAC scoring e.g. Aetna, Medicare in Cali, United Healthcare. If not covered, then costs $200.
5. Absolute score (does not account for age, gender, race, etc.). Score 0 = very low risk,  score 1-100 = low risk, score 101-299 = intermediate risk,  scores >300 = coronary heart disease (CHD) risk equivalent
6. Relative score considers percentile of plaque burden based on age, and gender. If >75th percentile, then considered high risk. If >90th percentile, then CHD risk equivalent
7. If CAC score is zero, then consider omitting or de-escalating cardioprotective medications (e.g. aspirin, statin)
8. Treatment is as easy as ABCDE (Aspirin, blood pressure, cholesterol, diet, and exercise)
9. New SCCT 2017 CAC Guidelines recommend rough estimate of CAC scores and plaque burden (mild, moderate, severe) on all chest CTs even if not gated.
10. Calcification of breast arteries on mammography is correlated with CAC and should be treated as a risk factor
11. Okay to exercise without further testing if low to intermediate CAC score. If score >300, then consider functional test or CCTA prior to exercise.

Goal: Listeners will effectively implement the use of CAC scores for personalized cardiovascular risk assessment and risk reduction.

Learning objectives:
By the end of this podcast listeners will:

1. Counsel patients on risks and benefits of CAC scoring
2. Utilize CAC scores to estimate cardiovascular risk
3. Interpret CAC scores
4. Recognize significance of calcified arteries on CT chest and mammography
5. Incorporate CAC score into personalized cardiovascular risk reduction

Disclosures:
Dr. Budoff reports grant support from from both National Institutes of Health and General Electric. Dr. Hecht is a consultant to Philips Medical Systems, and Arineta Scientific Advisory Board.

Time Stamps
00:00 Intro
03:55 Interview
04:45 Rapid fire questions
10:42 What is a CAC score?
12:40 Calcium score of zero
14:05 When to check CAC score
16:35 Counsel patient on CAC scoring
19:50 Warranty on CAC score
22:00 CAC score interpretation and cutoffs
25:29 Incidental calcium noted on CT chest, or mammography
30:35 Exercise restriction?
32:31 De-escalation of therapy if calcium score zero
34:16 Evidence for CAC scoring (landmark trials)
37:09 Take home points
40:04 Outro

Links from the show:

1. MESA-NHLBI.org Risk Calculator
2. Dr. James K. Min – CAC of zero 15 year warranty. JACC Aug 2015
3. Dr. Blaha – The Power of Zero in Primary Prevention
4. Dr. Budoff’s select publications on CAC scores 1and 2
5. Dr. Hecht select publications on CAC scores 1 and 2
6. Am J Cardiol. 2016 Sep 1;118(5):691-6. doi: 10.1016/j.amjcard.2016.06.015. Epub 2016 Jun 15. Impact of Replacing the Pooled Cohort Equation With Other Cardiovascular Disease Risk Scores on Atherosclerotic Cardiovascular Disease Risk Assessment (from the Multi-Ethnic Study of Atherosclerosis [MESA]). Qureshi WT1, Michos ED2, Flueckiger P3, Blaha M2, Sandfort V4, Herrington DM3, Burke G5, Yeboah J3.
7. Dr. Yaboa of Wake Forest Compares CAC to multiple other risk factors to identify those at risk for events.
8. SCCT Guidelines on Coronary Artery Calcium Scoring
9. Margolies L, Salvatore M, Hecht H, et al. Digital mammography and screening for coronary artery disease. JACC Cardiovasc Imaging 2016; DOI:10.1016/j.jcmg.2015.10.022.