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Coronary Artery Calcium Scores I

      To The Editor:
      I applaud Drs Orringer and Maki
      • Orringer C.E.
      • Maki K.C.
      HOPE for rational statin allocation for primary prevention: a coronary artery calcium picture is worth 1000 words.
      for their recent article in the August 2020 issue of Mayo Clinic Proceedings. It provides an excellent summary of the relevant literature for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in the current era of medicine. Overall, it provides a practical guide for clinicians that is based on the 2018 American Heart Association/American College of Cardiology/Multisociety Guideline on the Management of Blood Cholesterol (2018 Guideline) but provides further guidance on incorporation of coronary artery calcium (CAC) scores to more accurately determine ASCVD risk for individual patients. Although guidelines are valuable, patient care should be individualized, and incorporating CAC for individualized risk stratification can be very valuable.
      Although the article overall is very well written, the section on how to manage patients with CAC between 1 and 99 scores could be further elucidated. For patients with CAC scores of zero and those with CAC scores >100, there is fairly universal agreement on management (without statin and with statin therapy, respectively); however, the middle group of patients with CAC 1 to 99 scores is the quandary. As written, the article simply leaves patients in this group to clinician–patient discussion but without details on how to guide this discussion. I suggest taking the authors’ algorithm one step further.
      The CAC score can be used as an input for a revised or individualized 10-year ASCVD risk estimate, most notably by using The Multi-Ethnic Study of Atherosclerosis (MESA) calculator.
      MESA The Multi-Ethnic Study of Atheroscleriosis website.
      Similar to the rest of the authors’ algorithm, by incorporating the CAC score into the MESA calculator, clinicians can determine a risk score that is individualized for each patient. Clinicians can use this revised and more accurate risk estimate in a similar manner to the pooled cohort calculator from the 2018 Guideline (eg, recommend statin if 10-year risk of ASCVD is >7.5%, suggest only therapeutic lifestyle changes if risk is <5%, with an acknowledgment that there is some benefit to statins, but the benefit is sufficiently small that treatment can be deferred). The management of patients who have revised 10-year risks between 5% and 7.5%, unfortunately, remains unclear, and this should be left to clinician–patient discussion, as originally stated in the article. But at least for patients with revised risk estimates <5% or >7.5%, the guidance for clinicians and to patients can be clearer. And even for the patients with risks between 5% and 7.5%, there is at least a quantifiable risk that can be used as part of shared decision making rather than simply using the CAC score, which is too abstract to help patients understand their conditions.
      I express my gratitude to the authors and editors for their contribution to the medical literature, and I hope they find my additional personalization of the proposed algorithm as proper and valuable.

      References

        • Orringer C.E.
        • Maki K.C.
        HOPE for rational statin allocation for primary prevention: a coronary artery calcium picture is worth 1000 words.
        Mayo Clin Proc. 2020; 95: 1740-1749
      1. MESA The Multi-Ethnic Study of Atheroscleriosis website.

      Linked Article

      • Coronary Artery Calcium Scores II
        Mayo Clinic ProceedingsVol. 96Issue 1
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          In the discussion of coronary artery calcium (CAC) scoring and statin therapy, Orringer and Maki1 indicate that a CAC score >100 strongly supports the initiation of statin therapy, but they neglect to address the confounding role of high levels of physical activity on the CAC score. Physical activity is not included in the American Heart Association/American College of Cardiology risk calculator used to assess risk of atherosclerotic cardiovascular disease, despite the fact that regular physical activity is associated with a reduced risk of both all-cause and cardiovascular mortality.
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      • In Reply–Coronary Artery Calcium Scores I and II
        Mayo Clinic ProceedingsVol. 96Issue 1
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          We would like to thank Drs Fakheri and Langland for their comments on our paper. Unlike the relatively straightforward treatment implications of coronary artery calcium (CAC) scores of zero, or ≥100 Agatston units, management of those patients with CAC scores of 1 to 99 largely depends on clinical judgment in the context of shared decision making. The 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline1 notes that the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) accompanying CAC scores of 1 to 99 is generally ≥7.5% during later middle age and therefore suggests that individuals 55 years of age or older with such scores are appropriate candidates for initiation of statin therapy.
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      • HOPE for Rational Statin Allocation for Primary Prevention: A Coronary Artery Calcium Picture Is Worth 1000 Words
        Mayo Clinic ProceedingsVol. 95Issue 8
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          Allocation of statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in borderline- and intermediate-risk patients has traditionally been based on population-based global risk assessment and other clinical and laboratory characteristics. Patient-specific treatment decisions are needed to provide maximal benefit and avoid unnecessary treatment. Guideline-based lipid management proposes that coronary artery calcium scoring is reasonable to implement in patients with a 10-year risk of 5.0% to 19.9% (borderline to intermediate risk) by using the pooled cohort equations when the decision about whether to initiate statin therapy is uncertain.
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