Management of Asymptomatic Patients With Positive Coronary Artery Calcium Scans

Coronary Artery Calcium Scoring in Asymptomatic Patients

Coronary artery calcium (CAC) scoring is an important prognostic tool for personalized cardiovascular preventive care and has recently been incorporated into American College of Cardiology/American Heart Association guidelines. CAC provides direct visualization and quantification of CAC burden for risk stratification and primary prevention of cardiovascular events in an asymptomatic population. CAC scoring is recommended for individuals with intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk and selective populations with borderline ASCVD risk. In this review, we outline the interpretation of CAC scores for predicting the risk of cardiovascular events, and we highlight the guidelines for starting statin and potentially starting aspirin therapy. A CAC score of 0 is the strongest negative predictive factor for cardiovascular disease (CVD), and a 0 score can successfully de-risk a patient. On the contrary, higher CAC scores correlate with worse cardiovascular prognostic outcomes. The CAC scan is a widely available and reproducible means for an early look at the atherosclerotic burden, and it can help strategize early interventions. The CAC interpretation and the decision to start treatment need to be personalized based on individual risk factors. We believe the emerging literature supports our contention that the CAC score can be used more broadly to improve the prophylaxis and treatment of a wider range of apparently healthy patients.

Trends in coronary calcium score and coronary CT angiography imaging volume during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic disrupted the delivery of preventative care and management of acute diseases. This study assesses the effect of the COVID-19 pandemic on coronary calcium score and coronary CT angiography imaging volume.

MATERIALS AND METHODS

A single institution retrospective review of consecutive patients presenting for coronary calcium score or coronary CT angiography examinations between January 1, 2020 to January 4, 2022 was performed. The weekly volume of calcium score and coronary CT angiogram exams were compared.

RESULTS

In total, 1,817 coronary calcium score CT and 5,895 coronary CT angiogram examinations were performed. The average weekly volume of coronary CTA and coronary calcium score CT exams decreased by up to 83% and 100%, respectively, during the COVID-19 peak period compared to baseline (P < 0.0001). The post-COVID recovery through 2020 saw weekly coronary CTA volumes rebound to 86% of baseline (P = 0.024), while coronary calcium score CT volumes remained muted at only a 53% recovery (P < 0.001). In 2021, coronary CTA imaging eclipsed pre-COVID rates (P = 0.012), however coronary calcium score CT volume only reached 67% of baseline (P < 0.001).

CONCLUSIONS

A significant decrease in both coronary CTA and coronary calcium score CT volume occurred during the peak-COVID-19 period. In 2020 and 2021, coronary CTA imaging eventually superseded baseline rates, while coronary calcium score CT volumes only reached two thirds of baseline. These findings highlight the importance of resumption of screening exams and should prompt clinicians to be aware of potential undertreatment of patients with coronary artery disease.

Association between apnea-hypopnea index and coronary artery calcification: a systematic review and meta-analysis

BACKGROUND

The present study aimed to evaluate the association between presence and severity of obstructive sleep apnoea (OSA) and the presence of subclinical coronary artery disease (CAD) as assessed by coronary calcium score.

METHODS

Medline, Cochrane, and Google Scholar databases were searched. The presence of coronary artery calcification (CAC) and CAC score were assessed.

RESULTS

Irrespective of the cut-off value of apnoea-hypopnea index (AHI) (5 or 15 events/h), patients in the OSA group had higher rate of CAC presence and mean CAC score than those in the control group. Subgroup analyses of patients monitored with home sleep apnoea testing (HSAT) or in-hospital/laboratory polysomnography showed that the OSA group had higher rate of CAC presence and mean CAC score than the control group, except in the comparison of mean CAC score between AHI ≥5 vs. <5 events/h for patients using HSAT, which was not significant. Pair-wise comparison showed that CAC score may increase with increased OSA severity.

CONCLUSIONS

In participants without symptomatic coronary disease, the presence of OSA was associated with the presence and extent of CAC. However, potential confounders such as age, gender, and BMI and the diversity of CAC scores may affect the association.

A Pathophysiologic Primary Prevention Review of Aspirin Administration to Prevent Cardiovascular Thrombosis

OBJECTIVE

Cardiovascular disease is the leading metabolic cause of mortality in the United States. Among current therapies, low-dose aspirin has been shown to reduce cardiovascular thrombosis. However, aspirin also causes major complications (hemorrhagic stroke and gastrointestinal bleeding). The American Heart Association recommends that aspirin only be prescribed for "high-risk" individuals. No guidelines are available as to the duration of aspirin therapy.

METHODS

A reasonable approach to aspirin administration is to determine the appropriateness of aspirin therapy based on the pathophysiology of coronary artery thrombosis. It suggests that the coronary artery calcium (CAC) score be used as the basis for determining "high risk." This score was shown to accurately predict future cardiovascular events. The greater the CAC score, the greater the extent of coronary artery atherosclerotic plaque and future cardiovascular risk.

RESULTS

A CAC score >400 places an individual at very-high 10-year risk for an atherosclerotic event. Since aggressive medical therapy initiates stabilization of unstable atherosclerotic plaques within 1 month and reversal within 2 years, this treatment significantly reduces the risk of the individual for a cardiovascular event. Thus, most individuals aged <75 years with a CAC score of >400 should receive aspirin therapy for a maximum of 2 years.

CONCLUSION

Utilization of a CAC score greatly simplifies the decision of whom to treat with aspirin and for what duration. Importantly, focusing on two factors (hemorrhage and plaque stabilization) is easily understood by both the physician and the patient.

ABBREVIATIONS

CAC = coronary artery calcium; CVD = cardiovascular disease; LDL = low-density lipoprotein; OCT = optical coherence tomography.