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Cardiac Society of Australia and New Zealand position statement executive summary: coronary artery calcium scoring

Christian R Hamilton-Craig, Clara K Chow, John F Younger, V M Jelinek, Jonathan Chan and Gary YH Liew
Med J Aust 2017; 207 (8): . || doi: 10.5694/mja16.01134
Published online: 16 October 2017

Summary

Introduction

This article summarises the Cardiac Society of Australia and New Zealand position statement on coronary artery calcium (CAC) scoring. CAC scoring is a non-invasive method for quantifying coronary artery calcification using computed tomography. It is a marker of atherosclerotic plaque burden and the strongest independent predictor of future myocardial infarction and mortality. CAC scoring provides incremental risk information beyond traditional risk calculators such as the Framingham Risk Score. Its use for risk stratification is confined to primary prevention of cardiovascular events, and can be considered as individualised coronary risk scoring for intermediate risk patients, allowing reclassification to low or high risk based on the score. Medical practitioners should carefully counsel patients before CAC testing, which should only be undertaken if an alteration in therapy, including embarking on pharmacotherapy, is being considered based on the test result.

Main recommendations

  • CAC scoring should primarily be performed on individuals without coronary disease aged 45–75 years (absolute 5-year cardiovascular risk of 10–15%) who are asymptomatic.
  • CAC scoring is also reasonable in lower risk groups (absolute 5-year cardiovascular risk, < 10%) where risk scores traditionally underestimate risk (eg, family history of premature CVD) and in patients with diabetes aged 40–60 years.
  • We recommend aspirin and a high efficacy statin in high risk patients, defined as those with a CAC score ≥ 400, or a CAC score of 100–399 and above the 75th percentile for age and sex.
  • It is reasonable to treat patients with CAC scores ≥ 100 with aspirin and a statin.
  • It is reasonable not to treat asymptomatic patients with a CAC score of zero.

Changes in management as a result of this statement

  • Cardiovascular risk is reclassified according to CAC score.
  • High risk patients are treated with a high efficacy statin and aspirin.
  • Very low risk patients (ie, CAC score of zero) do not benefit from treatment.

 


  • 1 Heart and Lung Institute, The Prince Charles Hospital, Brisbane, QLD
  • 2 Centre for Advanced Imaging, University of Queensland, Brisbane, QLD
  • 3 The George Institute for Global Health, Sydney, NSW
  • 4 Westmead Hospital, Sydney, NSW
  • 5 Royal Brisbane and Women's Hospital, Brisbane, QLD
  • 6 St Vincent's Hospital, Melbourne, VIC
  • 7 Cardiovascular Research Centre, Australian Catholic University, Melbourne, VIC
  • 8 Griffith University, Gold Coast, QLD
  • 9 Gold Coast Heart Centre, Gold Coast, QLD
  • 10 University of Adelaide, Adelaide, SA
  • 11 Epworth HealthCare, Melbourne, VIC


Correspondence: c.hamiltoncraig@uq.edu.au
Competing interests:

No relevant disclosures.

  • 1. Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008; 358: 1336-1345.
  • 2. Wang Z, Hoy WE. Is the Framingham coronary heart disease absolute risk function applicable to Aboriginal people? Med J Aust 2005; 182: 66-69. <MJA full text>
  • 3. Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004; 291: 210-215.
  • 4. Budoff MJ, Shaw LJ, Liu ST, et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007; 49: 1860-1870.
  • 5. LaMonte MJ, FitzGerald SJ, Church TS, et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol 2005; 162: 421-429.
  • 6. Yeboah J, Young R, McClelland RL, et al. Utility of nontraditional risk markers in atherosclerotic cardiovascular disease risk assessment. J Am Coll Cardiol 2016; 67: 139-147.
  • 7. McClelland RL, Jorgensen NW, Budoff M, et al. 10-year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) study and the DHS (Dallas Heart Study). J Am Coll Cardiol 2015; 66: 1643-1653.
  • 8. Hecht H, Blaha MJ, Berman DS, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: expert consensus statement from the SCCT. J Cardiovasc Comput Tomogr 2017; 11: 157-168.
  • 9. Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging 2009; 2: 675-688.
  • 10. Blaha M, Budoff MJ, Shaw LJ, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging 2009; 2: 692-700.
  • 11. Shareghi S, Ahmadi N, Young E, et al. Prognostic significance of zero coronary calcium scores on cardiac computed tomography. J Cardiovasc Comput Tomogr 2007; 1: 155-159.
  • 12. Blaha MJ, Cainzos-Achirica M, Greenland P, et al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 2016; 133: 849-858.
  • 13. Valenti V, Ó Hartaigh B, Heo R, et al. A 15-year warranty period for asymptomatic individuals without coronary artery calcium: a prospective follow-up of 9,715 individuals. JACC Cardiovasc Imaging 2015; 8: 900-909.
  • 14. Greenland P, Bonow RO, Brundage BH, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. J Am Coll Cardiol 2007; 49: 378-402.
  • 15. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63(25 Pt B): 2889-2934.
  • 16. Arad Y, Spadaro LA, Roth M, et al. Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin, vitamin C, and vitamin E: the St. Francis Heart Study Randomized Clinical Trial. J Am Coll Cardiol 2005; 46: 166-172.
  • 17. Blaha MJ, Silverman MG, Budoff MJ. Is there a role for coronary artery calcium scoring for management of asymptomatic patients at risk for coronary artery disease? Clinical risk scores are not sufficient to define primary prevention treatment strategies among asymptomatic patients. Circ Cardiovasc Imaging 2014; 7: 398-408; discussion.
  • 18. Antithrombotic Trialists’ Collaboration; Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373: 1849-1860.
  • 19. Berger JS, Roncaglioni MC, Avanzini F, et al. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA 2006; 295: 306-313.
  • 20. Seshasai SR, Wijesuriya S, Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172: 209-216.
  • 21. Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes 2014; 7: 453-460.
  • 22. Min JK, Lin FY, Gidseg DS, et al. Determinants of coronary calcium conversion among patients with a normal coronary calcium scan: what is the “warranty period” for remaining normal? J Am Coll Cardiol 2010; 55: 1110-1117.
  • 23. Raggi P, Callister TQ, Shaw LJ. Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy. Arterioscler Thromb Vasc Biol 2004; 24: 1272-1277.
  • 24. Budoff MJ, Hokanson JE, Nasir K, et al. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging 2010; 3: 1229-1236.

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