Selective Use of Coronary Artery Calcium Testing for Shared Decision Making: Guideline Endorsed and Ready for Prime Time

ARTICLE: Selective Use of Coronary Artery Calcium Testing for Shared Decision Making: Guideline Endorsed and Ready for Prime Time

AUTHORS: Rhanderson Cardoso, Khurram Nasir, Roger S. Blumenthal, Michael J. Blaha 

JOURNAL: Ann Intern Med. 2019 Feb 12. doi: 10.7326/M18-3675. [Epub ahead of print] 

The use of traditional risk factors and laboratory markers to estimate 10-year risk for atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of clinical decision making for primary prevention of ASCVD in asymptomatic persons. In the United States, risk estimation begins with the pooled cohort equations, which were first introduced in the 2013 American Heart Association and American College of Cardiology (AHA/ACC) prevention guideline. The new 2018 AHA/ACC guideline still recommends use of these equations as a prudent first step in clinical decision making, despite acknowledging that they provide only moderate risk discrimination and may overestimate risk (1, 2).

Since publication of the paradigm-shifting 2013 guideline, concern has been raised that risk overestimation could lead to statins being recommended to many patients who are less likely to receive net benefit from therapy. For patients at either high or very low risk for ASCVD, imprecise risk estimation may not be clinically relevant. However, for all other patients, using the pooled cohort equations as a standalone risk assessment tool may be insufficient for definitive decision making.

The 2018 AHA/ACC risk assessment and cholesterol management guideline acknowledges the limitations of traditional risk prediction. It recommends considering additional clinical factors and other tests to more accurately assess cardiovascular risk for many adults with 10-year risk for ASCVD between 5% and 20% (3, 4). The presence of these “risk enhancers,” such as a family history of premature ASCVD, South Asian ancestry, inflammatory biomarkers, HIV infection, and rheumatologic disease, can increase risk (3, 4). However, as their name indicates, risk enhancers are only valuable for identifying persons who may be at higher risk than otherwise expected. Their absence does not reclassify risk downward, and borderline- to intermediate-risk patients—especially those with no traditional risk factors—may still face risk overestimation and potential overtreatment.

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