With the publication of the 2018 Cholesterol Clinical Practice Guidelines and the 2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease comes a greater focus on shared decision-making regarding the institution of pharmacologic therapy for patients at increased risk of experiencing future cardiovascular events. In particular, these guidelines now recommend consideration of coronary artery calcium (CAC) testing to enhance risk prediction and help guide management decisions. Despite the evidence supporting the current atherosclerotic cardiovascular disease (ASCVD) risk prediction model, the guidelines recognize that there are limitations to its application on individual patients. Indeed, up to half of patients who meet the criteria for statin therapy based on this risk tool have CAC scores of 0, corresponding to a 10-year ASCVD risk that is less than the 7.5% threshold now accepted as the cutoff for recommending statin therapy.1 Therefore, the guidelines state that it is reasonable to obtain CAC testing in adults at intermediate risk (10-year ASCVD risk of 7.5% to <20%) and selected adults at borderline risk (10-year ASCVD risk of 5% to <7.5%) if the decision about statin initiation remains uncertain. In this context, CAC testing can be a useful tool to both refine risk assessment as well as facilitate shared decision-making between the patient and clinician regarding the institution of statin-based therapy.2,3
Berman AN, Blankstein R. Improving Access to Guideline-Based Coronary Artery Calcium Testing for Cardiovascular Disease Prevention. JAMA Cardiol. 2019;4(10):965–966. doi:10.1001/jamacardio.2019.2963
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