![]() ![]() The appropriate patient for CACS is still debated, and the answer to this question will likely continue to evolve as data accumulate. If a low-risk result is obtained, reassurance and continued emphasis on lifestyle measures should be recommended. Following this line of thought, a high-risk CACS result indicates that a statin medication should be considered. Seek further information such as CACS, ABI or hs-CRP to help guide the decisionĬlinicians who seek additional information want to know whether Smith is at higher risk than would be predicted by risk factors due to genetic disposition for atherosclerosis. ![]() Recommend a statin on the basis of the patient's family history of premature CVD and his moderately elevated 10-year risk score.Not recommend a statin because the patient's 10-year ASCVD risk is less than 7.5 percent. ![]() Thus, according to the guidelines, in the case of Smith, it would be reasonable for a clinician to take one of the following actions: However, the guidelines do not make specific recommendations on how these tools should be used. In addition, the guidelines state that CACS, as well as ankle-brachial index (ABI), high-sensitivity C-reactive protein (hs-CRP), and family history of premature CVD may be considered (Class IIb) to inform treatment decision-making. The "2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults" recommends shared decision-making about the benefits and risks of a statin medication for primary prevention when the 10-year risk is 7.5 percent or higher in an adult who does not have diabetes. Smith leads a healthy lifestyle but is wondering if he should consider taking a statin medication to further lower his risk of CVD. Smith notes that his 52-year-old brother recently had coronary artery bypass graft surgery and his father died of a myocardial infarction at 55 years of age but feels their health problems were primarily due to long-term tobacco abuse. His 10-year risk, as determined by the ASCVD Pooled Cohort Risk Assessment Equations, is 5.7 percent. His blood pressure is 134/82 mm Hg, and he has a total cholesterol level of 212 mg/dL, a high-density lipoprotein cholesterol level of 54 mg/dL, triglycerides of 92 mg/dL, and a calculated low-density lipoprotein cholesterol level of 140 mg/dL. He is active and asymptomatic and takes no medication. A case: Statin or no statin?Ī 50-year-old African-American man, known in this case study as Smith, presents with concerns regarding cardiovascular risk. That question has not been adequately studied. Several large studies with long-term follow-up have shown that CACS adds incremental information in CVD risk identification and provides more-accurate CVD risk prediction compared with traditional risk factors in about 25 percent of individuals.ĭespite the potential utility of these data, it is not known if identifying individuals who are at higher risk by CACS - and intensifying the prevention regimen - lowers the risk of CVD events. ![]() The coronary artery calcium score (CACS) is strongly correlated with future risk of myocardial infarction and stroke, making it a potentially attractive tool to further clarify individual risk of CVD. Subclinical atherosclerosis and CVD risk prediction One such tool is imaging for subclinical atherosclerosis, most commonly accomplished by quantifying the amount of calcium in the coronary arteries by computerized tomography. "The best illustration of these limitations is that the majority of CVD events (up to 75 percent) occur in low- and intermediate-risk populations."īecause more-accurate means of determining individual CVD risk are needed, a search is ongoing for better tools to identify high-risk individuals before clinical events occur. "These risk algorithms are remarkably effective in predicting risk in populations, but have limitations in predicting individual risk," says R Todd Hurst, M.D., director of the Heart Health and Performance Program at Mayo Clinic's campus in Phoenix/Scottsdale, Arizona. National guidelines recommend the use of population-based risk algorithms, such as the Pooled Cohort Risk Assessment Equations, to determine atherosclerotic cardiovascular risk (ASCVD). However, the seventh item (cholesterol level) is a challenge because the optimal level is primarily determined by an individual's risk of CVD. Six of Life's Simple 7 (healthy diet, physical activity, no smoking, and well-controlled blood pressure, blood glucose and body weight) can be universally recommended by clinicians. ![]()
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