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Difficult Scenarios in Calcium Scoring

Coronary artery calcium (CAC) scoring is thought to be the most precise cardiovascular risk scoring tool currently available. However, interpretation in every case is not always straight forward. Here are some FAQs that experienced referrers have asked us:

Posted 03 October 2018

Which patients are most likely to benefit from CAC?

The value of a test lies in its ability to change behaviour and / or your management. CAC scoring is most informative in those who are (i) at intermediate risk, or (ii) low risk but with a strong family history of CVD.

Are there any other groups who should be considered?

A growing number of conditions are recognised as CVD risk markers which are not factored yet into risk calculators. These include inflammatory diseases (such as HIV, rheumatoid arthritis and systemic lupus erythematosus) or other potential risk markers such as erectile dysfunction or obstructive sleep apnoea.

How do I apply the calcium score to my patient?

Position statements exist from various societies including the Cardiac Society of Australia and New Zealand (CSANZ) and the Society of Cardiovascular Computed Tomography (SCCT). We provide an excerpt in our reports which we hope will guide you in translating the score to clinical care – see sample copy of report.

The percentile for my patient quoted in the report states it refers only to non-diabetic patients

Most CAC databases recruited only non-diabetics, because many patients with diabetes are already at high risk. One way of benchmarking your diabetic patient is to use the “MESA Start Risk Score Calculator”” which is available online. This calculator integrates clinical risk factors (including diabetic status) AND calcium core to provide a highly individualised score. Alternatively, use whichever score calculator you prefer that includes diabetes but use the estimated vascular age from our report in place of the true chronological age.

My patient has high cholesterol, but their CAC score is in the 1-99 (mild risk) category

There are differences currently between the CSANZ and the SCCT with regards to statin therapy – the Australian position statement does not recommend pharmacological management, whereas the SCCT advocates moderate intensity statin therapy within the context of shared-decision-making. The discrepant approaches likely reflect difference in what represents a reasonable number-needed-to-treat (NNT). Factors that might favour a more aggressive approach are a higher absolute magnitude of the CAC (e.g. 90 versus 9), and / or a percentile score >75%.

Further reading

1. Coronary Artery Calcium Scoring – Position Statement (2017). www.csanz.edu.au/resources
2. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computer Tomography. Hecht H et al, JCCT (2017)

The above information is of a general nature and is based on a review of published evidence and expert opinion. Western Radiology and Advanced Diagnostic Imaging and Intervention cannot accept responsibility for the quality or accuracy of information contained within the material used to prepare the above information. Health practitioners are expected to review specific details of each patient and professionally assess the applicability of the relevant information to that clinical situation. This information does not address all the elements of clinical practice and assumes that the individual clinicians are responsible for discussing care appropriately with consumers while meeting relevant legislative requirements.