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Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.

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Dr. Gluckman: 
Welcome to CME on ReachMD. I'm Dr. Ty Gluckman.

Dr. Wadhera:
And I'm Dr. Rishi Wadhera.

Dr. Gluckman: 
In this episode, we're going to talk about how to incorporate coronary artery calcium scores into clinical practice. Many of you may appreciate that there's been increased visibility of incorporating coronary calcium scoring into a risk assessment of individuals. Now, this has received the greatest amount of attention in individuals who are deemed to be an increased atherosclerotic cardiovascular disease risk based on a risk prediction tool. And then the decision is made to incorporate a coronary calcium score to either define a patient who may be having an overestimation of risk or to confirm the increased risk overall.

When we do a coronary calcium scan, this does not involve any exposure to IV dye. It's a brief procedure, and we get back both a total score that's usually reported in Agatston units, as well as a percentile where they match up to age, sex, and rates matched individuals overall. The higher your calcium score, the greater the burden of the atherosclerosis that you have, but it doesn't tell you anything about the degree of stenosis that exists overall.

It is important to realize that updated guidance in 2022 by the American College of Cardiology frames the decision-making about how intensively you're going to lower LDL cholesterol by incorporation of a coronary calcium scan result, such that if someone has an elevated total score or a percentile, you're going to be more aggressive and more intensive about LDL cholesterol lowering than someone who has a less elevated score or a less elevated percentile ranking overall in this patient population.

And it's just important to realize that as their score goes up, their atherosclerotic burden goes up, and therefore we're going to be more aggressive, certainly in terms of intensity of statin therapy, but also for the potential of incorporating non statin therapy in this regard. And this is nicely illustrated by that 2022 American College of Cardiology Expert Consensus Decision Pathway. I will say, for the individuals that have a coronary calcium score of zero, it's felt that these individuals may have an overestimation of risk in this patient population, and therefore they may be able to withhold the use of lipid lowering and namely, statin therapy, and again, match the intensity of the LDL cholesterol-lowering regimen, particularly with statin therapy, as their calcium score goes up.

It is important to call out that calcium scoring would not be appropriate testing for those with established atherosclerotic cardiovascular disease, those individuals that have diabetes, a familial etiology for their hypercholesterolemia, those who are active tobacco users. So there are some exceptions or callouts of populations for which calcium scoring may not be relevant overall.

Rishi, maybe you can just speak briefly about the access to calcium scoring in rural settings.

Dr. Wadhera: 
Yeah, thanks so much, Ty. I think you've highlighted that coronary artery calcium scores are a really important modality when we think about diagnosis and risk stratification. But I think we have to remember that individuals living in rural communities or rural parts of the country face barriers not only accessing primary care providers and specialist providers but also accessing imaging services. And so as we think about how to take care of our patients, we need to also factor in the social context in which they live and think about strategies to streamline access to these types of important diagnostic and imaging services.

Dr. Gluckman:
I love those insights. And these are really a great wrap-up to our discussion. I want to thank you all for listening.

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