A 60-year-old asymptomatic man presents for routine follow-up, concerned about the potential need for statin therapy. He has hypertension, but denies diabetes or present/prior tobacco use. His family history is not significant for premature coronary artery disease (CAD). The patient is overweight, and he has been exercising three times a week (treadmill for 20 minutes) and following a Mediterranean style diet.
His exam is unremarkable with a treated blood pressure of 128/78 mm Hg and body mass index (BMI) of 30.5.
His labs are as follows:
Total Cholesterol: 206
Low-Density Lipoprotein Cholesterol (LDL-C): 124
High-Density Lipoprotein Cholesterol (HDL-C): 48
Triglycerides: 164
Fasting Blood Glucose: 114
After discussing the potential role of a statin given an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10.6% by the new risk estimator, the patient is still very concerned. He has heard multiple negatives about long-term statin use, including the potential for diabetes, especially given his abnormal blood glucose.
Which of the following would be the next step in management of this patient?
Show Answer
The correct answer is: B. Order coronary artery calcium (CAC) scan.
The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines specifically discuss the "uncertain" patient.1 This uncertain state could reflect indeterminate or borderline risk assessment values close to 7.5%, potential adverse effects, or patient preferences. Therefore, "In individuals for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. These factors may include primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first degree male relative or <65 years of age in a first degree female relative, high-sensitivity C-reactive protein ≥2 mg/L, CAC score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity, ankle-brachial index <0.9, or elevated lifetime risk of ASCVD." Given that the case patient's estimated 10-year ASCVD risk is intermediate, the 2013 ACC/AHA prevention guidelines state, "The Work Group notes the contention that assessing CAC is likely to be the most useful of the current approaches to improving risk assessment among individuals found to be at intermediate risk after formal risk assessment."2
Therefore, the best approach is CAC scanning, also supported with a IIa recommendation from the 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults Guidelines for this indication.3 A score of zero in a 60-year-old man would be very reassuring since the median score of age is close to 100 in several cohort studies. Although a score of 1-10 is associated with 2-3 the risk of a score of zero in MESA, the clinician and patient may also feel more reassured (with a score of 1-10) that their 10-year risk is lower than average, and they may decide to focus solely on more aggressive lifestyle changes without a statin prescription. The final decision is up to the patient, and the clinician can only present the options for the patient based on the available data.
References
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2935-59.
Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010;56:e50-103.
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