A 55-year-old African American gentleman with no significant past medical history is seen in follow up. His cardiac review of systems is negative for chest discomfort or shortness of breath. He has had elevated blood pressures >130/80 on two prior clinic visits. There is no family history of premature coronary artery disease or sudden cardiac death. He engages in regular exercise, including resistance training for an hour each session 3 days a week and low-impact cardio for 20 minutes once a week. He has never used any tobacco products. Other than a daily multivitamin, he does not take any medications.
His blood pressure and pulse at the office visit are 139/80 mm Hg 70 beats per minute, respectively. He weighs 80 kg with a BMI of 24 kg/m2.
Using the Pooled Cohort Risk Equations (PCE), his 10-year atherosclerotic cardiovascular disease (ASCVD) Risk is estimated to be 8.5%, placing him at intermediate risk for ASCVD risk according to the 2018 ACC/AHA Multi-Society Cholesterol Guideline. The clinician engages the patient in a detailed discussion regarding the risks and benefits of statin therapy. After some consideration, the patient declines statin therapy as he feels well overall and believes that he is healthy.
According to the 2018 ACC/AHA Multi-Society Cholesterol Guideline, what should the clinician recommend in addition to lifestyle modifications (i.e., healthy diet, daily exercise, smoking cessation)?
Show Answer
The correct answer is: B. Consider coronary artery calcium (CAC) testing.
In the context of the AHA/ACC 2018 Multi-Society Cholesterol Clinical Practice Guidelines for adults 40-75 years of age without diabetes mellitus, the 10-year ASCVD risk (calculated using PCE) should guide therapeutic considerations for statin therapy.1 This patient falls into the intermediate risk category (≥7.5% to <20% 10-year ASCVD risk). To aid decision making in the subset of patients, clinicians are encouraged to identify available risk enhancing factors (Table 1), of which none are present in this scenario.
Table 1: Risk Enhancing Factors1
Family history of premature ASCVD (males, age <55 years; females, age <65 years).
Metabolic syndrome (increased waist circumference, elevated triglycerides [>150 mg/dL], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 in women mg/dL] are factors; tally of 3 makes the diagnosis).
Chronic kidney disease (eGFR 15–59 mL/min/1.73 m2 with or without albuminuria; not treated with dialysis or kidney transplantation).
Chronic inflammatory conditions such as psoriasis, RA, or HIV/AIDS.
History of premature menopause (before age 40 years) and history of pregnancy-associated conditions that increase later ASCVD risk such as preeclampsia.
High-risk race/ethnicities (e.g., South Asian ancestry).
Lipid/biomarkers: Associated with increased ASCVD risk:
Elevated Lp(a) ≥50 mg/dL or ≥125 nmol/L.
A relative indication for its measurement is family history of premature ASCVD.
Elevated apoB ≥130 mg/dL.
A relative indication for its measurement would be triglyceride ≥200 mg/dL
Reduced ABI <0.9.
ASCVD – atherosclerotic cardiovascular disease; LDL-C – low-density lipoprotein cholesterol; HDL-C – high density lipoprotein cholesterol; RA – rheumatoid arthritis; HIV/AIDS – Human immunodeficiency virus/ Acquired immunodeficiency syndrome; hs-CRP – high sensitivity C-reactive protein; Lp(a) – lipoprotein(a); ApoB – apolipoprotein B; ABI – ankle brachial index.
In intermediate risk patients who remain reluctant to initiate statin therapy or question its utility, coronary artery calcium (CAC) testing can be used to assess risk, given robust improvements in discrimination, calibration, and net reclassification (Class IIA recommendation).1 Specifically, a CAC score of 0 has been associated with a low 10-year ASCVD risk, and statin therapy can be withheld.2 However, ASCVD risks may be higher in those who are diabetic, have a family history of premature coronary heart disease, or are persistent cigarette smokers despite having a CAC of zero.1,2 Alternatively, a CAC score of ≥100 is equivalent to a 10-year risk of ASCVD ≥7.5%, i.e. individuals who would be expected to derive a net benefit from initiating statin therapy (Class IIA recommendation).1,3
Answer A is not correct. The use of CIMT to reclassify risk assessment in addition to traditional risk factors was explored in the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Ultimately, among intermediate-risk individuals by the PCE, CIMT was not recommended in routine clinical practice (Class III recommendation).4
Answer C is not correct. A coronary CT angiogram is not indicated in this patient, as he is asymptomatic. Coronary CT angiography requires the administration of intravenous contrast and is used to evaluate the degree of coronary luminal, narrowing those with symptoms suggestive of coronary heart disease. CAC scoring is used to determine the actual presence and extent of calcified coronary artery plaque, and does not require intravenous contrast.5
Answer D is not correct. Per the 2018 AHA/ACC Multi-Society Cholesterol Guideline, a Class 1 recommendation is given for adults age 40-75 years old, identified as intermediate-risk to start a moderate-intensity statin in the context of the risk discussion for optimal ASCVD risk reduction.1,6 A goal reduction in LDL-C by ≥30% is advised in this setting (Class 1A recommendation).1
References
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/
ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73;3168-3209.
Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association cholesterol management guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2015;66:1657–68.
Budoff MJ, Young R, Burke G, et al. Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the Multi-Ethnic Study of Atherosclerosis (MESA). Eur Heart J 2018;39:2401-08.
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.
Divakaran S, Cheezum MK, Hulten EA, et al. Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management. Br J Radiol 2015;88:20140594.
Yusuf S, Bosch J, Dagenais G, et al. Cholesterol lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016;374:2021–31.
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