CAC vs. Pooled Cohort Equations Score for Prevention Guidance

Quick Takes

  • More than 40% of participants were found to have an indication for statin therapy.
  • Coronary artery calcium (CAC) use led to fewer statin treatment recommendations compared to pooled cohort equation (PCE) use.
  • CAC-guided participants were more likely to adhere to statin use at 1 year than PCE-guided participants, and greater LDL reductions were also noted.
  • CAC guidance was associated with similar or lower estimated costs.

Study Questions:

How does coronary artery calcium (CAC) scoring compare to pooled cohort equations (PCEs) for initiation of statin therapy?


The CorCal (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events) was a randomized trial consenting 601 patients without known atherosclerotic cardiovascular disease (CVD), diabetes, or prior statin therapy recruited from primary care clinics and randomized to CAC (n = 302) or PCE guidance (n = 299) of statin initiation for primary prevention. This was a short-term pragmatic randomized clinical trial that included adults aged 50-85 years with no known history of CVD or diabetes and no history of statin use. Enrolled subjects and their physicians made final treatment decisions. Primary outcomes compared the proportion of statin recommendations received and subject adherence over 1 year between CAC- and PCE-arm subjects. Modeled medical costs, adverse effects, and low-density lipoprotein cholesterol (LDL-C) were additional measures of interest.


A total of 540 (89.9%) completed entry testing and received a protocol-based recommendation. A statin was recommended in 101 (35.9%) participants in the CAC-arm and 124 (47.9%) PCE-arm subjects. Compared to PCE-based recommendations, CAC-arm subjects were reclassified from statin to no statin in 36.0%, and from no statin to statin in 5.6% of cases, resulting in a total reclassification of 20.6%. Physicians accepted the study dictated recommendation to start a statin in 88.1% of CAC-arm vs. 75.0% of PCE-arm subjects (p = 0.01). Patient-reported adherence to this recommendation at 3 months was 62.2% vs. 42.2%, respectively (p = 0.009). At 1 year, statin adherence remained superior, LDL-C levels were lower, estimated costs were similar or reduced in CAC subjects, and few events occurred.


The investigators concluded that CAC guidance may be a more efficient, personalized, cost-effective, and motivating approach to statin initiation and maintenance in primary prevention. However, a larger trial is warranted to understand long-term outcomes.


This trial suggests that CAC is cost-effective for identifying adults (without CVD or diabetes mellitus) who may benefit from statin initiation. Furthermore, these adults were more likely to continue statin therapy in the CAC group compared to the PCE group. Moreover, CAC guidance was associated with similar or lower estimated costs. A larger trial is warranted to examine CVD events.

Clinical Topics: Dyslipidemia, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Atherosclerosis, Cholesterol, LDL, Coronary Artery Disease, Cost-Benefit Analysis, Diagnostic Imaging, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Primary Health Care, Primary Prevention, Risk Assessment, Vascular Calcification

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