CT CAC scoring endorsed to estimate heart disease risk

The American Heart Association (AHA) and American College of Cardiology (ACC) have endorsed CT coronary artery calcium (CAC) testing as a decision aid to determine a patient’s risk of heart disease.

A group of researchers from Johns Hopkins University in Baltimore published an editorial outlining the endorsement Feb. 12 in the Annals of Internal Medicine. They warned against using CAC testing as a screening tool and urged a cost-effective strategy to promote its widespread use.

“It is critical that the main stakeholders, especially primary care physicians, understand the newly proposed role for CAC testing and do not equate it with screening,” wrote Rhanderson Cardoso, MD, and colleagues. “Rather than bringing in many additional statin candidates, this testing should serve as a decision aid to “de-risk” certain patients and distinguish those who may benefit from preventive pharmacologic therapies.”

In 2018, the AHA/ACC strongly endorsed selective CAC testing, but the decision on when to use such testing had remained unclear. The updated guidelines recommend using CAC scoring when the benefit-risk balance is uncertain, including borderline- or intermediate-risk patients with a projected 10-year risk of atherosclerotic cardiovascular disease (ASCVD) ranging from 5 to 20 percent. Clinical judgement and patient preference should be the ultimate guide all decisions, Cardoso et al. wrote.

Additionally, factors such as the cost of the exam and the potential of downstream follow-up imaging to identify noncardiac findings should be considered. The added radiation exposure during the test should also be properly discussed with patients, the authors added.

“The next step for CAC testing in primary prevention is clearly universal coverage for appropriate candidates to ensure equal access. We must advocate for reasonable pricing (<$150),” the authors concluded. “We also must reinforce that CAC testing is a decision aid and should almost never be followed by downstream cardiovascular testing, such as stress testing or cardiac catheterization.”