Does Annette Need a Statin?

Annette, a 61-year-old real estate professional, comes to your office and is concerned about her future risk of heart attack since her father sustained his first myocardial infarction at the age of 60. She quit smoking 10 years ago with a prior 30-pack-year history but admits to continued dietary indiscretion and a relatively sedentary lifestyle. She has a history of hypertension for which she takes lisinopril.

Her vital signs at her visit today and results of labs are:

BP: 134/82 mm Hg
Pulse: 72 beats/min
BMI: 31.2
Waist circumference: 36”

Laboratory resultsTotal cholesterol: 194 mg/dL
Triglycerides: 180 mg/dL
HDL-C: 48 mg/dL
LDL-C: 110 mg/dL

Her 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimate is 6.2%. You discuss the possibility of performing a coronary artery calcium score (CACS) to refine her risk estimate. She is in favor of pursuing testing and is ultimately found to have an Agatston score of 52, which is at the 82nd percentile for her age, gender, and ethnicity. She is surprised by this result and asks you for your interpretation. You respond as follows:

A. Her score is consistent with mild coronary atherosclerosis and reclassifies her ASCVD risk estimate to < 5%; statin therapy is not recommended.

B. Coronary artery calcium represents healed plaque, and as such, is associated with a benign prognosis.

C. Coronary artery calcium has its origin from dysfunctional endothelial cells with altered calcium handling.

D. She has accelerated atherosclerosis and a discussion about risks and benefits of statin therapy should ensue.

Please click below for answer and discussion.

The correct answer is D. She has accelerated atherosclerosis and a discussion about risks and benefits of statin therapy should ensue.

CACS personalizes risk prediction through direct visualization of calcified coronary atherosclerotic plaque and has emerged as the most effective diagnostic tool to refine risk estimates in individuals without known ASCVD. Data generated over the last 25 years have consistently demonstrated that the extent of coronary artery calcification predicts future cardiac events. Importantly, the addition of the CACS to traditional global risk assessment significantly improves measures of discrimination and reclassification. The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults suggests that additional factors may be considered to inform treatment decisions in select individuals, including CACS. According to the guidelines, if a CACS is ≥ 300 Agatston units or in the ≥ 75th percentile for age, gender, and ethnicity, statin therapy may be recommended.

Acknowledging the significant heterogeneity in ASCVD risk that exists amongst those eligible for statin therapy, a new risk calculator that integrates CACS into traditional global risk assessment, has been developed. The calculator comes out of the Multi-Ethnic Study of Atherosclerosis (MESA) collaboration and can be viewed here.

Reference: Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.Circulation. 2014;129:S1-S45.

Note: This article first appeared on our partner site Preventive Cardiology.