COMMENTARY

A 43-Year-Old With a Calcium Score of 347: And the Audience Said . . .

Melissa Walton-Shirley

Disclosures

September 03, 2014

In yesterday's 11:00 am session in Rome-Village 1 at the European Society of Cardiology (ESC) 2014 Congress , we had the pleasure of testing the attitude and habits of cardiologists from around the European Union on coronary artery calcium scoring.[1] In a room filled with around 300 attendees, we were asked to vote on options as to how to approach a patient with an unknown family history, an abnormal lipid profile, and an absence of symptoms. This seemingly "healthy" 43-year-old male made a visit to his physician for reasons unclear, and this is the case scenario that ensued.

Dr Koen Nieman (Erasmus Medical Center, Rotterdam, the Netherlands) conducted the session with several interesting caveats and questions. (I asked some questions as well by secret iPhone submission—a first dalliance with the neat new app at the ESC—from the comfort of my chair, in total anonymity, just so no would know it was me . . . just in case they were "dumb" questions.)

You are welcome to take the exam questions, too, just so you know how close your practice is to the majority of the attendees.

Question 1

To assess this 43-year-old asymptomatic male patient's cardiovascular status, you would recommend:

    A. Tell him no need to worry (reassurance).

    B. Lifestyle recommendations.

    C. Preventive medications.

    D. A calcium score.

    E. Stress test.

And the audience said:

    B. 33%—Lifestyle recommendations.

    D. 19%—A calcium score.

    E. 14%—A stress exam.

The speaker then asked rhetorically, "Do we really know enough?" (So we guessed it must not be enough, or we'd all be getting up to leave.) He then pointed out, "If he were 20 years older, he would be in a high-risk group. Also, we didn't take into account family history," he said.

So, again for reasons unclear, he got a calcium score. Surprise! It was 347, which led to a short tutorial from the podium. "Calcium correlates with the presence of atherosclerosis, not instability, but it does reflect plaque burden and therefore CV outcomes," said Dr Niemen. He then went over the still-reliable "but slightly problematic" Agaston scoring system[2] and the technical aspects of scoring, including the "need to tag all the pink stuff that looks like calcium and then let the CT package do the rest." He discussed the optimal score of 0, the risk jump at a score of 100, then the significant jump again at 400. He pointed out that regarding this patient, we didn't just have the absolute score to deal with, we also had information regarding the impact of age and gender, and for this patient his calcium count is a concerning 90th percentile for age.

Next we had a short review of the Heinz Nixdorf study.[3] The researchers used the Framingham heart score combined with calcium scoring. Patients with intermediate risk, those with scores below 100, had a low probability of event rates. But if patients were at an intermediate Framingham heart score risk, those with Agaston scores greater than 400 demonstrated an event rate at five years of much greater than 10%.

Question 2

So, we have medicated his cholesterol and recommended a lifestyle modification. Is there anything else we would do?

    A. No, we are done.

    B. Follow-up calcium score in five years.

    C. CT angiogram.

    D. Stress exam

    E. Invasive angiogram.

And the audience said:

    D. 51%—Stress exam.

    A. 27%—We are done.

    C. 11%—CT angiogram.

The speaker then commented, "There are studies looking at stress exams and nuclear studies. With higher calcium scores of 400 or greater, 10% demonstrated ischemia, but with scores of >1000, 20% have ischemia."

Then, you knew it was coming. The patient was referred for a CT coronary angiogram (CCTA) that demonstrated distal disease, for which "there aren't data supporting improved outcomes with intervention. To summarize," Dr Nieman continued, "There aren't a lot of prevention guidelines in this sort of patient. If he's asymptomatic with an intermediate score, or if he asymptomatic and has diabetes or a strong family history, do calcium scoring."

Finally, the panel chose a few questions from the audience for discussion, and I sat there proudly beaming in the darkness because the last two were mine.

    1. Should this patient get aspirin apart from statin?

    The consensus from the speaker and panel was "yes."

    2. How many of you in the audience use coronary CTA?

    About one-sixth of docs (a rough estimate but a definite minority) raised their hands, and nearly all of them would direct the patient to use aspirin, again per a show of hands.

    3. Should the patient carry nitro?

    The speaker replied, "I don't think there is a need if he has no symptoms."

    4. Do you consider this patient a primary- or secondary-prevention patient? (a question the moderator seemed to like)

    "I would still consider it primary prevention, but it is a matter of semantics," replied Dr Niemen.

But those semantics, I insist, are important. In my mind's eye, coupled with a humble opinion, true primary-prevention targets should describe the virgin patient with no evidence of vessel disease, not just the lack of events. We should recommend lifestyle modification, exercise, and probably not statins. But if one has evidence of wall pathology, it's the earliest beginnings of disease. In addition, if one tests in the high-risk category of calcium scoring, then perhaps we should pair lifestyle modification and exercise with aspirin and the safety-belt med, nitro, for just in case. We should probably at least have the statin discussion, and we should definitely test for ischemia because of its correlation with adverse outcomes.

I love calcium scoring and heavily promote it among my patient population of males over the age of 50, in postmenopausal females, and those with a surprisingly early family histories of heart disease. I have no disclaimers other then I'd have to hear a lot of different data before I'd change my stance.

As a fitting ending, the moderator then said of the topic, "We could talk about it forever."

And the audience says?

We imagine we always will.

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