New Cholesterol Guidelines Endorse the Value of Coronary Artery Calcium Scoring

UH was early adopter of the simple but accurate test, has offered it at no cost since 2016

Innovations in Cardiovascular Medicine & Surgery - Winter 2019

The new cholesterol guidelines from the American College of Cardiology and American Heart Association recommend coronary artery calcium scoring as a key decision tool, when clinicians are deciding whether to use statins.

Sanjay Rajagopalan, MD

For cardiologist Sanjay Rajagopalan, MD, Chief, Division of Cardiovascular Medicine, University Hospitals Harrington Heart & Vascular Institute; and Director, Case Cardiovascular Research Institute, Herman K. Hellerstein MD Professor of Cardiovascular Research, Professor, Department of Internal Medicine and Radiology, Case Western Reserve University School of Medicine, this is welcome news.

“One of the most significant things is the importance given to coronary artery calcium scoring in patients when you are having to decide whether you need to treat them with medications such as statins, in order to lower risk” Dr. Rajagopalan says. “Traditionally, for primary prevention, we’ve been using a risk score approach to generate the risk of heart attack, stroke or cardiovascular death. The risk score model is helpful in categorizing patients into low, borderline, intermediate and high risk. Borderline or intermediate risk is defined in the guidelines as 5-20% percent risk at 10 years of having a heart attack, stroke or dying. The guidelines recommend obtaining a calcium in intermediate or borderline risk patients, to provide better evidence of future risk. The presence of calcium in the coronary artery connotes a high risk situation that places the patient at high risk for future events, and thus warrants treatment with a statin.

“Risk scores, by definition, are prone to error, where they might under or overestimate risk,” Dr. Rajagopalan says. “We have known that plugging in a bunch of numbers like your age, blood pressure and cholesterol into a computer to provide risk, which is what risk scores do, is only moderately accurate in predicting future risk. Many intermediate and sometimes low risk patients, based on a risk score, turn out to be high risk when we obtain a calcium score”, Dr. Rajagopalan says.

“Of all the measures developed over the past two and half decades, coronary artery calcium is the most robust and accurate surrogate for future cardiac risk,” asserts Dr. Rajagopalan. So why don’t we do this test in everybody rather than sticking with risk scores that seem to be intrinsically flawed? Dr. Rajagopalan says that third party payers have been slow to adopt reimbursement policies for this test but now with the guidelines vigorously advocating for it, things may start to change.

University Hospitals and the UH Harrington Heart & Vascular Institute was an early adopter of coronary artery calcium scoring and has taken significant steps to make it widely available to the Northeast Ohio community.

“At UH, we’ve taken the position for several years now that calcium scores should be provided at low or no cost,” Dr. Rajagopalan says. “Despite all the data, insurance companies don’t reimburse for it. We moved to a no-cost calcium score program two years ago. Since 2014, we’ve done more than 25,000 scans. We are at a point where we believe that calcium scoring must be used as a screening tool in the U.S. population.”

Dr. Rajagopalan and colleagues from UH will be presenting the institution’s experience with coronary artery calcium scoring at the upcoming meetings of the American College of Cardiology.

“Our findings are very interesting, and they confirm many of our beliefs about coronary artery calcium scoring,” he says. “It’s a very good test.”

Ideally, Dr. Rajagopalan says, a calcium score test is performed after the clinician has advised the patient on smoking cessation, diet and exercise and has obtained a lipid panel and measurement for hemoglobin A1C.

“Patients shouldn’t be given the impression that this one test is all they need,” he says. “I don’t want patients just to get a score and not do anything else.”

 “At University Hospitals, we’re providing calcium score to our community because it makes good medical sense to put patients in charge of their health and lives,” he adds. “It helps patients. It helps identify risk early on so that patients can then make the necessary changes in their lifestyle and work with their physicians to control risk factors such as high blood pressure, diabetes and cholesterol.”

For more information on the no-cost CACS program at UH, contact Dr. Rajagopalan at 216-844-5125.