Coronary Artery Calcium Scoring to Guide Preventive Strategies for ASCVD Risk Reduction

Publication Date: December 31, 2020
Last Updated: March 14, 2022

Recommendations

Absolute scores versus percentiles

Physicians reporting CAC scores should report both the absolute Agatston CAC score and the age, sex, and race/ethnicity-based CAC percentiles. ( B-NR , I )
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Borderline to intermediate risk adults

For adults 40–75 years of age, with LDL-C 70–189 mg/dL and a 10-year ASCVD of 5–19.9%, CAC scoring, can be useful to aid clinicians in determining the need for and intensity of preventive therapies. (B-NRIIa)
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Low risk adults

For adults 40 years of age or older, with LDL-C 70–189 mg/dL and a 10-year ASCVD risk of <5%, CAC scoring is reasonable, in those with a strong family history of premature ASCVD, to decide on the need for and intensity of preventive therapies. ( B-NR , IIa )
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Individuals with clinical ASCVD

For adults with clinical ASCVD, CAC scoring is not recommended. (, III (no benefit) )
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Race/ethnicity

Clinicians should use CAC scoring, when indicated, for ASCVD risk assessment, regardless of the patient's race/ethnicity or gender. ( B-NR , I )
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Adults less than 40 years of age

In selected adults <40 years of age with multiple major ASCVD risk factors or a family history of premature ASCVD, it is reasonable to use CAC>0 as a factor favoring intensification of lifestyle therapy and, if necessary, initiation of statin therapy. ( B-NR , IIa )
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CAC = 0

In adults 40–75 years of age with LDL-C 70–189 mg/dL and without diabetes, active cigarette smoking or a family history of premature ASCVD, it is reasonable to defer statin initiation in those with CAC = 0. (B-NRIIa)
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In adults age 76–80 years of age in whom the decision about initiation of statin therapy is uncertain, it is reasonable to use CAC = 0 as a factor favoring avoidance of statin therapy. (B-NRIIb)
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High CAC scores

In adults with predominant left main coronary calcification, multi-vessel coronary involvement, or a high CAC score, stress testing or invasive coronary arteriography, in the absence of clinically relevant symptoms, is not recommended. (III (harm))
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In adults with CAC scores ≥ 100, initiation of statin therapy is recommended. (B-NRI)
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In adults with CAC scores ≥300, and especially in those with CAC scores ≥ 1000, it is reasonable to use high intensity statin therapy, and if necessary, guideline-based add-on LDL-C lowering therapies to achieve a ≥50% reduction in LDL-C, and optimally and LDL-C <70 mg/dL. (C-LDIIa)
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Incidental findings

In adults found on a CAC scoring exam to have one or more pulmonary nodules, follow-up testing should be done in accordance with the Fleischner Society recommendations. (C-EOI)
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In adults found on a chest CT to have incidental mild CAC, it may be reasonable to obtain a dedicated CT scan for coronary calcium scoring to guide preventive treatment decision-making. (C-LDIIb)
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In adults found on a chest CT to have incidental moderate or severe CAC, initiation of statin therapy without dedicated CAC imaging is reasonable. (B-NRIIa)
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Severe primary hypercholesterolemia

In selected adults with severe primary hypercholesterolemia, in the absence of extreme LDL-C elevation, additional major ASCVD risk factors or a family history of premature ASCVD, CAC scoring may be reasonable to inform decision-making about the need for add-on therapy to maximally tolerated statins. (C-LDIIb)
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In adults with severe primary hypercholesterolemia and CAC>0, heightened ASCVD risk status is confirmed, favoring more aggressive, guideline based LDL-C lowering. (C-LDIIa)
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Diabetes mellitus

In adults 40–75 years of age with diabetes mellitus and an LDL-C 70–189, a moderate or high intensity statin is indicated, regardless of CAC score. (AI)
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In adults 40–75 years of age with diabetes mellitus in whom the decision has been made to initiate statin therapy, it is reasonable, for those with a CAC score >100, to choose a high intensity statin. (C-LDIIa)
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In adults 30–39 years of age with long-standing diabetes mellitus (type 1 diabetes of >20 years duration or type 2 diabetes of >10 years duration) and risk factors or microangiopathy, CAC scoring may be reasonable to aid in ASCVD risk stratification and statin treatment shared decision-making. (C-LDIIb)
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In adults older than 75 years of age with type 2 diabetes, in whom the decision to employ a statin for primary prevention is uncertain, CAC scoring is reasonable to aid in statin treatment shared decision-making. (C-LDIIa)
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Repeat CAC scoring

In adults with CAC = 0, it is reasonable to repeat CAC scoring at the following intervals:
  • Low risk (<5% 10 year risk): 5–7 years
  • Borderline to intermediate risk (5–19.9% 10 year risk): 3–5 years
  • High risk or diabetes: 3 years.
(B-NRIIa)
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In adults with CAC scores 1–99, it may be reasonable to repeat CAC scoring in 3–5 years if the results might change treatment decisions. (B-NRIIb)
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In adults with CAC scores ≥100 and an LDL-C ≥70 mg/dL, repeat CAC scoring at 3 years may be reasonable to assess for accelerated progression (>20–25% per year) and/or an increase to a CAC score >300, findings that may favor more aggressive LDL-C lowering. (C-LDIIb)
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Aspirin therapy

In patients with CAC ≥ 100, therapy with aspirin 81 mg daily is reasonable for those who do not have bleeding-related contraindications to such therapy. ( B-NR , IIa )
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Recommendation Grading

Overview

Title

Coronary Artery Calcium Scoring to Guide Preventive Strategies for ASCVD Risk Reduction

Authoring Organization

National Lipid Association

Publication Month/Year

December 31, 2020

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D003324 - Coronary Artery Disease

Keywords

Coronary artery calcium scoring, computed tomography, Subclinical coronary altherosclerosis, Altherosclerotic cardiovascular disease risk prediction, Lipid-therapy