Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
NCH Rooney Heart Institute, 399 9th Street North, Suite 300, Naples, FL, 34102, USA.
Curr Atheroscler Rep. 2023 Dec;25(12):911-920. doi: 10.1007/s11883-023-01161-8. Epub 2023 Nov 16.
To discuss and review the technical considerations, fundamentals, and guideline-based indications for coronary artery calcium scoring, and the use of other non-invasive imaging modalities, such as extra-coronary calcification in cardiovascular risk prediction.
The most robust evidence for the use of CAC scoring is in select individuals, 40-75 years of age, at borderline to intermediate 10-year ASCVD risk. Recent US recommendations support the use of CAC scoring in varying clinical scenarios. First, in adults with very high CAC scores (CAC ≥ 1000), the use of high-intensity statin therapy and, if necessary, guideline-based add-on LDL-C lowering therapies (ezetimibe, PCSK9-inhibitors) to achieve a ≥ 50% reduction in LDL-C and optimally an LDL-C < 70 mg/dL is recommended. In patients with a CAC score ≥ 100 at low risk of bleeding, the benefits of aspirin use may outweigh the risk of bleeding. Other applications of CAC scoring include risk estimation on non-contrast CT scans of the chest, risk prediction in younger patients (< 40 years of age), its value as a gatekeeper for the decision to perform nuclear stress testing, and to aid in risk stratification in patients presenting with low-risk chest pain. There is a correlation between extra-coronary calcification (e.g., breast arterial calcification, aortic calcification, and aortic valve calcification) and incident ASCVD events. However, its role in informing lipid management remains unclear. Identification of coronary calcium in selected patients is the single best non-invasive imaging modality to identify future ASCVD risk and inform lipid-lowering therapy decision-making.
讨论并回顾冠状动脉钙化评分的技术考虑因素、基本原则和基于指南的适应证，以及其他非侵入性成像方式的应用，如心血管风险预测中的冠状动脉外钙化。
CAC 评分最有力的证据是在特定人群中，年龄在 40-75 岁，10 年 ASCVD 风险处于边缘至中等水平。最近的美国建议支持在不同的临床情况下使用 CAC 评分。首先，在 CAC 评分非常高（CAC≥1000）的成年人中，建议使用高强度他汀类药物治疗，如果需要，还应使用基于指南的 LDL-C 降低治疗（依折麦布、PCSK9 抑制剂），以实现 LDL-C 降低≥50%，并尽可能将 LDL-C 降低至<70mg/dL。在低出血风险且 CAC 评分≥100 的患者中，阿司匹林的使用获益可能超过出血风险。CAC 评分的其他应用包括非对比胸部 CT 扫描的风险评估、年轻患者（<40 岁）的风险预测、作为核应激测试决策的门槛值的价值，以及帮助低危胸痛患者进行风险分层。冠状动脉外钙化（如乳腺动脉钙化、主动脉钙化和主动脉瓣钙化）与 ASCVD 事件的发生相关。然而，其在指导脂质管理中的作用仍不清楚。在选定的患者中识别冠状动脉钙是识别未来 ASCVD 风险并为降脂治疗决策提供信息的唯一最佳非侵入性成像方式。
