A Picture is Worth a Thousand Words

Low CAC Scores Fail To Receive Appropriate Treatment

While a low calcium score may impart low short term risk in an elderly patient, for instance, it may represent high lifetime risk in a young person (> 75th percentile for age, gender, race); placing them on a high risk trajectory for ASCVD complication to include cardiovascular death over the next, say, 30 years. 

Sadly, many young patients with a “low CAC score,” but high percentile rank (>75th), have been misinformed to simply “keep an eye on it” because it’s “not high yet.” That’s not good advice, considering we know that the earlier we initiate intense treatment, the more likely we are to get in front of the disease and prevent a lifetime of ASCVD complications. 

Coronary artery calcium scores carry a “warranty” of about 5-10 years. The Agatston score informs upon an individual’s near-term, or 10 year cardiovascular risk. 

However, when compared to others of the same age, gender and race, it also provides a percentile rank and informs us of one’s “lifetime” risk, or “30-year” risk. 

Many facilities use the risk calculator programmed into the CT scanner, which is often outdated and underestimates risk. MESA Calcium Calculator is preferred.

High CAC Scores Fail to Receive the Aggressive Treatment Needed

After decades of needless controversy, corruption and conspiracy (Watch The Widowmaker | Prime Video), multiple guidelines have finally embraced coronary artery calcium scores as part of the ASCVD risk stratification process. Tragically, there are many providers, to include specialists like cardiologists, who remain unconvinced, still holding out for some sort of RCT before embracing this technology that allows one to actually “see” the disease within the coronaries. 

Long standing endurance athletes have been identified as a subgroup that may have a predilection for higher coronary artery calcium scores. This may in part explain the seemingly paradoxical phenomenon of sudden cardiac death during endurance races. Athletes may have a false sense of optimal health (healthy athlete bias) and either fail to obtain proper screening, or feel they can treat it solely through natural means - like “running” away from it. See Killer Workouts - The Adult Athlete.

In other cases a high CAC score may give some patients a false sense of doom, causing them to perhaps even withdraw from optimal medical therapy due to the belief that nothing can be done, or that “it’s in my genes - everyone in my family had this.” Many patients read the report and falsely conclude that they are destined to have a heart attack. Comments like “it says here I have a 99% chance of having a heart attack in 10 years” are not uncommon.  

It’s important to communicate that no CAC score or percentile rank “guarantees” or “obligates” a person to having a future heart attack or stroke, but it does put them in good company with those who do when nothing is done about it. It is not a time to feel depressed about the diagnosis, but a time to feel fortunate that the diagnosis has been made before an ASCVD event has occurred knowing we have safe and effective therapies proven to halt and even regress atherosclerosis.