Use of Non-statin Therapies in Patients With High Coronary Artery Calcium (CAC) Scores

Erin D. Michos, MD, MHS, FACC, FASPC: One of the things we briefly mentioned earlier is…coronary calcium as a way to estimate risk. I was pleased to see that the ACC [American College of Cardiology] expert decision pathway had some discussion around coronary calcium. Pam, I was wondering, how do you use coronary calcium to think about nonstatin therapy as well as LDL [low-density lipoproteins] goals?

Pam Taub, MD, FACC, FASPC: I was very happy to see a lot of discussion around use of coronary calcium and nonstatin agents in the new ACC expert consensus pathway. Just to take a step back, calcium is a marker of subclinical atherosclerosis, it just hasn’t manifested yet. One of the things that I think is the art of medicine is detecting subclinical atherosclerosis and addressing it before the event happens. Calcium scoring is a very important tool that we can use in our practice to detect subclinical atherosclerosis. As we mentioned before, we don’t need to just use calcium scores. Sometimes we’ll see the calcification in the aorta. When I read echocardiograms, I often see calcification on the mitral valve. Also, on echos, you can see calcification in the aorta. There are a lot of new data about breast arterial calcification. Calcification anywhere in the body should alert us that this patient has subclinical atherosclerosis, and let’s get aggressive.

What the new expert consensus statement tells us is if you have a really high calcium score, over 1000, these are patients for whom you should go beyond statin therapy. These are patients where you should be using ezetimibe, PCSK9 inhibitors, inclisiran, and bempedoic acid, and get their LDL levels to less than 55 mg/dL. These patients have the same level of risk as our patients who’ve already had an event. I really like that expansion to the guidelines because now, it allows us to start thinking about these patients in a different way. Before we would just say, “You have an elevated calcium score. Let’s get you on a statin.” Now we have a more aggressive target for these patients with subclinical atherosclerosis.

Transcript edited for clarity