The Heart Foundation has today released a position statement for health professionals on the use of coronary artery calcium scoring for the primary prevention of cardiovascular disease (CVD) but calls for more research to define its role in Australia.
A coronary artery calcium score, or calcium score, is a measure of how much calcium is in the walls of the heart’s blood vessels. Calcium flecks are a feature of most cases of atherosclerosis affecting the coronary arteries.
The recommendations, published today in the Medical Journal of Australia, guide doctors on deciding when and how to use calcium scoring as part of determining a person’s risk of having a heart attack.
Heart Foundation Chief Medical Adviser and cardiologist, Professor Garry Jennings, said that in some people without previous cardiovascular disease, calcium scoring could be considered to help reclassify a person’s risk of heart attack or stroke following absolute CVD risk assessment.
“An absolute CVD risk assessment allows a doctor to estimate a person’s risk of heart attack or stroke over the next 5 years using the validated Australian CVD risk calculator.
“Calcium scoring could be considered for people with moderate risk of heart attack and stroke if their doctor is uncertain about the intensity of risk management,” Professor Jennings said.
“In addition, if a person is found to be at low risk of heart attack or stroke following absolute CVD risk assessment, and they have other factors that may enhance this risk, such as a family history of cardiovascular disease, calcium scoring could be suitable following a shared decisionmaking approach.”
Key recommendations:
1. Coronary artery calcium scoring could be considered for selected people with moderate absolute cardiovascular disease risk, AND for whom the findings are likely to influence the intensity of risk management.
2. Coronary artery calcium scoring could be considered for selected people with low absolute cardiovascular disease risk, AND who have additional risk-enhancing factors that may result in the underestimation of risk.
3. If coronary artery calcium scoring is done, a coronary artery calcium score = 0 Agatston units (AU) could reclassify a person to a low absolute cardiovascular disease risk status, with subsequent management to be informed by patient/clinician discussion and follow contemporary recommendations for low absolute cardiovascular disease risk.
4. If coronary artery calcium scoring is done, a coronary artery calcium score >99 AU OR ≥75th percentile for age and sex could reclassify a person to a high absolute cardiovascular disease risk status, with subsequent management to be informed by patient/clinician discussion and follow contemporary recommendations for high absolute cardiovascular disease risk.
The position statement was developed following extensive consultation and input from peak health bodies and has been fully funded by the Heart Foundation. An independent expert advisory group was appointed to provide advice on the interpretation of evidence and the development of these new recommendations.
Professor Jennings said that coronary artery calcium scoring won’t be appropriate for everyone, because in some groups of people, it won’t change how a person is treated or managed.
“Those groups include people who are already known to be at high risk of cardiovascular disease or people who have already had a heart attack or stroke.”
Calcium scoring is measured using a CT scan of the heart to determine how much calcium is visible in the coronary arteries. A score of zero indicates there is no calcified plaque.
Currently, coronary artery calcium scoring is not subsidised by Medicare, so the cost of the test is an out-of-pocket expense for people. The cost also varies across the country.
“It is vital that any decision to use coronary artery calcium scoring to reclassify risk status is informed by a discussion and shared decision-making process. The benefit of improved cardiovascular disease risk assessment must be considered against the impact of costs, which can vary significantly and limit access for many Australians.”
Professor Jennings said that despite the new recommendations being based on the best available evidence, more research is needed to understand how calcium scoring is directly relevant to Australians.
“This will help to define the role of calcium scoring in the prevention and management of cardiovascular disease in Australia.
“Our current advice is for people to see their GP for comprehensive clinical assessment of their cardiovascular risk via a Heart Health Check. Following an estimation of a person’s absolute cardiovascular disease risk, people can speak with their doctor about whether calcium scoring may be appropriate for them.”
The calcium scoring recommendations include evidence published since the release of the coronary artery calcium scoring position statement by the Cardiac Society of Australia and New Zealand (CSANZ) in 2017.
