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Coronary Artery Calcium (CAC) for Risk Stratification

Posted Apr 05 2013 3:00am

Multiple studies of Type 2 diabetics currently free of heart disease have demonstrated a risk for future cardiac events equivalent to those non-diabetics who've already had an initial event.  That's why diabetes is considered a coronary heart disease equivalent, similar to symptomatic carotid stenosis, abdominal aortic aneurysm, and peripheral arterial/vascular disease.  If any of these 4 conditions is noted, we're to assume the patient is at high risk (>20%) for a heart attack in the next 10 years and aim their LDL cholesterol towards a goal of <100md/dL or optional goal of <70mg/dL.

But as with the direction of healthcare these days, we're making every attempt to individualize rather than generalize.  In other words, aren't their some diabetics w/greater heart disease risk than others?  And if so, how do we differentiate one from the other?  After all, the Framingham risk calculator, Reynolds Risk score, and QRISK2 lump them all together.

With that thought in mind, a meta-analysis of 8 prospective studies was published last month in the British Medical Journal in which the authors concluded that coronary artery calcium score ≥10 is useful in separating the truly high risk from the merely moderate risk.  The authors arrived at their conclusion by following 6,521 participants w/T2DM for 5+yrs.  Compared to those w/CAC <10, those w/greater scores had five-fold greater relative risk of all-cause mortality & cardiovascular events.  So while I am not a great fan of excess radiation exposure, it would appear that imaging might aid in determining who should truly aim for the optional goal LDL of <70mg/dL.

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