Management of Coronary Calcifications

Diagnostic Assessment

Coronary artery calcification is a reliable marker of coronary atherosclerosis and vascular age, making it a robust predictor for risk assessment and future cardiovascular events, according to the European Society of Cardiology 1
Coronary calcium detection by computed tomography is not recommended to identify individuals with obstructive coronary artery disease (CAD), as stated by the European Heart Journal 2, 3
When coronary calcification findings are available from previous chest CT scans, these findings should be considered to enhance risk stratification and guide treatment of modifiable risk factors, as recommended by the European Society of Cardiology 1
Coronary CTA is not recommended when extensive coronary calcification is present, as it makes good image quality unlikely, according to the European Heart Journal 2, 4
Risk stratification is recommended based on clinical assessment and the result of the diagnostic test initially employed to make a diagnosis of CAD, as stated by the European Society of Cardiology 2, 3

Resting echocardiography is recommended to quantify left ventricular function in all patients with suspected CAD, according to the European Society of Cardiology 2, 5
Risk stratification, preferably using stress imaging or coronary CTA (if local expertise and availability permit), is recommended in patients with suspected or newly diagnosed CAD, as stated by the European Heart Journal 5, 6
In symptomatic patients with a high-risk clinical profile, invasive coronary angiography (ICA) complemented by invasive physiological guidance (FFR) is recommended for cardiovascular risk stratification, particularly if symptoms are inadequately responding to medical treatment, according to the European Society of Cardiology 6, 7
Invasive functional assessment must be available and used to evaluate stenoses before revascularization, unless very high grade (>90% diameter stenosis), as recommended by the European Heart Journal 4

Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended for all patients with coronary calcifications, according to the European Society of Cardiology 6, 7
Exercise-based cardiac rehabilitation is recommended as an effective means for patients with chronic coronary syndromes to achieve a healthy lifestyle and manage risk factors, as stated by the European Heart Journal 7, 8
Involvement of multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) is recommended, according to the European Society of Cardiology 8, 9

Medical treatment of symptomatic patients requires one or more drugs for angina/ischemia relief in association with drugs for event prevention, as stated by the European Heart Journal 9, 10
First-line treatment for symptom control is indicated with beta-blockers and/or calcium channel blockers to control heart rate and symptoms, according to the European Society of Cardiology 9, 10
Short-acting nitrates are recommended for immediate relief of effort angina, as recommended by the European Heart Journal 9, 10
Statins are recommended in all patients with chronic coronary syndromes, according to the European Society of Cardiology 10, 4
If LDL-C goals are not achieved with the maximum tolerated dose of a statin, combination with ezetimibe is recommended, as stated by the European Heart Journal 10, 4
For patients at very high risk who do not achieve their goal on a maximum tolerated dose of statin and ezetimibe, combination with a PCSK9 inhibitor is recommended, according to the European Society of Cardiology 10, 4

Aspirin 75-100 mg daily is recommended in patients with a previous MI or revascularization, as stated by the European Heart Journal 9, 10
Clopidogrel 75 mg daily is recommended as an alternative to aspirin in patients with aspirin intolerance, according to the European Society of Cardiology 9, 10
For patients who have undergone coronary stenting, aspirin 75-100 mg daily is recommended following stenting, as recommended by the European Heart Journal 10, 4
Clopidogrel 75 mg daily following appropriate loading is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type, according to the European Society of Cardiology 10, 4

Patients with diabetes mellitus often have more extensive coronary calcification and complex coronary anatomy, as stated by the European Society of Cardiology 1
Vasodilating beta-blockers may be preferred in patients with diabetes to avoid adverse metabolic effects, according to the European Society of Cardiology 1

Timely review of the patient's response to medical therapies (e.g., 2-4 weeks after drug initiation) is recommended, as stated by the European Heart Journal 9, 10
Annual influenza vaccination is recommended for patients with chronic coronary syndromes, especially in the elderly, according to the European Society of Cardiology 8, 9
Mobile health interventions are recommended to improve patient adherence to healthy lifestyles and medical therapy, as recommended by the European Society of Cardiology 1