Denial of Coronary Artery Calcium Scoring in Low-Risk Patients

Risk Stratification Analysis

The American College of Cardiology recommends that patients with a 10-year ASCVD risk of less than 5% are considered low risk and do not require CAC scoring, as seen in this patient with a 0.4% risk 1, 2, 3
The Society of Cardiovascular Computed Tomography considers CAC scoring appropriate for borderline to intermediate risk patients, but not for low-risk patients like this one, who has a 10-year ASCVD risk of 0.4% 2, 3
Family history alone, without other risk factors or elevated lipids, is insufficient indication for CAC scoring in a patient with such low calculated risk, as stated by the American College of Cardiology 1, 3

The 2019 ACC/AHA guidelines provide a Class IIa recommendation for CAC scoring only in adults aged 40-75 years with intermediate ASCVD risk (≥7.5% to <20%) or selected borderline-risk patients (5% to <7.5%), which does not apply to this patient with a 0.4% risk 1, 2, 3
The American College of Cardiology defines low risk as <5% 10-year ASCVD risk, which is the case for this patient with a 0.4% risk 1, 2, 3

The American Heart Association states that CAC scoring is not recommended in patients younger than 40 years for women due to very low prevalence of detectable calcium, and at 41, this patient is just at the lower age threshold 5
Even if CAC were performed and showed a score of 0, this would not change management since the patient already has optimal lipids and very low risk, as per the American College of Cardiology guidelines 4

The American College of Cardiology states that the radiation exposure from CAC scoring (approximately 1.5 mSv) cannot be justified in a patient with such low pretest probability of disease, as is the case with this patient 5

The US Preventive Services Task Force recommends against screening in adults at low CAD risk with <5-10% 10-year risk, which applies to this patient with a 0.4% risk 6
The American College of Cardiology Foundation guidelines from 2010 recommend against CAC scoring in high-risk patients (>20%) and low-risk patients (<10%), reserving it for intermediate-risk patients, as seen in this case 6, 5

The American College of Cardiology recommends continued lifestyle modification and reassessment of traditional risk factors as the appropriate management for this patient, rather than CAC scoring 1, 4, 3
Annual cardiovascular risk assessment using traditional risk calculators is sufficient for this patient, according to the American College of Cardiology guidelines 1, 3