Author + information
- Khurram Nasir, MD, MPH∗ ( and )
- Harlan M. Krumholz, MD, SM
- ↵∗Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, 1500 San Remo Avenue, Suite 340, Coral Gables, Florida 33139
We thank Drs. Correia and Lemos for their interest in our paper describing significant heterogeneity in atherosclerotic cardiovascular disease (ASCVD) risk among statin therapy candidates and highlighting the role of absent coronary artery calcification (CAC) in reclassifying risk to a category in which the guideline no longer recommends treatment (1). Overall, 49% of individuals with a 10-year ASCVD risk range of 5% to 20% was determined on the basis of clinical information, and as a result, candidates for statin therapy had CAC = 0 and a reclassified risk lower than the threshold suggested for treatment consideration (1). Although further clinical information may refine risk in these categories, the revised estimates with CAC testing reported in our paper, however, already accounted for risk factor–based pre-test probabilities.
It is also important to note that these findings do not recommend against treatment in described scenarios, but rather promote shared decision-making processes to inform patients regarding options available that can significantly reduce uncertainty surrounding traditional risk calculations. Furthermore, the framework for facilitating informed patient choices regarding statin use in our paper is centered on reclassified absolute risk estimates with CAC testing while weighing optimal management options. We presented the estimated number needed to treat across various CAC categories to inform discussions on the utility of long-term statin therapy from a broader societal perspective for appropriate resource allocation rather than guide individualized decision-making processes.
We disagree with Correia and Lemos’s emphasis on seeking net reclassification with CAC testing among those who are already candidates for statin therapy because information on risk up-regulation is unlikely to change management decisions. In these circumstances, testing for CAC = 0 to down-regulate risk can significantly influence a patient’s decision to avoid statin use and focus on prudent lifestyle changes.
Finally, we agree with Correia and Lemos that CAC testing is most useful in situations in which the decision regarding statin therapy is uncertain. In fact, our study emphasizes that this pragmatic approach is only worthwhile if the respective patient is a statin candidate and also willing to avoid therapy based on a revised lower risk with a CAC = 0. Among patients who will consider statin therapy even at lower-risk thresholds or wish to avoid it at any cost, further testing is of little value. In short, rather than dictate, our study informs the potential of CAC testing in appropriate situations to guide optimal patient decisions based on their preferences and values.
Please note: Dr. Nasir is on the advisory board for Quest Diagnostic; and is consultant for Regeneron. Dr. Krumholz is the recipient of a research grant from Medtronic, Inc. through Yale University; and is chair of a cardiac scientific advisory board for UnitedHealth.
- American College of Cardiology Foundation
- Nasir K.,
- Bittencourt M.S.,
- Blaha M.J.,
- et al.