The Impact of Age on the Likely Impact of Coronary Calcium Testing in the 2018 Cholesterol Guidelines
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and Venkatesh L. Murthy, MD, PHD3,4
1
Division of General Medicine , University of Michigan, Ann Arbor, MI, USA; 2Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA; 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; 4 Division of Cardiovascular Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05369-w © Society of General Internal Medicine 2019
BACKGROUND
The 2018 American College of Cardiology/American Heart Association cholesterol guidelines recommend substantially increasing use of coronary artery calcium testing.1 In particular, they say it is appropriate for interested individuals aged 45 to 75 with a 10-year risk of atherosclerotic cardiovascular disease (ASCVD) between 7.5 and 20%, who do not smoke, have diabetes, or already use a statin. If a patient has a CAC of 0, the guidelines advise that statin use is not necessary. However, calcification and ASCVD risk both increase with age.2 The implications of this on the appropriateness of imaging are not known. We sought to clarify how many people this recommendation might affect and how aging might alter the potential impact of this recommendation on treatment choices.
METHODS
We used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a large, community-based prospective cohort study of heart disease.3 We identified the subgroup of MESA participants who CAC testing would be considered appropriate in the 2018 cholesterol guidelines. We developed cubic splines fitted on age to address nonlinearities. We performed logistic regression then postestimation prediction using the cubic splines to estimate the likelihood a patient coronary calcium screening will be eligible for testing at each age. We used fractional polynomial regression of the relationship between age and the numbers of risk factors to be eligible for testing to learn how many risk factors would have to be positive for a patient to be appropriate at each age. We then examined the likelihood a test will have a CAC of 0 at each age. This work has not been presented publically. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-019-05369-w) contains supplementary material, which is available to authorized users. Received June 21, 2019 Revised July 26, 2019 Accepted September 12, 2019
This study received exemption from the Michigan Medicine IRB and we were given data access from BioLincc. All code is available at https://github.com/jeremysussman/ cacAge. This study received exemption from the Michigan Medicine IRB.
RESULTS
Of 6745 participants in the MESA study with a CAC scan, 808 subjects were outside of the guideline recommended age range of 45–75. A total of 3879 had a 10-year ASCVD risk outside the range of 7.5 to 20% recommended for testing. Eight hundred seven-three of the remaining patients either had diabetes, were current smokers, were on any lip
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