Implications of Coronary Artery Calcium Testing for Treatment Decisions Among Statin Candidates According to the ACC/AHA Cholesterol Management Guidelines
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This review evaluates the cost-effectiveness of using coronary artery calcium (CAC) to guide long-term statin therapy compared with treating all patients eligible for statins according to 2013 American College of Cardiology/American Heart Association cholesterol management guidelines for atherosclerotic cardiovascular disease. The authors used a microsimulation model to compare costs and effectiveness from a societal perspective over a lifetime horizon. Both strategies resulted in similar costs and quality-adjusted life years (QALYs). CAC resulted in increased costs (+$81) and near-equal QALY (+0.01) for an incremental cost-effectiveness ratio of $8,100/QALY compared with the treat-all strategy. For 10,000 patients, the treat-all strategy would theoretically avert 21 atherosclerotic cardiovascular disease events, but would add 47,294 person-years of statins. With CAC costs <$100, and higher cost and/or disutility associated with statin therapy, CAC strategy was favored. These findings suggest the economic value of both approaches were similar. Clinicians should account for individual preferences in context of shared decision making when choosing the most appropriate strategy to guide statin decisions.
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Using coronary artery calcium score to guide long-term statin therapy is cost-effective compared with treating all patients.
“Compared with a strategy of treating all patients, the use of CAC score to guide long-term statin therapy has been shown to be cost-effective [27].”
From 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk (2019) · cites this paper as [27]
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BackgroundSelf-citationThe Use of Subclinical Atherosclerosis Imaging to Guide Preventive Cardiology Management
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Effect of No-Charge Coronary Artery Calcium Scoring on Cardiovascular Prevention
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Self-citationCoronary artery calcium scoring: Its practicality and clinical utility in primary care
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“43 Hong et al 43 showed that coronary calcium testing was cost-effective when the patient and physician share decision-making about initiating statin therapy.”
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Subclinical cardiovascular disease and utility of coronary artery calcium score
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Cardiac-CT and cardiac-MR cost-effectiveness: a literature review
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“Even the individual perceived disutility in taking daily medication should play a key role in decisionmaking: a recent CEA of CS as marker for administering long-term statin therapy versus treating all eligible patients, according to 2013 American College of Cardiology/American Heart Association cholesterol management…”
BackgroundMethodUtilizing coronary artery calcium to guide statin use
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Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines
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“CACS-based preventive treatment was proved to be cost-effective in asymptomatic individuals at intermediate CAD risk.(8,9) In contrast, clinical CAD risk estimation scores, such as SCORE, tend to over- or underestimate risk on an individual level.”
BackgroundCoronary Artery Calcium Scoring in Current Clinical Practice: How to Define Its Value?
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Self-citationNew Model for Predicting the Presence of Coronary Artery Calcification
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Viewing the Value of Coronary Artery Calcium Testing From Different Perspectives
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Coronary and Extra-coronary Subclinical Atherosclerosis to Guide Lipid-Lowering Therapy
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“When comparing the use of CAC scoring to the “treat all with statin therapy” approach to guide shared clinical decision-making, CAC scoring is cost-effective and affords a reasonable option to risk stratify and facilitate shared decision-making [82].”
Role of Coronary Calcium Score to Identify Candidates for ASCVD Prevention
Nguyen, H. L., Liu, J., Castillo, M. D., & Shah, T. (2019) · Current Atherosclerosis Reports · doi:10.1007/s11883-019-0812-8 · Cited by 9 · see citing works
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Valério, R. S., Generoso, G., Fernandes, J. L., Nasir, K., Hong, J. C., & Bittencourt, M. S. (2022) · Arquivos Brasileiros de Cardiologia · doi:10.36660/abc.20210347 · Cited by 8 · see citing works
“Negro 791 (33) 180 (31) Hispânico 534 (23) 124 (21) Asiáticos 527 (11) 65 (11) Diabetes 472 (20) 0 (0)”
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“5% were considered.(33) In summary, patients with diabetes have a range of CVD risk, and the use of CAC, in addition to the PCE equation, can assist patients and providers in deciding whether long-term statin use is warranted.”
BackgroundSelf-citationDo we have new preventive strategies for optimizing cardiovascular health in women?
Stuenkel, C. A. (2019) · Climacteric · doi:10.1080/13697137.2018.1561665 · Cited by 6 · see citing works
Shabani, M., Pishgar, F., Akhtarkhavari, S., Quinaglia, T., Budoff, M. J., Bluemke, D. A., Barr, R. G., Post, W. S., Wu, C. O., Arbab‐Zadeh, A., et al. (2021) · Frontiers in Endocrinology · doi:10.3389/fendo.2021.785957 · Cited by 6 · see citing works
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Self-citationImaging atherosclerosis for cardiovascular risk prediction- in search of the holy grail!
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“Notably, the use of CACS for CVD risk assessment does not increase downstream medical costs because any increase in further testing among those with high CACS is more than offset by lower resource utilization among those with normal CAC scans.(44,45) CACS can be of particular value among Indians for a variety of”
Ties, D., van Dorp, P., Pundziūtė, G., Lipšic, E., van der Aalst, C. M., Oudkerk, M., de Koning, H. J., Vliegenthart, R., & van der Harst, P. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11112965 · Cited by 6 · see citing works
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Preventative Imaging with Coronary Computed Tomography Angiography
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Aortic Valve Calcifications as a Harbinger of Future Aortic Stenosis
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Self-citationTransatlantic guidelines on dyslipidemia and cardiovascular risk: key differences across the pond
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“Of note, assessment of coronary artery calcium (CAC) on computed tomography in intermediate-risk patients (excluding those with diabetes, current cigarette smoking, or a family history of premature ASCVD) may further aid the decision of whether to initiate statin therapy, as it was shown to improve risk stratification…”
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Abdul‐Rahman, T., Bliss, Z. S. B., Lizano-Jubert, I., Muñoz, M. J. S., Garg, N., Pachchipulusu, V. K., Ashinze, P. T., Miteu, G. D., Baig, R., Omar, D. A., et al. (2024) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2024.102378 · Cited by 3 · see citing works
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“However, previous cost-effectiveness analyses are consistent with the concept that CAC testing represents a reasonable option to risk-stratify as well as facilitate shared decision making without any significant downstream adverse outcomes, loss of quality of life, and/or increased costs [20].”
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Routine CAC-scoring prior to initiation of statin therapy – a European perspective
Mahabadi, A. A., Nasir, K., & Rassaf, T. (2019) · European Journal of Preventive Cardiology · doi:10.1177/2047487319839188 · Cited by 3 · see citing works
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Self-citationCoronary calcium is all we need for risk assessment, yet we do not use it often enough
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Transforming the Cardiovascular Disease Prevention Paradigm
Nasir, K., & Blankstein, R. (2025) · JAMA · doi:10.1001/jama.2025.2323 · Cited by 2 · see citing works
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“29 The single RCT comparing a CAC-based with a risk factor-based strategy consistently showed improved cardiovascular risk factor control without increased downstream resource use by more appropriate resource allocation to at risk patients.”
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Primary Prevention for Intermediate Risk
Greenland, P., & Glynn, P. A. (2024) · JACC Advances · doi:10.1016/j.jacadv.2024.100884 · Cited by 2 · see citing works
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Coronary artery calcium scoring: An adjunct to risk stratification, not a replacement for it
Zheutlin, A. R., & Greenland, P. (2026) · The American Journal of Medicine · doi:10.1016/j.amjmed.2026.03.012 · Cited by 1 · see citing works
Coronary Calcium Score vs. Computed Tomography Angiography as Tools to Stratify Cardiovascular Risk
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Self-citationThe journal of cardiovascular computed tomography: A year in review: 2022
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“Therefore, several studies have suggested the use of CACS to determine individualized therapeutic blood pressure goals [19,36], based on the recent evidence regarding the usefulness of CACS use in diverse clinical situations [21,37].”
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“Previous health economic studies have demonstrated the cost-effectiveness of CAC screening for primary prevention [19–24].”
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Cardiac imaging and circulating biomarkers for primary prevention in the era of precision medicine
Myhre, P. L., Lyngbakken, M. N., Tveit, S. H., Røsjø, H. R., & Omland, T. (2019) · Expert Review of Precision Medicine and Drug Development · doi:10.1080/23808993.2019.1660162 · Cited by 1 · see citing works
Risk scores and primary prevention
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REMOVED: Correlation between COVID-19 and cardiac calcification
Fogante, M., Cavagna, E., & Rinaldi, G. (2022) · Journal of medical imaging and radiation sciences · doi:10.1016/j.jmir.2022.01.002 · Cited by 1 · see citing works
RetractedPrognostic Value of Coronary Artery Calcium
Rezvanizadeh, V., & Budoff, M. J. (2021) · Springer eBooks · doi:10.1007/978-3-030-81515-8_6 · Cited by 1 · see citing works
Equity in Cardiovascular Disease Prevention: A Case for Universal Coverage of Calcium Scoring
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Self-citationThe not so secret power of cardiac CT: Prevention and value
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WITHDRAWN: Position Paper: Chronic coronary syndrome assessment and risk stratification in Portugal
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Score de calcio: la eterna promesa de la prevención cardiovascular
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Coronary Artery Calcium Scanning: Indications and Patient Management
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Self-citation
- Authors
- Hong, J. C., Blankstein, R., Shaw, L. J., Padula, W. V., Arrieta, A., Fialkow, J. A., Blumenthal, R. S., Blaha, M. J., Krumholz, H. M., & Nasir, K.
- Affiliations
- Johns Hopkins University (US)
- Brigham and Women's Hospital (US)
- Emory University (US)
- Florida International University (US)
- Baptist Hospital of Miami (US)
- Yale New Haven Hospital (US)
- Corresponding author
- Nasir, Khurram
- ORCID
- Venue
- JACC: Cardiovascular Imaging
- Publisher
- Elsevier BV
- Published
- 2017-08
- Volume
- 10
- Issue
- 8
- Pages
- 938-952
- ISSN
- 1876-7591 (ISSN-L)
- 1936-878X
- OpenAlex
- W2744830475
- Cited by
- 101
- References
- 58
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 7 · 2023: 8 · 2022: 9 · 2021: 25 · 2020: 13 · 2019: 13 · 2018: 11 · 2017: 2 · 2016: 1
- FWCI
- 2.26
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC. Cardiovascular imaging (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Johns Hopkins University
- Regeneron Pharmaceuticals
- Topics
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Keywords
- coronary artery calcium, statin therapy, cost-effectiveness, atherosclerotic cardiovascular disease, quality-adjusted life years, microsimulation model, shared decision-making, cardiovascular risk stratification
- MeSH terms
- Clinical Decision-Making, Aged, Aged, 80 and over, American Heart Association, Bayes Theorem, Computer Simulation, Coronary Artery Disease, Coronary Vessels, Cost-Benefit Analysis, Decision Support Techniques, Female, Humans, Male, Middle Aged, Monte Carlo Method, Predictive Value of Tests, Quality of Life, Time Factors, United States, Multivariate Analysis, Drug Costs, Treatment Outcome, Coronary Angiography, Practice Guidelines as Topic, Models, Economic, Quality-Adjusted Life Years, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Guideline Adherence, Vascular Calcification
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