Sometimes as parents, we try to progressively give our kids a little bit of autonomy. You might “let your kids make a decision” knowing that, despite their underdeveloped cortex, there’s NO WAY they can miss this layup…and they still find a way to select an inexplicably asinine option that wasn’t even on the list of available choices. So you end up “making the choice for them” after all…maybe we’ll let them try again in a few years.
And although Cardiovascular Risk Calculators are even worse than our kids most of the time, clinicians might be tempted to “let the Calculator decide what to do” when the Pooled Cohort Equation puts patients in the “High Risk Category” of having a >20% risk of coronary events over the next decade. I mean, you have to be pretty sick, pretty old, or both to be placed in that undignified bucket, and Guidelines have historically said that “whatever the Calculator said is good enough…don’t bother doing anything else.”
But what if Dad recommends getting a CAC anyway? As usual, he knows best, as THIS NEW ANALYSIS from the MESA BioBank suggests. It appears that even people in the >20% Risk Category by the 10 Year-Risk Calculators can be better stratified when incorporating CAC scores.
Nearly a quarter of these High Risk folks had a CAC of zero…and this group had a 73% lower risk of cardiovascular events than their High Risk counterparts with CAC>0 when followed over 10 years. The CAC Zero Group (kinda like Coke Zero…less metabolically damaging than Regular Coke) only experienced 3.52 events per 1,000 patient years (that’s pretty low) vs 13.46 in the CAC>0 Group. Put another way, there were only 11 total major adverse cardiovascular events in 10 years for the CAC zero group…and 137 in the CAC>0 group…yikes! Father CAC was right again!
Now you might be thinking, “Well, I bet these high-risk people who didn’t have cardiovascular events were already on lipid-lowering therapy.” Most of them weren’t! And the results remained identical even when those on cholesterol medications were excluded.
And you also might be thinking, “This study used the “Old Risk Calculator…we use the shiny new PREVENT Risk Calculator.” The researchers swapped in the PREVENT Risk Calculator for the analysis, and the CAC Zero group still had a 75% lower risk. The authors graciously referred to this as “Risk Calculator Miscalibration,” and I commend them for avoiding the use of the term “garbage” in lieu of more dignified euphemisms. I think Jimothy the Raccoon ought to be the new PREVENT mascot…it’s new and trendy, but it still spends a lot of time in the trash (or at least it should).
As always, understand the individual utility of each biomarker or diagnostic test to make the best individualized decision for the patient in front of you. But if you’re letting your kids, neckless raccoons, or Risk Calculators dictate your decisions, especially when it comes to risk of Cardiovascular Events, you may want to re-think that for the time being😊
