In the latest installment of “Cardiovascular Risk Calculators Belong in the Trash Can,” THIS STUDY came out looking at the relationship between various Risk Calculators and coronary plaque (measured by CAC and CCTA). You all are familiar with the “Got Plaque? Get a CAC!” strategy as the “Colonoscopy of the Heart…Without the Nasty Pregame Show” to identify calcified plaque in the coronary arteries, and CCTA is basically a CAC on steroids that further elucidates some of the high-risk plaque features and any degree of vessel obstruction.
So all of the 1,060 folks in this study were in the INTERMEDIATE risk category as determined by the various calculators. This clinically means, “We might do something…or not.” And since many clinicians don’t really like to do anything, this often means you get a limp handshake and a “See you next year!”
Everyone in this study was asymptomatic, and everyone was between the ages of 40 and 70. However, everyone in this study had a STRONG FAMILY HISTORY of heart disease, and we know that a big part of this adventure called Life is “Picking the Right Parents.”
So along with the Pooled Cohort Equations and PREVENT (whose futility I discuss HERE), there were a few other Risk Calculators assessed, which included PREDICT, QRISK3, and AusCVD (since this study was done in Australia). And there was WEAK CORRELATION across the board between any Risk Calculator score and baseline plaque burden (as identified by CAC). Lots of things can kill you in Australia, including snakes, spiders, poisonous marine invertebrates, and crappy Risk Calculators.
41% of the folks in this study had a CAC score between 1 and 400, and 39 people even had a CAC>400, which is “Crikey…That’s bad!” territory.
PREDICT was the “best of the worst” in regards to correlation between risk score and plaque burden, and QRISK3 had the best association with plaque progression at 3-year follow-up. However, none of the risk calculators were associated with total plaque volume after adjusting for factors such as hypertension, diabetes, age, and LDL cholesterol levels. Interestingly, QRISK3 at least includes Family History in its Risk Calculation, which is a critically important piece of information when ascertaining an individual’s overall risk of cardiovascular disease. Of additional note, Lp(a), the “Felon of the Lipid Neighborhood,” was not associated with baseline plaque burden in this particular study, although it is an independent risk factor for cardiovascular disease.
There are a bunch of other interesting elements of this study, and I encourage you to read the entire thing. But what can we take away from this?
-Risk Calculators still suck, even in Australia.
–Picking the Right Parents definitely matters when it comes to cardiovascular disease.
–We can identify disease with our imaging modalities (such as CAC and CCTA) rather than mess around with risk calculators and mere blood-based biomarkers. However, understanding the individual utility of each biomarker allows us to treat with precision and nuance.
The authors of this study summarized the study nicely below, and I applaud them for somehow avoiding the use of the words “garbage” and “trash” in the process:
“These findings suggest that current risk stratification approaches may substantially underestimate cardiovascular risk in individuals with genetic predisposition to CAD, potentially delaying initiation of preventive therapies.”
