Even Minimal Coronary Calcium ‘Not Benign’ in Young Patients With Chest Pain

Any coronary calcium, no matter how little, found in young patients presenting with chest pain is meaningful in terms of risk prediction and should be addressed, according to Danish research.

Clinicians tend to view a low coronary artery calcium (CAC) score favorably regardless of patient age, but the new data support the notion that in patients under 45 years old, “it's not a benign finding,” lead author Martin Bødtker Mortensen, MD, PhD (Aarhus University Hospital, Denmark), told TCTMD. “When you evaluate calcium in young individuals, you need to understand that you should use a completely different threshold than you do in the middle-age individuals and you will be able to use calcium scores to identify those who are at high cardiovascular risk.”

Specifically, he explained, in middle-aged patients, “we have traditional calcium thresholds of 100 or 300, but we know that in young individuals we very rarely see such high calcium scores.”

When you evaluate calcium in young individuals, you need to understand that you should use a completely different threshold than you do in the middle-age individuals. Martin Bødtker Mortensen

Practice differs internationally, but in the United States, younger patients don’t tend to be sent for CAC scans as readily as their older counterparts. In this study, published online today as a research letter in the Journal of the American College of Cardiology, Mortensen and colleagues evaluated 3,691 symptomatic patients aged 18-45 years (median 42 years) who were sent for CAC scans in Denmark, where this practice is standard of care based on the European guidelines.

Most patients (86.1%) had a CAC of 0, while scores ranged from 1-10 in 5.0%, 11-50 in 4.4%, 51-100 in 1.9%, and over 100 in 2.6%. Over a median 4.1 years of follow-up, the risk of coronary heart disease events increased with CAC. Among patients with no calcium, the event rate per 1,000 person-years was 2.0, increasing to 11.4 with CAC 10-51 and 29.5 with CAC over 100.

After adjustment for age and sex, compared with patients who had no calcium the risk of events was increasingly higher for patients with CAC 1-10 (HR 2.1; 95% CI 0.7-6.0), CAC 11-50 (HR 4.9; 95% CI 2.2-10.9), CAC 51-100 (HR 4.3; 95% CI 1.3-14.3), and CAC >100 (HR 12.0; 95% CI 5.8-24.9).

Any Calcium Warrants Evaluation

“Clinically, I see a lot of patients that for whatever reason end up having calcium scans and present for evaluation,” said Amit Khera, MD (UT Southwestern Medical Center, Dallas, TX), who commented on the study for TCTMD. “There are many patients who have a very low score, and others may blow that off as 'you’re fine.' That might be the case in older individuals—a low score is reassuring—but any score in a young individual is meaningful. To me, that’s the most important reinforcing take-home point.”

Khera said he likes to view the relationship between calcium and risk on a percentile basis. “If you're 40 and you have a score of 1, you're nearing the 90th percentile,” he said. “For heart disease, you don’t want to be in the high percentile over your lifetime. People look at that absolute score, saying it's only a 1 or 2 or 5, it's not that bad. Maybe, but it’s the trajectory and as we think about longer-term risk, that trajectory is something that should raise some concern.”

It’s the trajectory and as we think about longer-term risk, that trajectory is something that should raise some concern. Amit Khera

If a clinician sees a younger patient with any calcium, Mortensen advises treatment with a moderate-intensity statin and lifestyle modification. “And then, of course, I would go look for other potentially modifiable risk factors including smoking and hypertension,” he continued. “But we also know that smoking is a really important risk factor for developing atherosclerotic cardiovascular disease events in young age.” So for people who are smokers on top of having coronary calcium, said Mortenson, “I would really push for smoking cessation in that patient.”

The benefit of identifying high-risk patients early through CAC scans “is you can really make an impact and bend the curve the most,” Khera said. “The flipside is these are people who will be on treatment for decades. So [when] helping refine and calibrate to their risks short- and long-term, that's where in young people these concepts come in about long-term risk but also long-term need to take medicines. [It’s important] really try to find the best patients for those discussions.”

What to do about a CAC finding in a younger patient remains an open question. “That is the nuance, that is shared decision-making,” he continued. “People need to be more aggressive about exercise and diet, and it might be a wake-up call for them about being more aggressive about those things. If their cholesterol is borderline, it’s a shared decision-making conversation about whether or not medicine is necessary if it was already on the fence. But the main point is you shouldn’t be reassured because the score is low. You have to contextualize it—this is a young patient, and that is a very high percentile and portends poorly over the long term.”