Selective use of coronary calcification measurements in an expanded intermediate risk group

Risk assessment is an imperative initial step in the clinical management of cardiovascular risk factors. On the basis of the estimation of the 10-year absolute risk of manifesting coronary heart disease (myocardial infarction or coronary heart disease death), risk categories are conventionally divided into low, intermediate, and high. The most widely used quantitative risk assessment algorithm, the Framingham risk score for hard events, is based on traditional risk factors, but it does not fully account for all available cardiovascular risk factors. Current national guidelines defining coronary heart disease risk categories based on the Framingham risk score may inaccurately assign persons with a high burden of subclinical coronary atherosclerosis to a low-risk group (<10% risk), failing to predict the true risk of a cardiovascular event. Coronary artery calcification as a measure of subclinical atherosclerosis has already established itself as a useful adjunct for refining the broad intermediate risk category of adults, leading to more decisive management strategies. In a point-counterpoint format this article argues for the improved accuracy of coronary calcium scoring in predicting the risk of future cardiac events in persons with a low Framingham risk score (including women and different ethnic groups). To better incorporate recent scientific findings into cardiovascular assessment and to refine stratification in those with a low Framingham risk score, we therefore propose a timely algorithm supporting coronary calcium screening in a selected group of low-risk persons.