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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Effect of No-Charge Coronary Artery Calcium Scoring on Cardiovascular Prevention
Sadeer Al-Kindi1, Nour Tashtish2, Imran Rashid1
1Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio; School of Medicine, Case Western Reserve University, Cleveland, Ohio.
Insights
Removing cost barriers for coronary artery calcium (CAC) scans significantly increased test use. This led to better risk assessment, increased statin use, and improved cardiometabolic health, ultimately benefiting cardiovascular disease prevention.
Area of Science:
- Cardiology
- Preventive Medicine
- Health Economics
Background:
- Current cardiovascular disease prevention relies on probabilistic risk scores, which can misclassify risk and lead to over-treatment.
- Coronary artery calcium (CAC) scoring is underutilized in intermediate-risk patients due to reimbursement barriers.
- The real-world impact of removing cost barriers for CAC testing on cardiovascular outcomes is unknown.
Purpose of the Study:
- To evaluate the impact of reducing and eliminating the cost of CAC testing on its utilization and subsequent cardiovascular outcomes.
- To assess how removing cost barriers affects patient risk reclassification, statin eligibility, and cardiometabolic health parameters.
- To analyze downstream cardiovascular testing and revascularization rates following CAC testing.
Main Methods:
- A retrospective analysis of 52,151 patients undergoing CAC testing between 2014 and 2018 at University Hospitals Health System.
- CAC was offered at a low charge ($99) from 2014-2017 and at no charge from January 2018 onward.
- Evaluation of CAC use, patient characteristics, risk reclassification vs. pooled cohort equations (PCEs), statin use, cardiometabolic parameters, and downstream procedures.
Main Results:
- CAC testing uptake increased significantly when the cost was removed or reduced.
- CAC testing reclassified risk for many patients, with discrepancies noted compared to PCEs (e.g., 21% of high PCE patients had low CAC, 37% of low PCE patients had high CAC).
- Statin prescription increased by 24% in the year following CAC testing, associated with higher CAC scores. Significant improvements in total cholesterol, LDL, and triglycerides were observed, linked to CAC scores. Revascularization was predominantly in patients with CAC > 400.
Conclusions:
- Reducing or eliminating the cost of CAC testing drives significant patient uptake.
- This leads to improved cardiovascular risk assessment, increased preventive medication use (statins), and better cardiometabolic health.
- The findings support the broader implementation of CAC scoring by removing financial barriers to improve cardiovascular disease prevention strategies.
Abstract:
Prevention of cardiovascular disease is currently guided by probabilistic risk scores that may misclassify individual risk and commit many middle-aged patients to prolonged pharmacotherapy. The coronary artery calcium (CAC) score, although endorsed for intermediate-risk patients, is not widely adopted because of barriers in reimbursement. The impact of removing cost barrier on cardiovascular outcomes in real-world settings is not known. Within the University Hospitals Health System (Cleveland, Ohio), CAC was offered to patients with at least 1 cardiovascular risk factor at low charge between 2014 and 2017 ($99) and no charge from January 1, 2018 onward. CAC use and access, patient characteristics, reclassification of risk compared with the pooled cohort equations (PCEs) for atherosclerotic vascular disease, statin use, changes in parameters of cardiometabolic health, downstream cardiovascular testing, downstream coronary revascularization, and cardiovascular outcomes were evaluated. A total of 52,151 patients underwent CAC testing over the study period. Median 10-year PCE for atherosclerotic vascular disease, in the entire cohort was 8.3% (4.0% to 15.9%). Among patients with PCE >20%, 21% had CAC <100, whereas 37% of those with PCE <7.5% had CAC ≥100. Among patients who were not on statin before CAC testing, 1-year statin prescription was 24% and was significantly associated with higher CAC scores. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides all decreased significantly 1-year after CAC, and the degree of decrease was strongly linked with CAC scores. One year after CAC, 14% underwent noninvasive ischemic evaluation, 1.4% underwent invasive coronary angiography, and 0.9% underwent revascularization. The majority (74%) of revascularization procedures occurred in patients with CAC >400. In conclusion, reducing or removing the cost burden of CAC leads to significant test uptake by patients, which is followed by reclassification of statin eligibility, increases in the use of preventive medications, and improvement in risk factors, with very low rates of invasive downstream testing.
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