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Coronary Artery Calcium Score to Refine the Use of PCSK9i in Asymptomatic Individuals: A Multicohort Study

Miguel Cainzos-Achirica1,2,3, Renato Quispe3, Reed Mszar4

  • 1Division of Cardiovascular Prevention and Wellness, Department of Cardiology Houston Methodist DeBakey Heart and Vascular Center Houston TX.

Journal of the American Heart Association
|August 9, 2022
PubMed

Insights

Coronary artery calcium (CAC) scoring can help decide who needs PCSK9 inhibitors (PCSK9i) for preventing atherosclerotic cardiovascular disease (ASCVD). A CAC score of zero may indicate less need for PCSK9i in certain patient groups.

Area of Science:

  • Cardiology
  • Preventive Medicine
  • Medical Imaging

Background:

  • The utility of coronary artery calcium (CAC) in guiding proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) therapy is unclear for individuals without established atherosclerotic cardiovascular disease (ASCVD) and without familial hypercholesterolemia.
  • PCSK9i are potent lipid-lowering agents, but their optimal allocation in primary prevention requires refined risk stratification beyond traditional risk factors.

Purpose of the Study:

  • To evaluate the effectiveness of CAC scoring in stratifying ASCVD risk within three distinct PCSK9i eligibility frameworks not requiring familial hypercholesterolemia.
  • To determine if CAC can refine PCSK9i allocation strategies in primary prevention of ASCVD.

Main Methods:

  • Analysis of participants without clinically evident ASCVD from four large cohort studies (MESA, CARDIA, DHS, HNR).
  • Defined three PCSK9i eligibility scenarios: broad (high LDL-C), restrictive (high LDL-C + 2 risk factors), and high-risk (subclinical organ damage or high estimated risk).
  • Assessed CAC=0 prevalence and its association with 5- and 10-year ASCVD event rates across scenarios, adjusting for traditional risk factors.

Main Results:

  • The high-risk scenario exhibited the highest 10-year ASCVD event rate (27.8%).
  • CAC=0 was present in 35% (broad), 25% (restrictive), and 16% (high-risk) of participants.
  • CAC=0 was consistently associated with the lowest ASCVD incidence, and CAC burden independently predicted events, irrespective of the scenario.

Conclusions:

  • Coronary artery calcium scoring can refine PCSK9i allocation, potentially supporting more conservative prescribing in individuals with CAC=0.
  • CAC testing holds greater value in eligibility scenarios based on LDL-C and traditional risk factors, where CAC=0 is more prevalent.
  • The utility of CAC is less pronounced when PCSK9i eligibility is determined by non-coronary subclinical organ damage.

Keywords:
PCSK9iatherosclerosiscardiovascular diseasecoronary artery calciumprimary preventionrisk

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