CAC Score Guided Primary Prevention Reduces Plaque Progression Among Patients With Familial CAD: JAMA

The researchers revealed that in intermediate-risk patients with a family history of CAD, integrating CAC scoring with a primary prevention strategy was linked to lower atherogenic lipid levels and reduced plaque progression compared to standard care. These findings, published in JAMA, highlight the value of CAC scoring in guiding intensive preventive approaches for this patient group.

The researchers note that coronary artery calcium scoring is crucial in predicting cardiovascular risk, particularly in individuals at intermediate risk for coronary artery disease. Despite its prognostic value, the potential benefits of integrating CAC scoring with a primary prevention strategy had not been evaluated in a randomized trial. To address this gap, Nitesh Nerlekar, Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia, and colleagues aimed to determine whether incorporating CAC scores into a preventive approach could help slow plaque progression in intermediate-risk patients with a family history of premature CAD.

For this purpose, the researchers conducted a prospective, randomized clinical trial across seven hospitals in Australia between 2013 and 2020, with follow-up until June 5, 2021. They recruited asymptomatic individuals aged 40 to 70 years who had a family history of CAD, defined as onset before 60 years in a first-degree relative or before 50 years in a second-degree relative. Intermediate-risk participants underwent CAC scoring, and those with scores between 1 and 399 underwent coronary computed tomography angiography (CCTA). They were then randomized to CAC score–guided prevention or usual care. Follow-up CCTA at three years assessed plaque progression.

The following were the key findings of the study:

• The study included 365 participants with a mean age of 58 years, of whom 57.5% were male.
• There were 179 participants in the CAC score–informed group and 186 in the usual care group.
• At three years, the CAC score–informed group had a greater reduction in total cholesterol (−56 mg/dL vs −3 mg/dL) and LDL cholesterol (−51 mg/dL vs −2 mg/dL) compared to usual care.
• This reduction was associated with a lower pooled cohort equation risk calculation (0.5% vs 2.1).
• Plaque progression was significantly lower in the CAC score–an informed group for total plaque volume (15.4 mm³ versus 24.9 mm³), noncalcified plaque volume (5.6 mm³ versus 15.7 mm³), and fibrofatty and necrotic core plaque volume (−0.8 mm³ versus 4.5 mm³).
• These differences were independent of other risk factors such as baseline plaque volume, blood pressure, and lipid profile.

The researchers found that using CAC scoring to guide preventive strategies in intermediate-risk patients with a family history of CAD was associated with slower plaque progression and improved lipid control compared to usual care. A CAC score–informed approach, including lifestyle interventions and moderate-intensity statin therapy, led to sustained reductions in LDL-C levels and cardiovascular risk estimation scores.

"These findings highlight the potential of CAC scoring in refining risk assessment and guiding intensive prevention strategies, suggesting its valuable role in improving long-term cardiovascular outcomes for intermediate-risk individuals," they concluded.

Reference:

Nerlekar N, Vasanthakumar SA, Whitmore K, et al. Effects of Combining Coronary Calcium Score With Treatment on Plaque Progression in Familial Coronary Artery Disease: A Randomized Clinical Trial. JAMA. Published online March 05, 2025. doi:10.1001/jama.2025.0584