Thread by @khurramn1

While there is so much established about CAC..

for @Heart_SCCT Prevention Symposium, I was asked by @RonBlankstein to talk about

"what's next for CAC Testing in 2021 (and beyond)?"

What are the main applications in the future?

@miguelcainzos23 @jaideeppatelmd

#1 CAC has come a long way
-evolving to the needs of the past decade from screening test to a SDM tool
-best tie breaker, adding the dimension of de-risking
-cost-effective and reassuring ok to avoid treatment
-cautiously approved by ACC/AHA guidelines
@Heart_SCCT

#2
Looking forward, beyond established role as decision tool for statins and possibly ASA
we need to think beyond what the future may hold for CAC testing.

While I have a list of at least 10 applications, I will share today the top 5 immediate future roles for CAC testing

#3 First, If uncertain of risk, guidelines suggest start with risk enhancing factor vs CAC
Evidence for this rec? None
Now @jaideeppatelmd show even with multiple REF, CAC zero in 40%->reclassified risk low below statin threshold
CAC superior to REF
Next time #StartWithCACFirst

#4
Second, CAC not recommended for risk stratification among DM
Why? Not clear

But now evidence suggest not all DM equal
-#PowerOfZero means flexible treatment
-#HighCACCVDEquivalent secondary prevention measures should be applied to them.

#5 Similarly with LDL>190 or FH, guidelines don't recommend CAC
Both groups are not homogenous
#PowerOfZero reassuring (possible no PCSK9i)
CAC>100 very high risk->most aggressive management
CAC passes another test->societal resource allocation and informed choices

# 6 Third, With growing options addressing residual risk beyond statins reserved for CVD pt @miguelcainzos23 and I believe CAC testing most efficient and cost tool for future value based RCT design scaling in primary prevention
targeted approach->better likelihood of adoption

#7, Fourth To-date focus of CAC testing has been among non young

Now with 3 major studies showing a focused approach targeted almost 25-35% young have CAC & increased risk

In this regard, we feel, Age is just a number and it’s time to lower the bar for CAC testing

#8, Fifth With undeniable evidence, I sincerely hope upcoming chest pain guidelines will upgrade the role of #PowerOfZero as gatekeeper by listening to Wayne Gretzky—probably greatest hockey player of all time—“I skate to where the puck is going to be, notwhere it has been.”

Future?

#StartWithCACFirst if uncertain of risk for statins
#NotAllHighRiskSame Strong CAC role in DM, LDL>190 & #HEFH
#DoubleEnrichment targeted values based clinical trials
#AgeIsJustaNumber Screen high risk young individuals
#CACgatekeeperLowRiskChestPain Cant want more