Khurram Nasir Profile picture
Aug 14, 2021 11 tweets 9 min read Read on X
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

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More from @khurramn1

Dec 9, 2021
@TheBhupiThakur @jaideeppatelmd @MichaelJBlaha hi @TheBhupiThakur

For LDL>190 mg/dl
In MESA nearly 35% have #PowerOfZero
13 yr FU, event rate 3.5% (well below threshold for statin consideration)

atherosclerosis-journal.com/article/S0021-…
@TheBhupiThakur @jaideeppatelmd @MichaelJBlaha #2
For genetically confirmed #familialhypercholesteremia

See below, clearly not a homogenous disease, many shades of atherosclerotic disease

Events track with CAC score

With CAC zero, can possibly avoid PCSK9i (statins for all)
@rauldsf_santos @miguelcainzos23 @reed_mszar
@TheBhupiThakur @jaideeppatelmd @MichaelJBlaha @rauldsf_santos @miguelcainzos23 @reed_mszar #3 Across spectrum of Lipid disorders

Clear doesn't matter how you slice or dice the pie, the risk is related to atherosclerotic disease burden across the spectrum of lipid disorders
Read 7 tweets
Jul 23, 2021
#1

While as preventive cardiologist we all organize information from imaging and biomarkers in a debate with my dear friend @CBallantyneMD , asked tough Q what would I choose if I had one option?

The answer is clear and maybe not debatable anymore

@ASPCardio @Heart_SCCT
# 2 What ur risk? remains the foundational strategy in preventive cardiology and in this pursuit we continue to rely on risk factors and a growing list of biomarkers

@ASPCardio @CBallantyneMD @DrMarthaGulati
# 3
And the goal is worthy as the ACCURATE identifying those at higher but also at low risk is critical for treating the right patient at the right time with the right intervention, societal resource allocation and informed patient choices
Read 14 tweets
Aug 6, 2020
#COVID19 recovery?

My thoughts below

For most of us on the frontline including myself, the 100% focus in the last 4 months, rightly so, been on beating the initial sickness

Unaware it may be just the first of many battles

Sometimes we all need perspective (definitely I did)
#2
For me, As a physician, it was my collogues, including Dr Wu a surgeon one of the first doctors falling sick all across in US

learning from their personal experience as a patient….

getting insights on their anxieties, isolation and struggles was an eye opening experience
#3
Social media is full of stories with such struggles

As a population health scentist I always viewed these scattered reports with skepticism…

trained not to place to much emphasis on ancedotes…
Read 21 tweets
Jul 25, 2020
Debate CAC vs CTA in primary prevention?
I will start with a provocative statement
Screening, foundational strategy for decades in prev cardio is a seductive paradigm
Its so 1990’s
We are barking on the wrong tree
In 2020, I will explain why this strategy is a fallacy
#ASPC2020
#1 Both primary and secondary prevention lower disease burden and outcomes
#2 Marginal benefit of extensive screening
#3 Whats left to screen? Majority already treatment candidates
#4 Our stakeholders asking for "derisking" vs "screening"

#APSC2020
-Despite being being an avid advocate of CAC screening in past, it was time to move on
-Showed 1 in 2 statin candidates have #PowerOfZero
-Proposed CAC as SDM tool
-Concept confirmed in 3 other cohorts, better than any neg marker, cost-effective, and no statin treatment benefit
Read 8 tweets
Jul 17, 2020
Humbly honored for this recognition today

Thank you, @Heart_SCCT and especially my friends @RonBlankstein @Agatston_Center presenting it, made it more special

Truly proud to be among the pantheon of cardiology giants who were previously recognized.
In reality honor for #PowerOfZero is really a tribute to the man with Midas touch

Privilege to work & learn so closely, this relationship blossoming not only with him but entire family

@Agatston_Center is national treasure & even today remains a source of inspiration for me🙏
Early on I was lucky to run across 3 mentors @Agatston_Center @hmkyale @rblument1 who took immense interest in our mission

I then hit #jackpot with collaboration of most dynami, smartest individuals

#PowerOfFriendship of this group been the biggest gift from this journey
Read 9 tweets
Apr 28, 2020
#1 Many raised concerns reg racial disparities in face of recent COVID-19 pandemic
@eff_ve leading efforts @HMethodistMD to systematically examine inequalities reg susceptibility to SARS-CoV-2 infection in nation’s most diverse metropolitan area: Houston
medrxiv.org/content/10.110…
#2 @eff_ve building a novel data platform form to automatize ingestion, organization & analytics serving @HMethodistMD entire research community data needs via COVID-19 Surveillance and Outcomes Registry (CURATOR)

Operational details of this registry/platform coming soon.
#3 @eff_ve showed high probability of testing positive

-African American vs White; OR:1.84, 95% 1.49–2.27
-Hispanic vs non-Hispanic; OR, 1.70, 95% CI 1.35–2.14

explored 3 mechanism of disparities: SES, residence in higher population dense areas, & higher level of comorbidities
Read 6 tweets

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