ABC | Volume 112, Nº1, January 2019

Editorial Bittencourt et al Coronary artery calcium Arq Bras Cardiol. 2019; 112(1):1-2 1. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. The Expert Panel. Archives of internal medicine. 1988;148(1):36-69. 2. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA : the journal of the American Medical Association. 1993;269(23):3015-23. 3. Grundy SM, Cleeman JI, Merz CN, Brewer HB, Jr., Clark LT, HunninghakeDB, etal.ImplicationsofrecentclinicaltrialsfortheNationalCholesterolEducation ProgramAdultTreatmentPanelIIIguidelines.Circulation.2004;110(2):227-39. 4. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S1-45. 5. Pencina MJ, Navar-Boggan AM, D’Agostino RB, Williams K, Neely B, Sniderman AD, et al. Application of New Cholesterol Guidelines to a Population-Based Sample. New Engl J Med. 2014;370(15):1422-31. 6. DeFilippis AP, Young R, Blaha MJ. Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort. Ann Intern Med. 2015;163(1):68-9. 7. Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. [V Brazilian Guidelines on Dyslipidemias and Prevention of Atherosclerosis]. Arquivos brasileiros de cardiologia. 2013; 101(4 Suppl 1):1-20. 8. Nasir K, Bittencourt MS, Blaha MJ, Blankstein R, Agatson AS, Rivera JJ, et al. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). Journal of the American College of Cardiology. 2015;66(15):1657-68. 9. Hong JC, Blankstein R, Shaw LJ, Padula WV, Arrieta A, Fialkow JA, et al. Implications of Coronary Artery Calcium Testing for Treatment Decisions Among Statin Candidates According to the ACC/AHA Cholesterol ManagementGuidelines:ACost-EffectivenessAnalysis.JACCCardiovascular imaging. 2017;10(8):938-52. References This is an open-access article distributed under the terms of the Creative Commons Attribution License non‑pharmacological treatment strategies. Particularly for those individuals at intermediate, and maybe borderline, risk one may expect considerable uncertainty in the need for therapy for many individuals. For this group of patients, the guidelines recommend considering additional risk factors as potential tools to favor pharmacological treatment. For the use of CAC, a completely new approach has been proposed. Instead of a tool used only to selected higher risk individuals in whom treatment should be more aggressive, CAC is now proposed as a two-way tool (can move individuals both up and down the risk spectrum) for individuals in who treatment might be considered. On the one hand, if CAC = 0, pharmacologic treatment can be withheld or delayed for most individuals, whereas CAC > 0 favors treatment, particularly if > 100 units, > 75 th percentile or if > 0 in individuals younger than 55 years old. This unique ability of CAC to “derisk” individuals of intermediate risk is not trivial. In this group approximately, half of the population has a CAC = 0 and could be withheld for treatment for a considerable follow up. 8 Based on these new recommendations, a considerable reduction in the need for treatment can be anticipated in CAC is implemented as recommended. Interestingly, some data suggests that this approach can be cost effective from a societal perspective. 9 Still, some gaps in knowledge still remain for the widespread use of this strategy. First, the guidelines highlight that this approach might not be recommended in diabetics, smokers and individuals with a history of premature cardiovascular disease, though this is largely based on the limited data available for those subgroups rather than on evidence of harm. Second, this approach is not supported by randomized clinical trial, though trials in this area have been proposed. While some have also cautioned on the use of radiation, the current exposure from a CAC scan (0.89 mSv), less than one third of the annual background radiation exposure. Finally, a major gap in the widespread use of CAC both in the US and in Brazil is the current lack of reimbursement by most health care providers or the public system in Brazil. Despite those areas in need of further study and challenges in implementation, the new approach towards individualized risk assessment and shared decision making with the optional inclusion of CAC as part of the decision-making toolkit is a huge step toward a more precise treatment targeted at the individual’s preferences. 2