Coronary Artery Calcium-Based Approach to Lipid Management

Purpose of Review: We review the clinical utility and incorporation of coronary artery calcium (CAC) in traditional cardiovascular risk assessments to guide lipid management, specifically in the appropriate allocation of lipid-lowering therapies. We intentionally exclude discussion of non-pharmacologic lifestyle interventions, statin safety and its associated side effects, radiation safety, and the value of care with the use of CAC, as well as other nuances in lipid management that are beyond the scope of this review. Recent Findings: CAC-based cardiovascular risk assessment and statin allocation are endorsed by clinical practice guidelines. New research supports the additional value of CAC in guiding intensification, allocation, and re-allocation of statin and non-statin lipid-lowering therapies, such as PCSK9 inhibitors and icosapent ethyl. Further, emerging evidence demonstrates the potential impact of CAC for further risk stratification when abnormal levels of non-traditional components of the lipid profile such as apolipoprotein B and lipoprotein(a) are identified. Summary: CAC scoring has value for the management of lipid-lowering therapies, as it can aid shared decision-making regarding escalation or de-escalation of statin and non-statin therapies. With a CAC-based approach to lipid management, clinicians can personalize therapy to each particular patient, delivering intensive care to high-risk individuals who would benefit most while deferring treatment in low-risk patients who derive less benefit.