Does coronary artery calcium screening help cardiovascular risk stratification in asymptomatic young patients with diabetes mellitus? A knowledge gap

This editorial refers to ‘Impact of coronary artery calcium on mortality and cardiovascular events in metabolic syndrome and diabetes among younger adults’, by S. Masrouri et al., https://doi.org/10.1093/eurjpc/zwae039.

Ignoranti quem portum petat nullus suus ventus est Seneca, Epistolae LXXI

Coronary artery calcium (CAC), quantitatively assessed by the Agatston score, is considered to be a direct marker of atherosclerosis. In fact, the evidence and the burden of CAC predict future events independently of concomitant cardiovascular (CV) risk factors.¹ In this regard, CAC scoring may re-classify CV disease risk upward and downward in patients with calculated borderline clinical risks.^2,3 However, it actually shows one side of the atherosclerotic degeneration of coronary artery walls, which is the calcified part, while we have known for a while that the non-calcified part is extremely relevant in terms of CV risk and potential for personalized imaging-guided optimal medical treatment. Furthermore, some have argued that CAC is too late in identifying residual risk.¹ Innovative cardiac tomography (CT) methods enabling the evaluation of coronary artery plaque inflammation through perivascular fat imaging may potentially advance the detection of ‘residual risk’ overlooked by traditional plaque or ischaemia imaging techniques.¹

In this original research, Masrouri et al. examined the association between CAC with coronary and CV events as well as all-cause death among individuals with diabetes mellitus (DM), metabolic syndrome without DM, and those with neither condition. Pooled data were obtained from 5174 subjects aged 38–55 years (mean age 47.3 ± 4.2 years; 44.7% men) who underwent computed tomography—CAC assessment, with a median 14.2-year follow-up. Key results indicated that the presence and severity of CAC were independently associated with CV events and death over nearly 15 years after screening, across all metabolic groups but, interestingly, less evident in the presence of DM. Thus, according to current guidelines, insufficient robust evidence still exists supporting CAC assessment to re-classify CV risk in asymptomatic individuals with DM.^3,4

In this regard, precision medicine offers a promising approach to optimize risk prediction by integrating multidimensional data (i.e. genetic, clinical, and sociodemographic), accounting for individual differences⁵ (Figure 1). The use of complex data to depict the individual’s health status, predisposition, prognosis, and treatment response may allow to identify patients at higher and lower CV risk, tailoring the medical management and follow-up.

Figure 1

Precision medicine in cardiovascular disease prevention (created with BioRender.com).

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The promotion of CV prevention and the use of precision medicine in particular clinical settings, such as DM, may have a pivotal role in decreasing the global burden of CV disease, taking into account the sustainability of related actions.⁶ However, the final diagnostic–therapeutic decision remains left to the experienced clinical judgement of the caring physician navigating in the uncertain Scilla and Cariddi sea.

References

Author notes