Coronary Artery Calcification

Overview

Cardiovascular disease is a leading cause of death.  Early detection and management of cardiovascular disease, including coronary artery disease, can modify future cardiovascular risk. 

Coronary artery calcification (CAC) is associated with an increased risk of cardiovascular events and its presence is increasingly being reported as an incidental finding on computerised tomography (CT) scans, as recommended by The British Society of Cardiovascular Imaging and British Society of Cardiovascular CT. 

NICE guidance (NG238) (1) recommends cardiovascular risk assessment of all patients with coronary artery calcification using QRISK 3.

Targeted Lung Health Check (TLHC) program

The Targeted Lung Health Check (TLHC) program  is being rolled out across BNSSG. As a result of the scans done as part of this program there may be incidental findings including coronary artery calcification. 

These incidental findings are currently being passed to GPs to further assess and investigate. Patients will be informed about their incidental findings and advised to contact their GP for further advice.

The incidental finding of coronary calcification on a low dose CT performed has caused concern among some PCNs due to the uncertainty around optimal management of these patients. Part of the challenge is that these are new findings as a result of innovative preventative care, and we don’t yet know what the best management is. The National Cancer and Cardiovascular teams are working on a pathway for GPs which we will circulate as soon as is available (2). 

Until then, GPs should use the guidelines on this page to guide management.

Who to Refer

Most patients with a finding of CAC do not require referral to cardiology. Please see below for advice on which few patients may need to be referred and how most patients can be managed in primary care:

Symptomatic patients

See NICE CG95: Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (3)

• Patients with acute or unstable chest pain (suspected acute coronary syndrome [ACS]) should be referred urgently for hospital assessment - see red flag section below.
• Patients with recent onset chest pain of suspected cardiac origin but no immediate indication for hospital assessment (3): see the Rapid Access Chest Pain Clinics page for further advice.
• Patients with non-cardiac chest pain: consider other diagnoses or request Cardiology Advice & Guidance if uncertain about need for cardiac investigation.

Asymptomatic patients

Asymptomatic patients should NOT be referred but should have modifiable cardiovascular risk factors addressed.  NICE guidance (NG238) (1) recommends cardiovascular risk assessment of all patients with coronary artery calcification using QRISK 3. Primary prevention should be considered based on QRISK score.

Red Flags

Patients with acute or unstable chest pain should be assessed promptly and referred urgently for hospital assessment if ACS is suspected. See Angina page and red flags.

What to do before referral

All patients (symptomatic and asymptomatic) should have the following management in primary care:

Provide lifestyle advice as follows:

• Smoking cessation.
• Weight loss if overweight or obese.
• Eating a healthy diet.
• Keeping alcohol consumption within recommended limits.
• Being physically active.

Investigations

• BP
• Bloods including HbA1C, lipids, UE.

Assess cardiac risk and offer statins if appropriate

• See Primary Prevention guidelines on the Hyperlipidaemia page.

Assess blood pressure and treat hypertension

• See the Hypertension page.

Test for diabetes and optimise treatment

• See theDiabetes Mellitus - Guidelines page.

Advice and Guidance

If specific advice is required regarding findings or managment in primary care please consider Cardiology Advice & Guidance.

Referral

Symptomatic patients

Patients with symptoms suggestive of angina/ chest pain of suspected cardiac origin should be referred to one of the Rapid Access Chest Pain Clinics.

Please send an ECG with the Rapid Access Chest Pain Clinical referral if it has already been done, but do not delay referral awaiting result.

Patients should be advised that they will be contacted by telephone or post and should book their appointment as soon as possible. Please ensure up to date contact details are given on the referral.

Contact details for urgent additional queries

• BHI - contact on call cardiology registrar via switch.
• Weston - please contact the Cardiology Department on 01934 647030 or email: wnt-tr.racpcweston@nhs.net
• NBT - contact on call cardiology registrar via switch.

Resources

References

(1) Cardiovascular disease: risk assessment and reduction, including lipid modification | NICE

(2) TLHC and coronary artery calcification (CAC)

(3) Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis | Guidance | NICE

Other Resources

• Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE
• Hypertension in adults: diagnosis and management | Guidance | NICE
• Type 2 diabetes in adults: management | Guidance | NICE
• 2020 Reporting incidental cardiac calcification on non-gated thoracic CT - British Society of Cardiovascular Imaging and British Society of Cardiovascular CT (bsci.org.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.