Cardiovascular Risk Heterogeneity in Adults with Diabetes: Selective Use of Coronary Artery Calcium in Statin Use Decision-making

  • Sudipa SarkarEmail author
  • Olusola A. Orimoloye
  • Caitlin M. Nass
  • Roger S. Blumenthal
  • Seth S. Martin


Current American College of Cardiology/American Heart Association and American Diabetes Association guidelines recommend statin therapy for all patients with diabetes between the ages of 40 and 75, including those without cardiovascular disease (CVD). While diabetes is a major CVD risk factor, not all patients with diabetes have an equal risk of CVD. Thus, a more risk-based approach warrants consideration when recommending statin therapy for the primary prevention of CVD. Coronary artery calcium (CAC) is a noninvasive imaging modality that can help risk stratify patients with diabetes for future CVD events. CAC has been extensively studied in large cohorts such as the Multi-Ethnic Study of Atherosclerosis and found to outperform other novel risk stratification tools including carotid intima-media thickness. Moreover, a CAC score of 0 has been shown to be useful in downgrading the estimated risk of a CVD event in patients with diabetes and an intermediate Pooled Cohort Equation score. As clinicians weigh the recommendation for a lifelong therapy and the problem of statin nonadherence and patients weigh concerns about adverse effects of statins, the decision to initiate statin therapy in patients with diabetes is ideally a shared one between patients and providers, and CAC could facilitate this discussion.


coronary artery calcium diabetes cardiovascular disease 


Compliance with Ethical Standards

Conflict of Interest

SSM has no disclosures specifically related to coronary artery calcium imaging. He has received personal fees for serving on scientific advisory boards for Amgen, Sanofi/Regeneron, Quest Diagnostics, Esperion, Akcea Therapeutics, and Novo Nordisk. He reports grants/research support from the NIH, PJ Schafer Cardiovascular Research Fund, the David and June Trone Family Foundation, American Heart Association, Aetna Foundation, Maryland Innovation Initiative, Nokia, Google, and Apple; in addition, he is listed as a co-inventor on a patent application pending on a method of LDL-C estimation. All remaining authors declare that they do not have a conflict of interest.


  1. 1.
    Eldor R, Raz I. American Diabetes Association indications for statins in diabetes: is there evidence?, Diabetes Care. 2009;32 Suppl 2:S384–91.CrossRefGoogle Scholar
  2. 2.
    Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229–34.CrossRefGoogle Scholar
  3. 3.
    Bulugahapitiya U, Siyambalapitiya S, Sithole J, Idris I. Is diabetes a coronary risk equivalent? Systematic review and meta-analysis. Diabet Med. 2009;26:142–8.CrossRefGoogle Scholar
  4. 4.
    Evans JM, Wang J, Morris AD. Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies. BMJ. 2002;324:939–42.CrossRefGoogle Scholar
  5. 5.
    Rana JS, Liu JY, Moffet HH, Jaffe M, Karter AJ. Diabetes and prior coronary heart disease are not necessarily risk equivalent for future coronary heart disease events. J Gen Intern Med. 2016;31:387–93.CrossRefGoogle Scholar
  6. 6.
    American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42:S103-S23.CrossRefGoogle Scholar
  7. 7.
    Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019.Google Scholar
  8. 8.
    Gore MO, McGuire DK, Lingvay I, Rosenstock J. Predicting cardiovascular risk in type 2 diabetes: the heterogeneity challenges. Curr Cardiol Rep. 2015;17:607.CrossRefGoogle Scholar
  9. 9.
    Mirbolouk M, Blaha M. The asymptomatic patient: risk factor score or calcium score?Google Scholar
  10. 10.
    Malik S, Zhao Y, Budoff M, et al. Coronary artery calcium score for long-term risk classification in individuals with type 2 diabetes and metabolic syndrome from the multi-ethnic study of atherosclerosis. JAMA Cardiol. 2017;2:1332–40.CrossRefGoogle Scholar
  11. 11.
    Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med. 2008;358:1336–45.CrossRefGoogle Scholar
  12. 12.
    Erbel R, Mohlenkamp S, Moebus S, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol. 2010;56:1397–406.CrossRefGoogle Scholar
  13. 13.
    Rana JS, Gransar H, Wong ND, et al. Comparative value of coronary artery calcium and multiple blood biomarkers for prognostication of cardiovascular events. Am J Cardiol. 2012;109:1449–53.CrossRefGoogle Scholar
  14. 14.
    Polonsky TS, McClelland RL, Jorgensen NW, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA. 2010;303:1610–6.CrossRefGoogle Scholar
  15. 15.
    Blaha MJ, Cainzos-Achirica M, Greenland P, et al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2016;133:849–58.CrossRefGoogle Scholar
  16. 16.
    Silverman MG, Blaha MJ, Krumholz HM, et al. Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: the Multi-Ethnic Study of Atherosclerosis. Eur Heart J. 2014;35:2232–41.CrossRefGoogle Scholar
  17. 17.
    Nasir K, Bittencourt MS, Blaha MJ, 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). J Am Coll Cardiol. 2015;66:1657–68.CrossRefGoogle Scholar
  18. 18.
    Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2:675–88.CrossRefGoogle Scholar
  19. 19.
    Joshi PH, Blaha MJ, Budoff MJ, et al. The 10-year prognostic value of zero and minimal CAC. JACC Cardiovasc Imaging. 2017;10:957–8.CrossRefGoogle Scholar
  20. 20.
    Goff DC Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S49–73.CrossRefGoogle Scholar
  21. 21.
    Elkeles RS, Godsland IF, Michael D, et al. Coronary Calcium Measurement Improves Prediction of Cardiovascular Events in Asymptomatic Patients With Type 2 Diabetes: The PREDICT Study. MJ Budoff. Eur Heart J 2008;18:2193–4.Google Scholar
  22. 22.
    Anand DV, Lim E, Hopkins D, et al. Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy. Eur Heart J. 2006;6:713–21.Google Scholar
  23. 23.
    Silverman MG, Blaha MJ, Budoff M, et al. Coronary artery calcium and cardiovascular events in diabetes: implications for primary prevention therapies: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2018;126.Google Scholar
  24. 24.
    Blankstein R, Gupta A, Rana JS, Nasir K. The implication of coronary artery calcium testing for cardiovascular disease prevention and diabetes. Endocrinol Metab (Seoul). 2017;32:47–57.CrossRefGoogle Scholar
  25. 25.
    Dahagam C HV, Goud A, D’Souza J, Abdelqader A, Blumenthal RS, Martin SS. Role of statins in glucose homeostasis and insulin resistance. Curr Atheroscler Rep. 2016;10.Google Scholar
  26. 26.
    Erqou S, Lee CC, Adler AI. Statins and glycaemic control in individuals with diabetes: a systematic review and meta-analysis. Diabetologia. 2014;57:2444–52.CrossRefGoogle Scholar
  27. 27.
    Teramoto T, Shimano H, Yokote K, Urashima M. New evidence on pitavastatin: efficacy and safety in clinical studies. Expert Opin Pharmacother. 2010;11:817–28.CrossRefGoogle Scholar
  28. 28.
    Kambhampati S, Ashvetiya T, Stone NJ, Blumenthal RS, Martin SS. Shared decision-making and patient empowerment in preventive cardiology. Curr Cardiol Rep. 2016;18.Google Scholar
  29. 29.
    Spatz ES, Montori VM. Primary prevention with statins: strategies to support shared decision-making. Curr Cardiovasc Risk Rep. 2017;11.Google Scholar
  30. 30.
    McGinnis B, Olson KL, Magid D, et al. Factors related to adherence to statin therapy. Ann Pharmacother. 2007;41:1805–11.CrossRefGoogle Scholar
  31. 31.
    Barrett B, Ricco J, Wallace M, Kiefer D, Rakel D. Communicating statin evidence to support shared decision-making. BMC Fam Pract. 2016;17:41.CrossRefGoogle Scholar
  32. 32.
    Kianoush S, Al Rifai M, Whelton SP, et al. Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging. J Diabetes Complicat. 2016;30:1408–15.CrossRefGoogle Scholar
  33. 33.
    Hong JC, Blankstein R, Shaw LJ, et al. Implications of coronary artery calcium testing for treatment decisions among statin candidates according to the ACC/AHA Cholesterol Management Guidelines: A Cost-Effectiveness Analysis. JACC Cardiovasc Imaging. 2017;10:938–52.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Sudipa Sarkar
    • 1
    • 2
    Email author
  • Olusola A. Orimoloye
    • 2
  • Caitlin M. Nass
    • 1
  • Roger S. Blumenthal
    • 2
  • Seth S. Martin
    • 2
  1. 1.Division of Endocrinology, Diabetes, and Metabolism, Asthma and Allergy Center Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreUSA

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