ReviewThe effects of coronary artery calcium screening on behavioral modification, risk perception, and medication adherence among asymptomatic adults: A systematic review
Introduction
Cardiovascular disease (CVD), the leading cause of morbidity and mortality in the United States (U.S.), contributes to significant health and economic burden on individuals and societies [1]. In the U.S., CVD alone accounts for 1 in 3 deaths and total direct and indirect costs of more than $300 billion per year [1]. Coronary artery disease (CAD), the commonest form of CVD, accounts for 1 in 6 deaths in the U.S. [1]. Coronary atherosclerosis starts in a subclinical phase and slowly progress over years before the development of clinical cardiovascular events [2]. While 80% of the 180,000–250,000 sudden cardiac deaths (SCDs) in the U.S. are attributed to CAD [3], [4], 50% of all SCDs occurs in persons without prior overt diagnosed CAD [5]. Additionally, a significant number of patients that experience silent myocardial infarction (MI) remains asymptomatic, especially those with other comorbid conditions. Risk assessment tools such as the Framingham Risk Score (FRS) and the European Heart Score based on established traditional CAD risk factors (age, hypertension, dyslipidemia, diabetes and smoking) have been useful in determining the risk of CAD in asymptomatic adults [6], [7]. However, these tools explain 60–65% risk for CAD [8], [9], [10], thereby often underestimating the risk among patients with subclinical disease [11], [12]. This has given rise to the need for other screening methods or tools to assess the risk for CAD, especially in asymptomatic individuals.
Coronary artery calcium (CAC), detected by computed tomography (CT), is a subclinical marker of CAD that predicts the risk of CAD with high prognostic significance among asymptomatic individuals [13]. Assessment of CAC enables risk stratification diagnosis of CAD and directs the treatment and management of CAD among asymptomatic individuals. The amount of calcium deposits along the atherosclerotic coronaries arteries [26] in an individual helps estimate the severity of the risk for CAD [14], [15] and predicts future cardiac events, including MI and SCD [16]. Several studies have shown that CAC is an independent predictor of coronary events [17], [18], [19], and particularly useful in the reclassification of individuals at low or intermediate risks for CAD [19], [20] by traditional risk score assessment [21]. It has been reported that asymptomatic individuals with CAC ≥100 were 7–10 times more likely to have cardiac events than those with CAC score of zero [18], and those with CAC >1000 had 36% chance of MI or cardiac mortality within 28 months [22]. Additionally, studies have demonstrated a strong positive correlation between CAC and traditional risk factors [23], [24]. Thus, the presence of these risk factors increases the amount of calcium deposits in coronary arteries as indicated by high levels of CAC scores, thereby augmenting the risk of CAD. While the existing evidence supports the importance of CAC in predicting future cardiovascular events [1], [8], [13], an emerging area of interest is the effects of the knowledge about CAC score in motivation for beneficial behavioral change, risk perception, medication or treatment adherence, and positive health outcomes [25], [26], [27].
Reduction of CVD morbidity and mortality requires primary and secondary prevention through behavioral or lifestyle modification and control of risk factors, along with early detection through screening tools [25], [28]. CAC score is a screening tool that facilitates early detection of CAD and improves risk stratification in asymptomatic individuals [20], with the potential to improve treatment, management, and prevention strategies [29]. However, the effects of knowledge of CAC score in modifying an individual's behavior, risk perception of CAD, and adherence to treatment or medication for other comorbid conditions has not been adequately studied [30], [31]. Therefore, we conducted a systematic review of the literature on CAC scores as a motivational tool for positive behavioral change, risk perception, and medication adherence. This review on the utility of CAC in CAD management and prevention is important because patient's compliance with established recommended guidelines for traditional risk factors reduction has been limited [32]. As such, this review will provide insight on the importance of CAC screening and scores, and has broader implication for clinical practice, behavioral interventions, policy development.
Section snippets
Literature search and selection
In December 2013 and March 2014, two librarians at the James H. Quillen College of Medicine at East Tennessee State University performed a comprehensive literature search in five databases, including CINAHL, PsychInfo, Web of Science, Cochrane Central Register of Control Trials, and PubMed (Medline), using search terms ([“coronary artery calcium”] AND [“motivation” OR “lifestyle” OR “risk perception” OR “medication adherence”]) provided by the researchers (Fig. 1). All the retrieved
Characteristics of eligible CAC studies
Of the 1626 publications retrieved in the initial search, 15 met our eligibility criteria (Fig. 2). The first study to address the potential of CAC as a motivating tool in clinical practice was published in 1996 using a population from Torrance, California, USA [35]. This study found that while CAC score was significantly associated with increased odds of new aspirin usage, new cholesterol medication, consulting with physician, losing weight, decreasing dietary fat, it increased worry. As of
Discussion
Over 15.4 million adults in the U.S. have coronary heart disease (CHD) [1]. Since not all atherosclerosis evolve to hemodynamically significant CAD, it means million more adults have subclinical CAD and are at risk of future cardiac events. Although the association of traditional risk factors (e.g., dyslipidemia, diabetes, smoking, and hypertension) and CAD has been established [7], [55], 1 in 5 Americans continue to smoke [56], 1 in 3 are overweight [57], less than half of adults aged 18 years
Conclusion
Studies suggest that cardiovascular events are preventable through risk factor modification efforts. Thus, by behavioral or lifestyle modification and subsequent reduction in CVD risk [76], [77], the leading cause of death in the U.S. [1] and worldwide, would be reduced. There is underutilization of CVD risk factors control medication, which makes the identification of subclinical markers such as CAC that facilitate medication adherence with overall reduction of CVD morbidity and mortality,
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest.
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2022, Journal of Diabetes and its ComplicationsCitation Excerpt :The negative predictive value of a CAC of zero in this patient population was high, suggesting that the absence of CAC in this patient population may be interpreted as a reassuring result, although limited by the relatively short follow-up duration. Studies with CAC scoring (without image depiction) in non-diabetes patient populations have reported that for individuals who were informed of positive CAC, higher scores were associated with a range of positive changes.31–35 The most common behaviors that changed included adherence to statin and aspirin therapy, improved diet, and increased exercise.36,37
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