Clinical Scorecard: Extreme Cases of Coronary Atherosclerosis in Low-Risk Patients and Its Absence in High-Risk Individuals: Insights from the SCAPIS Extremes Study

At a Glance

Key Highlights

• 1. Absence of coronary plaques despite very high estimated cardiovascular risk occurred in 1.2% of non-diabetic and 14.0% of diabetic individuals.
• 2. Severe-extensive coronary plaques despite low estimated cardiovascular risk occurred in 0.7% of non-diabetic and 0.3% of diabetic individuals.
• 3. Traditional risk factors such as male sex, older age, smoking history, hypertension, hyperlipidemia, and family history of CVD were associated with severe plaque burden despite low risk, while inverse patterns were observed in those without plaques despite high risk.

Guideline-Based Recommendations

Diagnosis

• Use coronary computed tomography angiography (CCTA) to assess coronary plaque burden for improved cardiovascular risk stratification beyond traditional risk scores.

Management

• Interpret traditional cardiovascular risk scores cautiously, considering potential over- or underestimation of risk.
• Consider lifestyle factors such as physical activity, education level, and body mass index in risk assessment, especially in diabetic patients.

Monitoring & Follow-up

• Monitor individuals with discordant risk and plaque burden phenotypes for potential cardiovascular events despite estimated risk category.

Risks

• Risk algorithms may misclassify individuals leading to overtreatment or undertreatment of cardiovascular risk factors.
• Presence of severe coronary atherosclerosis in low-risk individuals may predispose to unexpected cardiovascular events.

Patient & Prescribing Data

Individuals aged 50–64 years from the general population, including both diabetic and non-diabetic subjects.

Extreme phenotypes with mismatch between estimated cardiovascular risk and coronary atherosclerosis highlight the need for personalized risk assessment and potential adjustment of preventive therapies.

Clinical Best Practices

• Incorporate coronary artery calcium scoring and segment involvement scoring via CCTA in cardiovascular risk evaluation when feasible.
• Recognize that traditional risk scores may not fully capture individual atherosclerotic burden; consider imaging in selected patients.
• Address modifiable risk factors such as smoking, hypertension, and hyperlipidemia aggressively, especially in patients with discordant risk and plaque findings.
• Promote moderate physical activity and healthy body weight, particularly in diabetic patients with high estimated risk but absent coronary plaques.

References

• SCAPIS Study Overview
• SCORE2 Cardiovascular Risk Estimation