Because coronary artery calcium (CAC) is usually considered to be the most accurate tool for cardiovascular disease (CVD) risk assessment, future guidelines should also consider combining the traditional risk factor-based paradigm with a more personalized atherosclerosis imaging model. The finding of a CAC score >100 may bring about statin therapy initiation discussions among clinicians and patients; CAC could also be used to motivate statin-reluctant patients and aid decision making in patients at risk for drug-drug interactions.

Current U.S. guidelines urge clinicians to gauge treatment success by calculating the percentage drop in a patient’s cholesterol levels. But European and Canadian guidelines call on physicians to aim for a fixed cholesterol number instead. The “percentage” approach is not only discordant with international guidelines, say senior author Seth Martin, MD, MHS, an assistant professor of medicine at the Johns Hopkins University School of Medicine.Martin, but requires confusing and messy arithmetic that often discourages clinicians from using it. Moreover, the authors write, the “percentage” approach has fueled the misconception that cholesterol levels no longer matter. They do, the authors say. Harmonizing the “percentage drop” and “target number” approach to measuring therapeutic success would go a long way to improving clarity in clinical decisions.

The next set of guidelines should include concrete tips on how to communicate risk in concrete rather than abstract terms and how clinicians can strike a balance between being the active problem-solvers patients expect them to be while giving patients autonomy and final say.

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