Healthier World with Quest Diagnostics

Episode: Utilizing Biomarkers with Coronary Artery Calcium (CAC) Scoring for Cardiovascular Risk

Date: September 22, 2025
Guests: Dr. Mark Penn (Founder & CMO, Cleveland HeartLab), Millicent (Key Nurse Practitioner), Dr. Mason Latsko (Host, Clinical Education Specialist)
Duration: 19 minutes

Episode Overview

This episode focuses on the evolving use of coronary artery calcium (CAC) scoring and the pivotal role of advanced biomarker testing in cardiovascular risk assessment. Dr. Mason Latsko guides a discussion with Dr. Mark Penn and nurse practitioner Millicent, examining both the strengths and limitations of CAC scoring and how biomarkers like ApoB, MPO, Lp-PLA2, and hsCRP offer complementary—and sometimes superior—insights, especially for patients outside the typical CAC testing windows.

Key Discussion Points & Insights

1. The Basics and Utility of CAC Scoring

[01:30 – 03:15]

• What is a CAC score?

  • Measures calcified plaque in coronary arteries using non-invasive CT (B).
  • Offers a snapshot of overall atherosclerotic burden, improving risk stratification beyond traditional markers like age and smoking status.

• Evolution in Clinical Practice:

  • Used to determine a patient’s risk and prompt preventive action (C).
  • Shift from using stress testing (which only shows major blockages) to CAC scoring, which offers a broader assessment of calcified disease.

  “The coronary calcium score kind of gives us a bigger picture than just a stress test … it says that you had the disease and disease has progressed.” —Dr. Mark Penn [02:51]

2. Limitations and Appropriate Use of CAC Scoring

[03:53 – 06:38]

• When is CAC scoring less informative?

  • Detects only calcified (hard) plaque, missing dangerous soft/non-calcified plaque.
  • Not useful in very young, low-risk individuals (e.g., males <40, females <50 with no risk factors)—low scores may be falsely reassuring.
  • A zero score doesn’t guarantee low risk; non-calcified plaques can rupture and cause events.

• Not appropriate for:

  • Patients with active cardiac symptoms (e.g., chest pain)
  • Assessing blood flow or narrowing degree in arteries.

  “A low or zero score may provide false reassurance to that individual about their long-term cardiovascular risk.” —Millicent [05:09]

3. Impact of Statin Therapy on CAC Scores

[07:01 – 07:57]

• Why shouldn’t CAC scores be used for ongoing monitoring in patients on statins?

  • Statins can increase calcium scores by stabilizing (calcifying) soft plaques—a positive effect, not indicative of progression.
  • Increases in CAC after starting statins may cause patient anxiety but actually reflect therapeutic benefit.

  “You want [the statin] to slowly leach the lipid, leave the calcium and harden that artery, because again, calcified arteries don’t rupture.” —Dr. Mark Penn [07:13]

4. Rerunning CAC: When & For Whom

[08:15 – 10:08]

• Little benefit for repeated scans in patients with:

  • High initial scores (>300)
  • Ongoing statin/lipid lowering therapy
  • Very low scores in older age with little risk

• Reasonable to recheck in:

  • Moderate initial scores, particularly if it might change management (e.g., statin initiation/intensification)
  • Moderate risk zero-score patients after 5–7 years

5. Biomarker Testing as a Solution

[10:33 – 13:57]

• Biomarkers highlighted: hsCRP, MPO, Lp-PLA2, ApoB

• Used to:

  • Assess risk outside CAC optimal testing windows (e.g., young patients, those on statins)
  • Detect risk from soft plaque and ongoing inflammation—invisible to CAC
  • Precisely track risk and therapy response (especially for those on lipid therapy)

  “We know that age alone is an increasing risk factor … There are other solutions to assess their risk, and they're equally non-invasive, and those include biomarkers.” —Millicent [10:52]

• Marker Summaries:

  • hsCRP: General inflammation, correlates well with CAC, especially useful in young patients.
  • MPO & Lp-PLA2: Markers of vulnerable/active soft plaques, indicate risk not seen on CAC.
  • ApoB: Direct measure of lipid-driven risk, useful before/during therapy to monitor effect.

6. Synergy: Biomarkers + CAC Scoring

[13:57 – 16:38]

• Combined approach:

  • Biomarkers and CAC scoring provide complementary risk insights; abnormalities in either indicate increased risk, but dual abnormalities multiply concern.
  • If both are abnormal, risk is even higher—necessitating aggressive management.

  “Biomarkers and calcium scoring were synergistic, not redundant … If you had an abnormal calcium score and an abnormal MPO, you had more risk.”—Dr. Mark Penn [14:32]

• Reconciling Zero CAC with Abnormal Biomarkers:

  • CAC of zero doesn’t eliminate risk if biomarkers are elevated—soft, rupturable plaque may still be present and pose near-term risk.

  “There are patients who have zero calcium scores who go on to have a heart attack because they have fatty lesions. And those fatty lesions rupture.” —Dr. Mark Penn [15:46]

7. Beyond Cardiovascular—Cardiometabolic Implications

[16:56 – 18:41]

• High CAC and biomarker levels also reflect broader cardiometabolic disease (including risk from metabolic syndrome, obesity, diabetes).

• Modern risk assessment must “de-silo” beyond the heart—also targeting liver, kidney, and even brain health (dementia risk).

• Focus on aggressive, comprehensive interventions to normalize biomarkers and stall overall cardiometabolic disease progression.

  “We need to take a cardiometabolic approach—de-silo the assessment, meaning I’m not just looking for heart issues anymore, I’m looking for cardiometabolic issues and then getting aggressively treating those things …” —Dr. Mark Penn [18:17]

Notable Quotes & Memorable Moments

• “A low or zero [CAC] score may provide false reassurance …” —Millicent [05:09]
• “You want [the statin] to slowly leach the lipid, leave the calcium and harden that artery, because again, calcified arteries don’t rupture.” —Dr. Mark Penn [07:13]
• “[Biomarkers] are equally non-invasive … using those biomarkers to evaluate their risk and to also help us with our clinical judgment …” —Millicent [11:02]
• “If you had an abnormal calcium score and an abnormal MPO, you had more risk. The point being, you have calcified plaque, you have vulnerable plaque … That’s worse.” —Dr. Mark Penn [14:54]

Timestamps for Important Segments

• 01:30 – What is CAC scoring and why it’s used
• 03:53 – Limitations and best-use timing for CAC
• 07:01 – Effects of statin therapy on CAC
• 08:15 – When/if to repeat CAC scores
• 10:33 – Introducing biomarkers as alternative/complementary risk tools
• 12:07 – Detailed explanation of specific biomarkers
• 14:32 – How CAC and biomarkers are synergistic
• 15:40 – Managing discrepancies between CAC and biomarker results
• 16:56 – Broader “cardiometabolic” risk implications

Conclusion

This episode underscores the emerging consensus that CAC scoring is best used as a one-time, strategic risk assessment tool, primarily for moderate-risk, asymptomatic adults aged 40–70. For ongoing risk monitoring—especially in those already treated with statins, those with established high scores, or younger/older individuals—biomarker testing provides powerful, non-invasive insights. Together, CAC and biomarkers allow clinicians to personalize prevention strategies, addressing not just cardiovascular, but broader cardiometabolic health.