Referral: coronary artery calcium scoring
- To
- Cardiology practice, Hamburg
- Subject
- Referral of Mrs Anna Keller, born 1979, for coronary artery calcium scoring
Dear colleagues,
I am referring Mrs Keller, 47, for a coronary artery calcium score to refine her cardiovascular risk before committing to long-term lipid-lowering therapy.
Findings: arterial hypertension since 2023 (ramipril, increased to 10 mg today; home mean 136/86 mmHg), LDL cholesterol 162 mg/dl, non-HDL 186 mg/dl, HbA1c 5.9 %, BMI 27.4, former smoker (10 pack-years, stopped 2019), mild hepatic steatosis on ultrasound (May 2026), eGFR 92 ml/min. Family history: father with myocardial infarction at 58. Lipoprotein(a) is ordered with the next blood draw. SCORE2 is about 3 %, low to moderate for her age; the family history and the LDL level are the reasons for the question.
Simvastatin 20 mg was stopped in March 2024 for myalgia with a CK of 210 U/l; atorvastatin 20 mg is started today as a rechallenge. Current medication: ramipril 10 mg, atorvastatin 20 mg, sertraline 50 mg, vitamin D3 1,000 IU.
The 2021 ESC prevention guideline lists coronary artery calcium scoring as a risk modifier that may be considered in people at low-to-moderate risk. I would be grateful for the score and your assessment of whether the result changes the treatment intensity.
With kind regards,
Dr. med. Sarah Weber
Internal medicine and general practice, Hamburg
Drafted from the chart and today's visit. A draft: it carries the physician's name only after signing.