Author + information
- Harvey S. Hecht, MD⁎ ( and )
- Marc Colmer, MD
- ↵⁎Lenox Hill Heart and Vascular Institute, 130 East 77th Street, New York, New York 10021
We are delighted to respond to Dr. Mensah's query regarding the changes in risk factors and major preventive practices during the 2 generations of the “fantastic voyage” (1). Sadly, there is a large gap between progress in prevention and the spectacular progress in diagnostic testing and intervention. This prevention gap may be attributed to several factors:
1. In primary prevention, there is a disconnect between risk assessment by risk factor analysis (Framingham Risk Score, Procam, European Society of Cardiology) and the actual risk determined by events, which is much more accurately predicted by coronary calcium scanning (2,3).
2. Despite the superiority of coronary calcium scanning to identify candidates for aggressive prevention, its widespread use for screening has been road-blocked by demands for randomized controlled trials showing its effect on outcomes. This criterion has never been fulfilled by the Framingham Risk Score, Procam, European Society of Cardiology, or, for that matter, by nuclear stress testing, rest and stress echocardiography, cardiac catheterization, and most interventions. Nonetheless, they are accepted as gospel.
3. This “deadly double standard” (4) and the continued reliance on risk-factor-based prognostication will continue to deprive high-risk patients of the possibility of early identification, with an unconscionable and unnecessary increased morbidity and mortality.
4. Indeed, there has been an explosion of risk factor identification (including high-sensitivity C-reactive protein), none of which have added to the area under the receiver-operator characteristic curve for the standard risk factors' ability to prognosticate. We think that there has not been and will not be a major breakthrough in prevention, akin to what has dramatically occurred in diagnostic testing and intervention, until risk factors are used not for risk assessment, but to identify treatable causal factors after risk has more accurately been established by the level of subclinical atherosclerosis (5).
5. To those who raise cost effectiveness concerns related to widespread screening for subclinical atherosclerosis, reduction in the cost of calcium scanning to the level of mammography will make it the most cost-effective modality.
6. Finally, in both secondary and primary prevention, there has been a misplaced focus on simple changes in the treated risk factors, for example, low-density lipoprotein, rather than on measures of subclinical atherosclerosis and disease activity and endothelial function to evaluate the response of the disease, rather than the risk factors, to treatment.
- American College of Cardiology Foundation
- Hecht H.S.,
- Colmer M.
- Detrano R.C.,
- Guerci A.D.,
- Carr J.J.,
- et al.