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- Rita F. Redberg, MD* ()
- ↵*Robert Wood Johnson Foundation, UCSF School of Medicine, 505 Parnassus Avenue, Suite M-1180, San Francisco, California 94143-0124
The 5 letters to the editor concerning the Gottlieb et al. (1) study and the accompanying editorial (2) all focus on what is the value of a coronary artery calcium score (CACS) in risk prediction and the role of population characteristics: age, sex, and presence and type of symptoms in determining that value.
Drs. Timmis and Correia and I all agree that the accuracy of any diagnostic test is dependent on the population in which it is used.
Dr. McEvoy says that “the role of CS, if any,” is in “reclassification.” I agree with him that further research is needed to determine if there is any value in such reclassification.
Dr. Blaha and colleagues state that the utility of CACS is “to guide selection of appropriate pharmacotherapy.” They cite no references for this speculative statement. While this is a potential use for CACS, there are no data to suggest that CACS has any benefit in deciding who should receive medications for hypertension or hypercholesterolemia.
However, none of the letters address the key clinical point of whether an imaging test such as coronary artery calcium will give us new information that leads to better patient care and improved outcomes. Despite the use of CACS for the last 20 years, there are still no data for either the asymptomatic or symptomatic group to show that this information benefits our patients. That is why the most recent U.S. Preventive Services Task Force (USPSTF) recommendation statement on congestive heart disease (CHD) risk assessment concluded that “the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors studied to screen asymptomatic men and women with no history of CHD to prevent CHD events” (3). The USPSTF cochairs state that the critical gap in the evidence for screening with CACS is the lack of information on subsequent reductions in risk for CHD events in persons identified by CACS (4). Before subjecting healthy men and women to a test with significant radiation—2 to 7 mSv (5) or 100 chest roentgenograms—one must be able to tell patients that there is a benefit from having this test. With no known benefit, CACS fails this essential criteria, and the harm, including cancer risk from radiation, and incidental findings prevail.
- American College of Cardiology Foundation
- Gottlieb I.,
- Miller J.M.,
- Arbab-Zadeh A.,
- et al.
- Redberg R.F.