Why Donald Trump Is Better Off Knowing His Calcium Score

Why Donald Trump Is Better Off Knowing His Calcium Score
Letter to Editor

Matthew J. Budoff, MD; Seth J. Baum, MD; Pam R. Taub, MD


March 19, 2018

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To the Editor:

Re: Donald Trump Has Coronary Calcium: Is That Helpful to Know? by John Mandrola, MD

As preventive cardiologists, we have a different take on the utility of coronary artery calcium (CAC) scores in primary prevention.

Knowledge Is Power

We have entered the age of personalized medicine; we can individualize treatment on the basis of disease detection rather than treat all 70-year-olds as if they were the same. The CAC score affords the patient and physician with valuable knowledge regarding the presence or absence of coronary artery disease. Moreover, the CAC score quantifies plaque, allowing us to more precisely determine the patient’s specific level of risk. Using calcium scores to guide decision-making regarding medications such as statins and aspirin is based on extensive literature (>2000 published papers related to clinical CAC score use).

There is ample evidence that not all intermediate-risk patients are created equal. CAC equals atherosclerosis, and there is no stronger predictor of cardiovascular events. The American College of Cardiology/American Heart Association Guidelines state: “Assessing CAC is likely to be the most useful of the current approaches to improving risk assessment among individuals found to be at intermediate risk after formal risk assessment.”[1] Given the plethora of additional therapies beyond statins now available for prevention of heart attack and stroke (cholesterol-lowering treatments such as PCSK9 inhibitors, ezetimibe, and therapeutic lifestyle changes), doctors can refine their treatments based on CAC results.

Reasons Why It Is Imperative to Use the CAC Score

1. Lowers healthcare costs 

Approximately 50% of intermediate-risk patients have CAC scores of zero, meaning there is no detectable plaque. The so-called “Power of Zero” informs patients and their clinicians of a very low risk of the patient experiencing a heart attack within the ensuing 5-10 years. Such knowledge enables physicians to avoid excessive diagnostic testing and therapies that may even harm patients. In the EISNER study,[2] patients were randomly assigned to CAC or no testing, and those found to have zero scores had lower healthcare costs over the ensuing 4 years. This cost savings resulted from the avoidance of unnecessary medications and costly testing. Thus, this simple, low-risk, inexpensive test led to a significant cost savings in the CAC cohort, which represented approximately 50% of intermediate-risk people.

2. Robust reclassification of intermediate-risk patients

In every large study of intermediate-risk patients, the CAC score reclassifies more than 50% of people. That is remarkable, as testing such as C-reactive protein reclassifies 1%-6%. CAC screening appropriately changes the diagnosis in more than half of the people. Yeboah and colleagues,[3] evaluating the intermediate-risk participants of Multi-Ethnic Study of Atherosclerosis (MESA), demonstrated that the net reclassification improvement with CAC was 0.659, meaning that 65.9% of patients were properly reclassified by use of the CAC score.