There are 2 main reasons why clinicians pursue diagnostic testing for subclinical atherosclerosis in asymptomatic patients without known coronary artery disease: (1) to refine risk in order to assist with better treatment decisions and (2) to motivate patients at risk in order to optimize health behaviors. The latter rationale follows the logic that by presenting objective evidence of disease, patients will internalize and act on this information more so than a theoretical risk number. Both reasons are rational, intuitive, persuasive, and purely theoretical. Evidence is lacking that such testing results in better health outcomes. Indeed, as the systematic review by Hackam et al1 demonstrates, it is shocking how little evidence there is. The modest evidence that does exist is clearly not powered sufficiently to draw any conclusive inferences about the impact of testing on important patient-centered outcomes. Why is this?
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