Coronary Heart Disease Risk Assessment by Traditional Risk Factors and Newer Subclinical Disease Imaging:  Is a “One-Size-Fits-All” Approach the Best Option?

Coronary heart disease (CHD) and other atherosclerotic cardiovascular diseases (CVDs) remain the leading cause of death and disability in women as well as men in the Western and developing world.¹ Clinical CHD, manifested as angina or an acute coronary syndrome, results from thrombosis in an unstable atherosclerotic plaque in the coronary arteries.² Clinicians and researchers alike are keenly interested in the identification of optimal methods for prediction of CHD risk. Thus, it is not surprising that there is great interest in direct imaging of the heart for the presence and extent of coronary artery atherosclerosis detected by cardiac computed tomography (CT). Multiple studies of tens of thousands of patients referred for cardiac CT measurement of coronary artery calcium (CAC) provide consistent evidence that the presence and extent of CAC predicts strongly increased risks for CHD.³ However, much of the evidence for CAC is derived from middle-aged and older referral populations, usually including more men than women,⁴ and only a few recent studies have been conducted in unbiased, community-based populations.^5- 6 Moreover, while CAC increases markedly with age and is more prevalent in younger men than in women, prospective studies of CAC for risk prediction have largely used a one-size-fits-all definition of CAC scores for low vs high levels of CAC (eg, Agatston score of 400) rather than an age- and sex-standardized scoring system. Current guidelines suggest that there may be a role for CAC screening but do not yet recommend full implementation in practice.^4,7 Findings from an interesting study published in this issue of the Archives highlight the need for better levels of evidence for women and other understudied populations.⁸