Not about the study, but how do we feel about leveraging the CAC for the opposite effect? I get a CAC done every year - because the "zero" result convinces my PCP that I don't need to be on a statin!
You know better than most that a lack of evidence does not mean evidence of lack. Nor does a poorly designed trial (which most would agree, just looks like a trial of statin use) mean that the intervention under study is of no value. We can argue the utility of CAC scoring, but until there is a properly conducted trial that can demonstrate the value ( or lack thereof) of this test in terms of a reduction of MACE and mortality, the decision to use CAC scoring is a clinical one, like so many other decisions we make daily which are without hard evidence. Until further evidence is presented, I will continue to use CAC scoring in select patients to help make decisions about ASCVD risk reduction. If the information obtained from any test helps to make management decisions, such as whether to add a statin, then it has value. Is the PREVENT risk calculator sufficient to make informed decisions about ASCVD? That is for primary prevention--once it is established that a patient has coronary plaque, that risk calculator is no longer valid!
Second and third derivative surrogates just lead us further down the primrose path. Wishful thinkers continue to grasp at chimeras in an attempt to realistically assess cardiac risk. Does that mean we should stop trying to find preventive remedies or tests that can reliably show risk levels? Of course not. But stop applying useless measures that are based on tiny differences in endpoints---both surrogate and real. It is hard to believe that many still think cholesterol levels mean anything. Thankfully, there has been real progress in the treatment of acute MI over the past few decades. But the ability to predict these sudden and potentially catastrophic events has continued to be elusive. Better to admit this rather than applying useless measures for something we hope to be true.
I absolutely agree that this study tested for a useless and clinically meaningless imaging endpoint. You would think (and have hoped) that this many years after this test hit mainstream consciousness, that we would be well past such silly surrogates by this point. That we aren’t, is quite telling, and frankly embarrassing for CAC enthusiasts. “You mean you’d been recommending this test based on LESS evidence than this, for all those years?!?”(Mind blown).
I further agree that this trial design is bizarre. If you’re gonna test a CAC-inclusive strategy….you need to allow the test result (CAC score) to determine your intervention. By mandating that everyone in the CAC arm get Lipitor 40….you’ve made the CAC pointless, redundant, and unnecessary. This was essentially just a test of Lipitor 40 vs nothing in this primary prevention cohort….but we’ve already done that….decades ago.
When proponents of CAC purportedly want to test a CAC-guided strategy yet still fail to do anything of the sort, it may be a sign that CAC proponents have lost the plot.
My use (as a patient) of CAC is that I suspect that it is a better indication of risk than simply having high total cholesterol or high LDL. There is a separate question of what to do with a high-risk individual. Do you think that there is evidence for CAC as a measure of risk? In other words, for a patient with high cholesterol, would CAC give you a better sense of how at-risk the patient is?
I'll answer the same way I did the first time. Our group was one of the leaders in the country in calcium scanning.
It has two clinical uses primarily in my mind.
The first is people who come in with atypical chest pain normal EKG and and enzymes were scanned in the emergency room. A score of zero ended the work up. Not just in the ER -it ended the work up.
Now you can argue about soft plaque and we could've missed it? Four years on the board and 12 as a leader of the practice, I'm not aware of one single bad outcome either that went to litigation or not as a result of the strategy. Maybe we should go to Vegas.
It the lowered the risk of radiation. It was done with a dedicated scanner-actually reduced radiation because people didn't go on to get Pet or other nuclear studies-yes a normal EKG could mean a stress test but that's like asking to leave an emergency room in 2025 without getting a CAT scan. Not going to happen.
Secondly, while anecdotal, there are many people in Austin that have benefited . Every February someone is dragged in who would've only come in after they've had an event. Yes they get identified and yes, they get put on statins.
While some of them have low scores, a not insignificant number have very high scores . Several symptomatic and were blowing it off.
They would've come to attention in a more serious manner.
Should it be paid for?
At this point, it doesn't matter it's the cost of a co-pay when discounted. Now that physician office scans are hospital based procedures it could be less expensive when discounted.
Clinically, the docs have continued to use it and have found that it helps in the management of their patients. That probably speaks more to value than anything else given time crunch all docs experience.
I appreciate Dr. M's expert input always but expert general cardiologists have found it helpful now going on two decades when used appropriately. The use did not change when the financial incentives are almost completely removed (hospital now owns the facility). The scans are interpreted now by only a few people. Essentially the vast majority of physicians ordering the scans have no financial reward anymore than they would if they ordered a lab test in the hospital lab.
Matt Phillips MD
Past president and Emeritus physician Austin Heart
…ok but… the point of today’s Sensible Medicine is the useless (mystifyingly illogically designed) study published by JAMA. Perhaps your comments would be more pertinent if focused there…?
Not about the study, but how do we feel about leveraging the CAC for the opposite effect? I get a CAC done every year - because the "zero" result convinces my PCP that I don't need to be on a statin!
The most interesting question raised is whether CAC helps convince skeptical patients to take a statin, which the trial was not designed to show.
Drs Mandrola and Foy-
You know better than most that a lack of evidence does not mean evidence of lack. Nor does a poorly designed trial (which most would agree, just looks like a trial of statin use) mean that the intervention under study is of no value. We can argue the utility of CAC scoring, but until there is a properly conducted trial that can demonstrate the value ( or lack thereof) of this test in terms of a reduction of MACE and mortality, the decision to use CAC scoring is a clinical one, like so many other decisions we make daily which are without hard evidence. Until further evidence is presented, I will continue to use CAC scoring in select patients to help make decisions about ASCVD risk reduction. If the information obtained from any test helps to make management decisions, such as whether to add a statin, then it has value. Is the PREVENT risk calculator sufficient to make informed decisions about ASCVD? That is for primary prevention--once it is established that a patient has coronary plaque, that risk calculator is no longer valid!
Second and third derivative surrogates just lead us further down the primrose path. Wishful thinkers continue to grasp at chimeras in an attempt to realistically assess cardiac risk. Does that mean we should stop trying to find preventive remedies or tests that can reliably show risk levels? Of course not. But stop applying useless measures that are based on tiny differences in endpoints---both surrogate and real. It is hard to believe that many still think cholesterol levels mean anything. Thankfully, there has been real progress in the treatment of acute MI over the past few decades. But the ability to predict these sudden and potentially catastrophic events has continued to be elusive. Better to admit this rather than applying useless measures for something we hope to be true.
I absolutely agree that this study tested for a useless and clinically meaningless imaging endpoint. You would think (and have hoped) that this many years after this test hit mainstream consciousness, that we would be well past such silly surrogates by this point. That we aren’t, is quite telling, and frankly embarrassing for CAC enthusiasts. “You mean you’d been recommending this test based on LESS evidence than this, for all those years?!?”(Mind blown).
I further agree that this trial design is bizarre. If you’re gonna test a CAC-inclusive strategy….you need to allow the test result (CAC score) to determine your intervention. By mandating that everyone in the CAC arm get Lipitor 40….you’ve made the CAC pointless, redundant, and unnecessary. This was essentially just a test of Lipitor 40 vs nothing in this primary prevention cohort….but we’ve already done that….decades ago.
When proponents of CAC purportedly want to test a CAC-guided strategy yet still fail to do anything of the sort, it may be a sign that CAC proponents have lost the plot.
My use (as a patient) of CAC is that I suspect that it is a better indication of risk than simply having high total cholesterol or high LDL. There is a separate question of what to do with a high-risk individual. Do you think that there is evidence for CAC as a measure of risk? In other words, for a patient with high cholesterol, would CAC give you a better sense of how at-risk the patient is?
I'll answer the same way I did the first time. Our group was one of the leaders in the country in calcium scanning.
It has two clinical uses primarily in my mind.
The first is people who come in with atypical chest pain normal EKG and and enzymes were scanned in the emergency room. A score of zero ended the work up. Not just in the ER -it ended the work up.
Now you can argue about soft plaque and we could've missed it? Four years on the board and 12 as a leader of the practice, I'm not aware of one single bad outcome either that went to litigation or not as a result of the strategy. Maybe we should go to Vegas.
It the lowered the risk of radiation. It was done with a dedicated scanner-actually reduced radiation because people didn't go on to get Pet or other nuclear studies-yes a normal EKG could mean a stress test but that's like asking to leave an emergency room in 2025 without getting a CAT scan. Not going to happen.
Secondly, while anecdotal, there are many people in Austin that have benefited . Every February someone is dragged in who would've only come in after they've had an event. Yes they get identified and yes, they get put on statins.
While some of them have low scores, a not insignificant number have very high scores . Several symptomatic and were blowing it off.
They would've come to attention in a more serious manner.
Should it be paid for?
At this point, it doesn't matter it's the cost of a co-pay when discounted. Now that physician office scans are hospital based procedures it could be less expensive when discounted.
Clinically, the docs have continued to use it and have found that it helps in the management of their patients. That probably speaks more to value than anything else given time crunch all docs experience.
I appreciate Dr. M's expert input always but expert general cardiologists have found it helpful now going on two decades when used appropriately. The use did not change when the financial incentives are almost completely removed (hospital now owns the facility). The scans are interpreted now by only a few people. Essentially the vast majority of physicians ordering the scans have no financial reward anymore than they would if they ordered a lab test in the hospital lab.
Matt Phillips MD
Past president and Emeritus physician Austin Heart
…ok but… the point of today’s Sensible Medicine is the useless (mystifyingly illogically designed) study published by JAMA. Perhaps your comments would be more pertinent if focused there…?
You are correct John there is no outcome evidence supporting the use of CAC. Of course, absence of proof is not proof of absence.