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Coronary artery calcium may predict mortality risk in the elderly
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Coronary artery calcium scoring may be an effective tool for monitoring mortality risk in elderly and young patients, according to research published recently in the Journal of the American College of Cardiology.
Screening the elderly for coronary artery calcium may lead to the reclassification of risk scoring methods. Conducting studies that evaluate whether preventive therapies can be withheld in elderly people who have little or no coronary artery calcium may be beneficial, but may also be unethical, according to the researchers. However, there is little risk associated with the absence of coronary artery calcium. The researchers suggest that physicians may be encouraged to allay primary prevention in the elderly in light of the findings.
The cohort study included 35,388 participants with no CAD. Electron beam tomography was used to screen for coronary artery calcium. The study was conducted in Nashville, Tenn. and Torrance, Calif.
Follow-up evaluation was conducted in all participants for a mean of 5.8 years after screening. The researchers calculated univariate and multivariate statistical analyses for time to mortality. They classified participants using the Framingham risk score, then reclassified them using the coronary artery calcium score. A proportion range of 14.1% to 43.1% of men with a coronary artery calcium score >400 could have been reclassified. For women with a score of >400, a range from 9.0% to 45.2% could have been reclassified.
The researchers conclude that “it may not be ethical to design studies to assess whether the absence of coronary artery calcium allows withholding preventive therapies in elderly patients with risk factors.” I disagree. If coronary artery calcium provides risk assessment information in the elderly, the next step is not to have “physicians mitigate the intensity of primary prevention,” as the authors suggest, but to design randomized clinical trials, such as in the elderly who currently do not meet current preventive treatment guideline therapy, by determining their coronary artery calcium. Randomize those with elevated scores to treatment vs. placebo. The only unethical stance would be to not test strategies in the elderly.
– C. Noel Bairey Merz, MD
Cardiology Today Editorial Board member
For more information:
- J Am Coll Cardiol. 2008;52:17-23.