(Circulation. 1999;99:2610-2612.)
© 1999 American Heart Association, Inc.
Editorials |
Risk Stratification for the Detection of Preclinical Coronary Artery Disease
From the Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Mich.
Correspondence to Bertram Pitt, MD, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0366.
Key Words: : Editorials • coronary disease • risk factors • tomography • calcium
The cost of lost human
value and dollars spent ($90 billion annually) due to coronary
disease in our society is of great concern and is reason for increased
efforts to prevent coronary artery disease and its
consequences.1 The reduction in mortality, acute
coronary event rate, and need for coronary
revascularization attributable to lipid lowering
with HMG-CoA reductase inhibitors in the recent primary
coronary prevention trials has therefore been
encouraging.2 3 These studies have prompted many
physicians and informed adults to be more aggressive with
coronary risk detection and intervention. However, despite the
success of these trials, only a minority of persons at risk with
elevated cholesterol levels are treated effectively. This
has led to an increased emphasis on the National
Cholesterol Education Program Adult Treatment Panel II (ATP
II) guidelines4 and direct advertising to the public by
the pharmaceutical industry. Every adult American has been urged to
know their cholesterol level. These efforts are certainly
laudable and have met with at least some success. However, the
increased attention and enthusiasm for risk factor modification to
prevent myocardial infarctions (MI), stroke, and death have been
tempered by the realization that the costs of primary prevention may be
beyond what society is willing to spend. Health insurers, employers,
and governments throughout the western world understand the potential
value of coronary prevention but are concerned that the costs
will greatly increase total healthcare expenditures and are difficult
to justify compared with other societal needs. It is therefore not
surprising that there are increasing efforts
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