A short perspective piece in the New England Journal of Medicine (the world’s leading journal of general medicine) shows what we’re up against in any attempt to provide medical care on a rational basis. A 55-year-old white man is described. He had normal blood pressure, exercised regularly, was not overweight, not diabetic, and had never smoked. He did not have a family history of premature coronary artery disease (CAD). In short, he was as low risk a subject for CAD as it is possible to be given his age and sex. The only problem was that he had bad judgement; he underwent a screening medical test without understanding what he was doing. In response to a newspaper ad he had an electron-beam computerized tomographic scan (EBT). His coronary-artery calcium (CAC) score was 39. Five years later he did it again. This time his CAC score was 119. For undisclosed reasons he was taking rosuvastsatin (Crestor) mg daily. Of course, blood lipid levels were normal. The radiologist who supervised the EBT told the patient that he was at great risk for death from CAD and likely would not make it to 60. Terrified, he sought the assistance of a cardiologist.
The use of EBT and CAC scoring is of no proven use in the prognosis or management of CAD. None. No medical organization recommends its use. There are studies that have attempted to make use of CAC scoring as a prognostic guide, but they are not convincing. What does one do with a healthy man with excellent exercise tolerance whose CAC score is rising? A score of 100 is said to put one at low risk and above 300 at high risk. But no intervention study has shown that this score apart from other information can be used to improve outcomes. Indeed, this patient with obviously good cardiac function likely would not benefit from coronary revasularization even if he was shown to have coronary narrowing.
We’ve known for 30 years that revasularization in patients with normal cardiac ejection fraction conveys no benefit compared to medical management alone. This hasn’t stopped an ocean of angioplasties, but it’s important to remind cardiologists of it. This patient, whatever his CAC score, certainly had a normal ejection fraction, though it wasn’t given in the article. All these limitations of CAC scoring and more is presented in the NEJM paper. The anxious patient underwent a stress echocardiogram. The examination showed no electrocardiographic changes or wall motion abnormalities. In other words, his heart was fine. What did his cardiologist do? He prescribed another drug, aspirin 325 mg daily, and upped the dose of rosuvastatin to 20 mg daily. Why? For the same reason mountains are climbed.
There was no reason for this patient to be on any drug, much less two, and one of them at a greater dose than previously taken. There are no data that overall mortality is improved when healthy subject take aspirin prophylactically. There is also no evidence that statins prevent deaths from CAD when given to patients at low risk for the disease.
The patient should not have had his CAC score measured. But once it was done a cardiologist fully conversant with the limitations of the procedure and very knowledgeable about CAD could not resist the therapeutic imperative. The NEJM then broadcast this misguided treatment to the world. Three strikes and we’re all out. Establishing a rational basis for medical care is up against the human predicament. In this case the need to treat and be treated. It’s irresistible.
