Alex Zheutlin

Highest respect for @EricTopol , but I think his message on CAC is slightly off target We are still looking too much at summary prediction metrics and not enough at the actual clinical question When someone is in the gray zone, does CAC help decide whether to start a statin? Look under the hood 1. Among those with PREVENT risk 3–<5%, where statins are being considered, about 60% have CAC=0 2. Among those with PREVENT risk 5–<10%, where statins are recommended, about 40% have CAC=0 3. Their observed event rates are also below the risk levels where PREVENT would otherwise recommend treatment 4. And the reclassification results tell the same story. A large proportion of patients move below the treatment threshold once CAC is known This is the information a patient and physician actually care about If nearly half of people sitting in the statin decision zone can potentially defer therapy after CAC=0, isn’t that exactly the point of shared decision-making? And CAC=0 is not a lifetime pass @MichaelJBlaha and others have shown, and now endorsed by guidelines, a repeat CAC in 3-5 yrs in selected patients identify the few with CAC zero at risk, allowing to modify treatment plans Also CAC is not just about starting statins...it can guide dosing strategy (as per guidelines) On the other end, those with the highest CAC especially in intermediate risk, where one should pursue more intensive targets I just wish we would spend less time on irrelevant metrics and more time asking the right clinical question and looking carefully at what the data actually show How well can CAC change the treatment decisions? isn’t that the whole spirit of shared decision-making? @rblument1 @DrMichaelShapir @RonBlankstein @JAMA_current @NilayShahMDMPH @HMethodistCV @Sadeer_AlKindi