SCREENING FOR ASYMPTOMATIC CORONARY ARTERY DISEASE: SEEKING VALUE IN A MULTI-MODALITY WORLD


John J. Mahmarian, M.D., Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX, USA

There are multiple potential candidate testing modalities for evaluating patients at risk for coronary artery disease (CAD) which include stress ECG testing; stress echocardiography and myocardial perfusion imaging (MPI); and cardiac computed tomography (CT). Stress echocardiography and MPI are considered inappropriate in low and intermediate risk patients but may have value in patients at high CAD risk. Stress ECG is inappropriate as a routine screening test but may have value in high risk patients who plan to start vigorous exercise. CT coronary angiography is considered inappropriate in any asymptomatic patient but non-contrast CT for determining the coronary artery calcium score (CACS) is appropriate in low risk patients with a strong family history of CAD and in those who are at intermediate risk. CACS has gained favor since it is a rapid, simple, inexpensive 10-second test that requires no patient preparation, has no contraindications, has very low radiation exposure, and is the only test to detect early atherosclerosis. CACS prognostic value has been demonstrated in multiple large clinical trials and in conjunction with stress MPI. Early CAD detection may significantly reduce cardiac morbidity following the initiation of statin therapy and CACS may also identify which asymptomatic patients require aggressive treatment. CACS may therefore provide the best value of current testing modalities in asymptomatic patients who are at risk for CAD.