Assessing stable coronary artery disease

Abstract

To the Editor: The article by Nagaraja and Lincoff 1 is an excellent review of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches trial. It highlights the continuing evolution of patient-centered approaches in the management of stable coronary artery disease. Their algorithm contains the phrase "cardiac computed tomography to assess calcium score and exclude left main disease." Are the authors referring to the coronary artery calcium score (CACS) or coronary computed tomography angiography (CCTA)? I believe they mean the latter, but as both are computed tomographic modalities of the heart and the difference may not be readily appreciated by a general medicine audience, it may be helpful to clarify.The CACS is most useful in risk assessment in primary prevention, particularly to improve specifi city in older adults and allow for a personalized and risk-driven decision in use of lipid-lowering medications. For patients with established coronary artery disease and an abnormal stress test, it seems unlikely that the CACS will add any clinically useful information and may provide false reassurance, particularly in exclusion of disease. Noncalcifi ed plaque, including that in the left main, would not be visible on CACS.Further, it is noncalcifi ed plaque that is