In Reply We thank Sauza-Sosa et al for their interest in our article1 published in JAMA Cardiology on coronary artery calcium (CAC) in a group of older individuals and its possible value in risk assessment for asymptomatic people. As pointed out by Sauza-Sosa et al, a previous article by Schenker et al2 found that CAC score in a referred patient population did not succeed in identifying a very-low-risk group. In that study, 606 patients were referred for diagnostic evaluation because of possible cardiac symptoms. The event rate in that referred patient population was 3.6 per 100 patients per year (3.6% per year).2 In an Editorial that accompanied the Schenker article, Greenland and Bonow3 summarized data on the prognostic implication of a CAC score of 0 from 14 previous studies. In completely asymptomatic people, not a referred patient population, cardiovascular disease event rates were much lower than in the referred patient population from Schenker et al.2 In the generally healthy cohorts reported in our recent article,1 rates of coronary heart disease events (eTable 3 in the Supplement) in people with CAC scores of 0 ranged from 0.16 to 0.31 per 100 person-years. These rates are approximately 10-fold to 20-fold lower than the event rate in the article by Schenker et al2 cited by Sauza-Sosa et al. It is critically important to recognize that the cohort studies in our article included completely asymptomatic individuals, not patients derived from referral settings.1 A more complete discussion of this distinction is available in the Editorial by Greenland and Bonow.3
Greenland P, Yano Y, Lloyd-Jones DM. Coronary Calcium Score and Cardiovascular Risk in Elderly Populations—Reply. JAMA Cardiol. 2018;3(2):180–181. doi:10.1001/jamacardio.2017.4350
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