To the Editor The interpretation of data in the article by DeFina et al1 is of concern. One interpretation of the findings is that individuals with high levels of coronary artery calcium (CAC) who are physically active are at very low risk of coronary heart disease (CHD). A 2018 article from this same group2 reported that the incidence of CHD varied from 1.3 per 1000 per year for a CAC of 0 to 18.9 per 1000 per year for a CAC greater than 400 Agatston units (AU). The differences by CAC were reduced by the addition of fitness to the model, but individuals with high CAC levels and high fitness had much higher CHD rates than those with CAC of 0 and low fitness; in multivariate models, CAC of 0 vs 400 AU was associated with 6.5-fold increased risk of CHD when cardiorespiratory fitness was included in the model. High CAC levels and low cardiorespiratory fitness are both determinants of clinical CHD. Men with high fitness and high levels of CAC are at high but attenuated risk.2 A 2019 article3 noted that reported excellent health also attenuated the association of CAC with CHD.
Kuller LH. Risks of High Coronary Artery Calcium. JAMA Cardiol. 2019;4(7):712–713. doi:10.1001/jamacardio.2019.1403
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