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June 28, 2004

The Search for the "Holy Grail" of Clinically Significant Coronary Atherosclerosis

Arch Intern Med. 2004;164(12):1266-1268. doi:10.1001/archinte.164.12.1266

For presentations to be effective, one must "get to the point." The point of this editorial on the article by Pletcher et al1 is that the clinical utility of fast computed tomography (CT) scanners (ie, the electron beam [EB] and double helical CT scanner) is still limited. Electron beam CT is not ready for prime time.

It is interesting that some individuals' coronary angiograms are stable for years while others are very unstable with rapidly progressive lesions that result in sudden death or one of the acute coronary syndromes. The diagnostic "Holy Grail" of coronary atherosclerosis is not to be able to identify coronary atherosclerosis, which almost all Americans have, but to be able to identify individuals with unstable coronary atherosclerotic lesions and thus be able to attempt to prevent one of the acute coronary syndromes or sudden death. While calcium in the coronary arteries is almost invariably associated with atherosclerosis and extensive calcium characterizes the coronary arteries of elderly patients and patients with chronic stable angina, individuals with unstable coronary disease are not always identified by EBCT. A patient with potentially unstable coronary atherosclerotic lesions may have mildly calcified or noncalcified culprit arteries.2 In the study by Shemesh and associates,2 calcium was not detected in 19% of patients with acute myocardial infarction. Likewise, patients with stable and unstable coronary atherosclerosis may have similar calcium scores. Therefore, EBCT is not the "Holy Grail" that many hoped or wished it were.