Imaging tests for cardiovascular risk assessment hold great promise.\u00a0 Both coronary artery calcium (CAC) scanning and carotid intima-media thickness (CIMT) testing have been shown in multiple prospective studies to predict cardiovascular outcomes and, more recently, to improve risk reclassification based upon the Framingham Risk Score.\u00a0 Coupled with frustrations about the performance of the Framingham Risk Score as well as the movement towards personalized medicine, it is understandable why there is great enthusiasm for broader implementation of these tests.\u00a0 This enthusiasm has taken tangible form in the Texas Atherosclerosis Imaging Bill, HB 1290, which was passed by the Texas Legislature in 2009 mandating insurance coverage for CAC scanning or CIMT testing every 5 years in an accredited laboratory for men aged between 45 and 75 years and women aged between 55 and 75 years who also have diabetes or \u201ca risk of developing coronary heart disease, based on a score derived using the Framingham Heart Study coronary prediction algorithm, that is intermediate or higher.\u201d<\/p>\n
The question is: in our intention to do something, are we sure we know what it is we are doing?\u00a0 And more importantly, is our understanding of these tests and their full implications for population level implementation at a stage where legislative action is warranted? In a recent editorial<\/a>, I tried to address these issues by taking a closer look at Texas HB 1290.<\/p>\n While some have argued that legislative coverage mandates are never warranted, there are some prerequisite questions that should reasonably be asked before considering such tools: How many people will this affect?\u00a0 What are the costs?\u00a0 What are the risks?\u00a0 How many lives can we save or CVD events can we prevent?\u00a0 Is there agreement on how to use these tests and interpret the results?\u00a0 What do the experts say about how we should use these tests? What do patients think? Insurers? Public health officials?<\/p>\n To the extent that these data are available in public testimony and records, it seems that most of these questions were either not addressed or not in sufficient detail commensurate with such a novel bill with broad implications.\u00a0 In my calculations, if all people in the designated age range and risk category specified by the bill were scanned, this group would comprise 2.4 million individuals with an initial cost of $480 million.\u00a0 Those are astounding figures that alone should give us pause to ask \u201cwhat are we getting in return?” To be sure, there would almost certainly be a large number of patients at high risk for CVD events who would be detected (~285,000 by my calculations), and intensifying preventive therapies in this group may globally improve cardiovascular outcomes.<\/p>\n