New Data Suggest Screening Heart Disease by Identifying Plaque, Not Just Risk

Nearly 40% (n = 64) of patients presenting with acute coronary syndrome (N = 166) were deemed low risk according to scoring lower than 5 on the Atherosclerotic Cardiovascular Disease (ASCVD) risk score in new data from the 2024 European Society of Cardiology Congress. Additionally, 12% (n = 20) of patients were considered borderline risk with an estimated risk score of 5-7.5%.

Lead author Amir Ahmadi, MD, a cardiologist at Mount Sinai Foster Heart Hospital Morningside and assistant professor at the Icahn School of Medicine, and presenting author Anna Mueller, MD, an internal medicine resident, highlighted the need for new approaches that go beyond symptomatology and risk scores to directly detect underlying coronary disease.

This transcript has been lightly edited for clarity.

Transcript

What was the most interesting finding from your investigation on symptom-based screening methods for acute coronary syndrome?

Mueller: Overall, it's been a very humbling experience to work as a physician and to provide so much reassurance to patients that we traditionally consider low risk or no risk, and now are seeing that there are a lot of people who still have heart disease, even though they're considered to be low risk or no risk based on these factors.

These risk scores were developed when we had no real understanding about the pathology of heart attacks. We didn't have good imaging tools to assess subclinical coronary disease. Now that we do have these things, I think it's time to change how we assess for cardiovascular disease. And you know, we like to compare it to cancer screening, where we don't wait for colon cancer for you to develop symptoms or to just get a colonoscopy if you have risk factors; you screen everyone independent of that. And I think maybe the future is going to be similar for heart disease.

Ahmadi: As we mentioned, what we are really saying is that if people that just came in with a heart attack saw a cardiologist that is practicing according to the guidelines 2 to 3 days prior to the heart attack, half of them would be missed, and about close to half of them would not even be offered the statin because they were in a low-risk category. And what this suggests is that a fantastic effort that started in the [1960s and 1970s], that we identified risk factors now could be replaced by actually identifying the disease.

It's quite interesting for the public to know and for us to realize that when we talk about heart disease and screening for heart disease, we are really not looking at the disease. We are looking at the risk of disease, and we are looking at the guesstimation of that risk. The recent technology of [the CT scan] that started in the early 2000s—CT of the heart—completely disrupts that because now we can actually focus and look at the disease itself, treat the heart disease itself, which is the plaque in the coronary arteries, as opposed to treating the risk of disease—I think that's the main message.

Now, whether or not we can go to a population-level screening, that should be dealt with with a randomized trial, with further studies that show the cost-effectiveness of that. So, we are not making any suggestions for that at this point, but the concept of going from treating and detecting the risk of disease to treating and detecting the disease itself is what we are hoping to achieve and are suggesting by the outcomes of this paper.

Reference

Mueller A, Konje SK, Barman NB, et al. Symptoms and ASCVD score fail to identify majority of the patients at risk of first myocardial infarction. Paper presented at European Society of Cardiology Congress 2024; August 30-September 2, 2024; London, UK.