Performance of subclinical arterial disease detection as a screening test for coronary heart disease

Traditional risk factors are poor screening tests for coronary heart disease, whereas clinical arterial disease represents its strongest predictor. This raises the question whether subclinical arterial disease may also predict coronary disease. Using published data of prospective studies of subclinical arterial disease, we calculated the incidence of coronary event associated with the absence or presence of atherosclerosis as defined by dichotomous characterization of the following markers: low or high intima-media thickness or the absence or presence of plaque, assessed by carotid ultrasound; zero or high total coronary artery calcium score assessed by computed tomography; normal or decreased ankle-arm index pressure assessed by Doppler stethoscope; and low or high aortic pulse wave velocity assessed by mecanography. A dose-response relationship was found between the absence and presence of atherosclerosis and coronary event incidence. Yearly incidence was <1% in the absence of atherosclerosis regardless of the marker used. Coronary event incidence was >1% in the presence of atherosclerosis and increased in a gradual way, depending on the marker tested, to reach 3% maximum with massive coronary calcifications. The relation between clinically overt arterial disease, such as angina, transient ischemic attack, stroke, or myocardial infarct, and yearly incidence of subsequent events reported in the literature prolonged the dose-response curve of subclinical disease. Therefore, detection of arterial disease, not only clinically overt but also subclinical asymptomatic, is a worthwhile screening test for future coronary event.