This story touting the benefits of certain screening tests for heart disease concludes with a claim that is simply unbelieveable: that doctors practicing aggressive prevention techniques are seeing heart attacks and strokes “disappear.” Although the story includes a few cautionary comments, it low-balls the costs of screening, ignores many potential harms of inappropriate screening, misrepresents the quality of evidence, and fails to accurately describe existing alternatives. The story gives the megaphone to a doctor who “invented one of the imaging tests” to make over-the-top claims of the benefits of screening. The story also includes, without rebuttal, this sensationalistic and fear-mongering comment from the doctor: “Unless you do the imaging, you are really playing Russian roulette with your life.”
Cardiovascular disease is the leading killer in the United States. The demand for better screening tests is strong, but readers of this story are not told that coronary calcium scoring, carotid ultrasound, and LDL particle size screening are not recommended for broad use by leading medical groups. Screening tests are double edged swords. When used in the right context, they can define a person’s risk and improve outcomes. When misapplied, they are wasteful of resources and expose people to unnecessary risks. The coronary calcium score, carotid ultrasound and sophisticated assessment of LDL cholesterol can be important diagnostic tools when applied in the correct patient population, but readers of this story deserved to be clearly informed that their value for most people is yet to be proven.
The story does discuss costs. However, it low-balls what people may be actually charged for the scans, which may include facility fees, reading charges and other costs. For example, one insurance company cost calculator (https://www.alegent.com/body.cfm?id=4735) estimates the cost of heart CT scan for calcium to be more than $600 and a carotid ultrasound to be about $700 for people paying for their own scans, so instead of the “less than $100 for both” figure reported in this story, a person getting both scans might be hit with a bill for well over $1000. Also, the statement that these scans are “often covered by insurance” is misleading, since insurers are likely to cover the scans only for patients considered to have an elevated risk, not for everyone. For example, Aetna, one of the largest insurers in the United States, considers coronary calcium scoring investigational, not medically necessary. See http://www.aetna.com/cpb/medical/data/200_299/0228.html
The only quantifiable statement about benefits included in this story is that “doctors who are practicing aggressive prevention are really seeing heart attacks and strokes disappear from their practices.” A claim that any combination of tests and treatments can completely prevent heart attacks and strokes is unbelieveable. The incremental benefits that some recent studies have reported in certain patient groups are not clearly spelled out in this story. Those the kinds of numbers that readers should have been provided.
As with costs, this story mentions harms, yet generally misleads readers. While the story emphasizes potential long-term benefits of screening, there is no mention of the downstream risks of tests and treatments triggered by the initial screening scans. For example, someone found to have a high coronary calcium score may be referred for an invasive coronary angiography exam, which in rare cases can cause serious injury or death. This story fails to point out the typical downsides of screening, especially for low-risk individuals who are less likely to gain important benefits.
The Aetna insurance company statement mentioned above states that “the definitive value of calcium scoring for assessing coronary heart disease risk has not been established in the peer-reviewed published medical literature.” The United States Preventive Services Task Force (USPSTF) recommends against scanning for coronary calcium in low risk individuals and says the evidence is insufficient to make a recommendation either way for people at increased risk for coronary heart disease. ( http://www.uspreventiveservicestaskforce.org/3rduspstf/chd/chdrs.htm) As far as screening for carotid artery stenosis, the USPSTF states emphatically that for the general population: “Do not screen with ultrasound or other screening tests.“
By contrast, this story trumpets the unabashed enthusiasm displayed by Dr. Agatson for the three tests that goes well beyond the general impression of most cardiologists in the United States. The closing line of the story includes an astonishing assertion that screams for documentation: “One of the best-kept secrets in the country in medicine is the doctors who are practicing aggressive prevention are really seeing heart attacks and strokes disappear from their practices. It’s doable,” Agatston says. The claim that a few screening tests can make heart attacks and strokes disappear flies in the face of even the most optimistic interpretations of recent studies that indicate some incremental advantage to adding coronary calcium scoring to risk fact calculations for certain patients.
This story exemplifies disease-mongering by highlighting threats of terrible consequences and wildly exaggerating the number of people likely to benefit from these scans. With statements like, “unless you do imaging, you are really playing Russian roulette with your life” and “Agatson thinks that the coronary artery calcium scan should be routinely scheduled at age 50…” provide the uninitiated reader with the impression that everyone needs one of these tests. While the comments of Dr. Michos modify the unabashed enthusiasm, the overall tenor is over the edge.
Considering that the United States Preventive Service Task Force and other major medical groups do not recommend coronary calcium scoring or carotid ultrasound screening for most people, this story should have included comments from someone explaining that consensus opinion.
The premise of this story is that screening tests can make a dramatic difference in heart disease. In reality, the tests may offer an incremental improvement in predicting risk among certain people who fall into a gray middle zone of risk based on conventional methods. There is a reference to the use of these tests in people with intermedicate risk, but the broad claims at the beginning and end of this story overwhelm any reasonable comparison between the touted tests and established alternatives. The story mentions diet and lifestyle changes only in the context of a claim that these tests “give patients a chance to make major changes in their diet and lifestyle.” The story fails to note that people routinely stick to bad habits even when told they have a high risk of health problems or that since improving diet and lifestyle has benefits for everyone, an alternative approach would be to focus more effort and attention on effective strategies for changing behavior.
The story makes it clear that the three tests discussed are available at most hospitals.
Coronary calcium scoring has been a hot topic in heart disease prevention for well over a decade. Does it still qualify for the “relatively new” description used in this story? Certainly there is an evolving scientific discussion about which individuals are likely to benefit from these tests, but that sort of nuance is largely missing from this story.
The story does not rely on a press release.