In a column published on jamesstein18.substack.com, a preventive cardiology specialist argues that routine surveillance testing and repeat imaging for stable heart disease patients are clinically unnecessary and fail to prevent myocardial infarction or death. The author writes that cardiovascular disease is driven by plaque biology rather than plumbing blockages, meaning that monitoring risk factors through blood work is far more effective than repeating scans and stress tests.
Why Cardiology Culture Shifted Toward Testing
For decades, standard medical practice relied heavily on annual stress tests, routine electrocardiograms, and repeat imaging to track patient health, jamesstein18.substack.com reported. The author writes that this culture of vigilance was built on the logical assumption that if a test originally identified a condition, repeating it would show whether the disease was improving. However, the author argues that atherosclerotic cardiovascular disease does not behave in a way that makes routine surveillance useful, as heart disease stems from plaque instability rather than simple blockages.
The 2023 chronic coronary disease guidelines specifically recommend against routine periodic stress testing for patients whose clinical status remains unchanged. Furthermore, the author notes that repeated testing frequently uncovers incidental findings that trigger downstream procedures, exposing patients to unnecessary radiation, bleeding risks, and complications.
Monitoring Risk Factors Instead of Plaque Stability
Rather than attempting to track individual plaques—a capability modern medicine lacks—the author focuses treatment on controlling underlying risk factors. Citing imaging studies such as GLAGOV and PACMAN-AMI, the author explains that lowering LDL cholesterol and apoB to sufficient levels allows plaques to stabilize and regress by reducing intraplaque inflammation and shrinking the lipid core.
In clinical practice, the author aims for LDL cholesterol levels below 55 mg/dL and triglycerides below 100 mg/dL for most patients with established atherosclerotic cardiovascular disease, which generally corresponds to an apoB level below 65 mg/dL. Additional targets include maintaining systolic blood pressure below 130 mmHg at home, avoiding cigarette smoke entirely, and optimizing hemoglobin A1c levels for older adults or patients with longstanding diabetes.
When Coronary Artery Calcium Scans Should Never Be Repeated
According to the author, a coronary artery calcium (CAC) scan should almost never be repeated once an initial abnormal score has guided patients toward necessary risk factor modification and statin therapy. The author writes that a single CAC score offers only modest prognostic evidence, and the clinical data supporting serial calcium scoring to improve patient management is exceptionally thin.
Effective lipid-lowering therapy frequently causes CAC scores to increase because shrinking lipid cores leave behind denser, more consolidated calcium deposits. Consequently, a rising CAC score can occur simultaneously with a declining overall cardiovascular risk. The author identifies only one narrow scenario where repeating a CAC scan is justifiable: when a patient with a baseline score of zero refuses lipid-lowering medication, and a newly positive score might convince them to adopt healthier behaviors.
Frequently Asked Questions
Why do effective statin therapies sometimes cause coronary artery calcium scores to rise?
As apoB and LDL cholesterol levels drop, the lipid-rich core of an arterial plaque shrinks and the remaining calcium becomes denser and more consolidated. This physical consolidation leads to a higher CAC score on imaging, meaning the score can increase even as overall cardiovascular risk decreases, as noted in studies published in the Journal of the American College of Cardiology.
What specific LDL cholesterol target does clinical practice recommend for patients with atherosclerotic cardiovascular disease?
The author aims for an LDL cholesterol level below 55 mg/dL for most patients with established atherosclerotic cardiovascular disease. This target generally corresponds to an apoB level below 65 mg/dL and a triglyceride level below 100 mg/dL.
Under what specific condition is repeating a coronary artery calcium scan considered acceptable?
The author occasionally repeats a CAC scan only in a patient who has a baseline score of zero and refuses lipid-lowering therapy. If obtaining a positive score would successfully motivate that patient to change their health behavior, the scan is considered.
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