Author + information
- Xiao Lin,
- Ling-Qing Yuan, MD, PhD and
- You-Shuo Liu, MD, PhD∗ ()
- ↵∗Department of Geriatrics, Institute of Aging and Geriatrics, Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Furong District, Changsha, Hunan 410011 China
We read with great interest the recent paper by Yoon et al. (1) published in a recent issue of iJACC. The authors reported that, in a large cohort of consecutive asymptomatic women, the presence and severity of breast arterial calcification (BAC) were significant predictors of the presence of subclinical coronary artery disease (CAD), including coronary arterial calcification and coronary atherosclerotic plaque, but bone mineral density (BMD) T score and low bone mass did not. We commend the authors for performing such a large and interesting study; however, there are several concerns with this study.
First, the study enrolled 2,100 asymptomatic women who underwent dual-energy X-ray absorptiometry to detect BMD, and 1,321 were postmenopausal women, which meant that one-third of the cohort consisted of premenopausal women. In addition, in their study, the authors defined “osteopenia” as a BMD T score below –1.0 and “osteoporosis” as a BMD T score below –2.5. However, Z scores, not T scores should be used, and a Z score of −2.0 or lower is defined as “below the expected range for age” in women before menopause according to the recent consensus of the International Society for Clinical Densitometry (2). Thus, the authors should use Z scores for premenopausal women to evaluate BMD. Therefore, we suggest that the authors should divide the subjects into 2 groups: premenopausal and postmenopausal, and use Z or T scores for the different groups, respectively. Thus, the relationship between BMD and CAD in premenopausal women should be analyzed again according to Z score.
Second, the present study was a retrospective design and found that BAC acted as an independent and incremental value over that of conventional clinical risk factors for CAD. However, another prospective Health Insurance Portability and Accountability Act-compliant and case-controlled study (3) reported that no significant correlation was observed between BAC and coronary heart disease in women. It may be that a different type of study could explain the differences in results between the 2 investigations. When women had a mammogram and could be counseled each time to control their risk factors of CAD, such as diabetes mellitus, smoking, physical inactivity, poor diet, and obesity, it would help them attenuate the risk of CAD and women could gain considerable benefits from prevention messages (4). Therefore, it is very meaningful to investigate how BAC changes over time when the cardiovascular risk factors were treated or disappeared. Moreover, the attitude toward BAC for women is also an important factor. If clinicians could help women feel empowered to engage in their health and make great effort to control the BAC risk factors rather than be afraid, even terrified, of those factors, then the detection of BAC could be used as a source of motivation to decrease the risk of future cardiovascular events. Therefore, it would be better if the authors had carried out a prospective study about the role of BAC in predicting the risk of CAD.
Please note: Supported by National Natural Science Foundation of China awards 81770833 and 81770881, National Basic Research Program of China (973 Program) award 2014CB942903, and Research Project of Graduate Students in Hunan Province award CX2017B069. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Yoon Y.E.,
- Kim K.M.,
- Han J.S.,
- et al.
- ↵International Society for Clinical Densitometry. 2015 ISCD Official positions: Adult. Available at: www.iscd.org/official-positions/2015-iscd-official-positions-adult/. Accessed October 21, 2015.
- Polonsky T.S.,
- Greenland P.