Primum Non Nocere Old Principle Revisited

Williams et al. (1) reported the consequences of coronary computed tomographic angiography (CCTA)-assisted diagnosis on invasive coronary angiography, preventive treatments, and clinical outcomes. Undoubtedly, CCTA-derived disease burden (nonobstructive and obstructive) is associated with nonfatal and fatal myocardial infarction (MI). Having said this, the positive and negative predictive value of CCTA to detect lesions associated to MI is questionable, because the number of mild (372), moderate (300), and severe (452) coronary lesions were many more than the total number of MIs. (There were 9 and 17 myocardial infarction cases occurring before and after the implementation of preventive measures, respectively.) It is not even clear whether those identified lesions at baseline were the culprit lesions of such events. Are those 26 MIs linked to focal lesions on CCTA? In other words, have authors adjudicated the MIs to a specific plaque? Or is the total burden of the coronary disease just a marker of a higher-risk population?

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