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To the Editor: We have several concerns about the study by Dr Greenland and colleagues.¹ First, the authors emphasized the lack of association between the CACS and risk among persons with an FRS less than 10%. In fact, such an interaction would be difficult to detect, and this study adds little evidence, given the low number of persons in the study with an FRS less than 10% (n = 98) and the low number of events in that subgroup (n = 1). Furthermore, measurement of the CACS in this low-risk subgroup is unlikely to be cost-effective.²

Second, the predicted event rates used in the authors' Figure 1 and in the ROC curve analysis are based on a model of linearly increasing risk with increasing CACS (untransformed). This probably leads to systematic underestimation of risk at low scores and overestimation of risk at high scores, as it assumes that risk increases . . . [Full Text of this Article]

Mark J. Pletcher, MD, MPH
mpletcher@epi.ucsf.edu

Jeffrey A. Tice, MD
Department of Epidemiology and Biostatistics
University of California, San Francisco

Michael Pignone, MD, MPH
Division of General Internal Medicine and Clinical Epidemiology
School of Medicine
University of North Carolina–Chapel Hill

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