Does screening for peripheral arterial disease improve risk stratification for patients at intermediate risk for coronary artery disease?

developing coronary artery disease (CAD) are seen in primary care. Intermediate risk is classified as a calculated Framingham 10-year risk of 10% to 20% for patients without a history of arteriosclerotic disease or diabetes. A recent audit showed that 14% of patients aged 35 to 75 years in my family practice meet this profile. Recent Canadian dyslipidemia guidelines 1 have been criticized for promoting the overuse of statins for patients at low risk of developing CAD. 2 Statins decrease the relative risk of coronary events by approximately 30%. 3 If a patient has a 5% risk of developing CAD in the next 10 years, using a statin for 10 years would only reduce his or her absolute risk by 1.5% (0.3 x 5%); 67 patients would have to be treated for 10 years to prevent 1 myocardial infarction and 66 of these patients would not benefit from the treatment. With statins costing about $1 per day, treating 67 patients for 10 years would translate to $245 000 in drug costs alone. Patients at high risk of developing CAD (Framingham 10-year risk >20%) derive greater benefit from statins, and there is more evidence to support treating them. Several ways to further stratify patients at intermediate risk have been proposed. A family history of early CAD (a first-degree relative who developed CAD at age 50 years or younger) doubles the calculated Framingham risk. 4 A plethora of biomarkers, including C-reactive protein, B-type natriuretic peptide, aldosterone, renin, fibrinogen, D-dimer, plasminogen-activator inhibitor type 1, homocysteine and urinary albumin-to-creatinine ratio, 5 have been suggested as candidates to improve risk stratification. However, the accuracy of these biomarkers and the resulting risk adjustment is not clear, and a recent study found that even the use of multiple markers adds little to the Framingham score. 5 Using at least two high-sensitivity C-reactive protein measurements has been found to be a reliable marker for a new risk calculator in women (the Reynolds score) 6 but the additional complexity and expense of implementing this new score may limit its use in primary care. I am not using these biomarkers in my practice. There are other tests that can be used for risk stratification. The US Preventive Services Task Force recently reviewed CAD screening; the Task Force gave electrocardiography, cardiac stress exercise testing, and electron beam computed tomography (EBCT) an "I" rating (insufficient evidence to make a recommendation for or against) …