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The Authors Reply We appreciate the interest and comments from Dr. Balta et al. on our study, “Prevalence of angiographically defined obstructive coronary artery disease in asymptomatic patients with type 2 diabetes according to the coronary calcium score,” which was published in Internal Medicine (1). Coronary artery calcium (CAC) scoring has emerged as a promising tool for screening patients for coronary artery disease (CAD) (2). In particular, there has been much attention paid to the ability of CAC scoring to rule out the presence of obstructive CAD (3). The results of our study showed that a CAC score of 0 on 64-slice dual-source computed tomography (DSCT) cannot reliably exclude obstructive (CAD) on conventional coronary angiography (CAG) in asymptomatic patients with type 2 diabetes. The ability of CAC scoring alone to detect obstructive CAD seems to be limited because it cannot detect obstructive CAD caused by non-calcified plaques. We found that significant coronary artery stenosis by non-calcified plaques frequently occurs in patients with type 2 diabetes, even in the complete absence of calcification. Thus, computed tomography angiography (CTA) should be combined with CAC scoring when screening for CAD in asymptomatic patients with type 2 diabetes. However, a recent meta-analysis showed that the presence of CAC has a high negative predictive value for obstructive CAD, thus suggesting that a CAC score of 0 can safely exclude obstructive CAD (3). Therefore, our conclusion cannot be generalized to other populations. In our study, patients with normal coronary arteries or non-obstructive CAD on DSCT were not referred for CAG. As noted by Dr. Balta et al., our study would be stronger if these patients were evaluated with CAG, because multidetector CT angiography was shown to be unable to replace CAG (4). However, another prospective study showed that multidetector CT angiography has an extremely high ability to exclude obstructive CAD, thus suggesting that it can be used as an effective noninvasive alternative to CAG to rule out obstructive CAD (5). Therefore, it would not have been ethically justified to perform invasive CAG in asymptomatic patients with negative results on DSCT. Despite this potential limitation, the results of our study indicate that CAC scoring alone has a limited role for screening asymptomatic patients with type 2 diabetes for CAD. We hope that future studies will guide the optimal use of CAC scoring, CTA and CAG for screening this population for CAD.

Reply to the Letter by S. Balta Regarding "Patients Should Undergo Conventional Angiography to Reveal Any Suspected Coronary Artery Lesion"