Comment on "Coronary artery calcium in type 2 diabetes: a nested case-control study": authors' reply.

132 To the Editor The coronary artery calcium score (CACS) emerges as a useful marker of coronary ar‐ tery atherosclerosis and cardiovascular risk.1,2 Cor‐ onary calcifications are related to coronary artery plaque burden but not to plaque instability and cannot be used to exclude coronary atherosclero‐ sis. The measurement of the CACS may play an im‐ portant role in the reclassification of subjects into high and low risk of cardiovascular death. Due to an increasing burden of diabetes in the Polish population, the correct assessment of atherosclerotic burden and risk stratification in these subjects is crucial.3 To date, there have been several studies aiming to determine the role of CACS measurement in patients with diabetes. Sosnowski et al.4 conducted an interesting nested case‐control study comparing the CACS between subjects with and without type 2 diabetes. In their report, symptomatic subjects with diabetes demon‐ strated a higher CACS, showing a link between di‐ abetes and coronary calcifications independent of other risk factors. Their findings support the pres‐ ence of higher coronary artery plaque burden and cardiovascular risk in diabetic subjects. Interest‐ ingly, despite the exclusion of individuals with high pretest probability of coronary artery disease, the high proportion of patients with diabetes had a CACS higher than 400, which is considered as a surrogate for high cardiovascular risk. It is widely accepted that the CACS, plaque morphology, and plaque burden assessed by multidetector comput‐ ed tomography provide an incremental prognos‐ tic value in subjects with suspected coronary ar‐ tery disease.5 However, it is still unclear whether and how this increased risk should be managed. Nevertheless, the reclassification of cardiovascu‐ lar risk based on the CACS and plaque morphol‐ ogy seems to be an attractive concept, and more data are needed to modify the preventive strate‐ gy based on imaging data. The issue is particular‐ ly important in diabetic subjects with a high car‐ diovascular risk per se.