Statins are the UK’s most commonly prescribed drugs and are among the most widely prescribed drugs globally. Though their use in people at high risk of stroke and heart disease is uncontroversial, recent recommendations to treat much larger numbers of people at low risk have caused a storm of controversy. Most hotly debated are the nature and frequency of side effects of statins and whether arguably small gains in life expectancy are worth the risk.
The coronary artery calcium score has high sensitivity for detecting coronary stenosis—so a negative result makes significant coronary stenosis unlikely—but low specificity, and 60% of those without coronary artery disease will also have a positive result
Thus many low risk patients may be diagnosed with coronary artery disease using the calcium score, although they may have clinically insignificant or “bystander” disease. These patients may benefit little from investigation and treatment and may be harmed
The exercise tolerance test is a quick, functional investigation that measures maximum exercise tolerance. In low risk patients who are likely to achieve a high workload the test can identify patients with high relative survival without the need for further imaging