We read with interest the letter by Rutter and Nesto (1) in reply to our review article; however, we believe we had already addressed several, if not all, of the concerns they express. In fact, we made the following statements in our study. 1) “Our goal was to verify whether existing data support the use of these techniques (ischemia and atherosclerosis imaging) in isolation or as complementary tools for improved risk prediction” (not necessarily management!). 2) “Continued research will be needed to confirm that the integration of several imaging modalities improves clinical outcome in a cost effective manner.” 3) “Figure 1 is an algorithm with… an attempt to integrate ischemia and atherosclerosis imaging… based on personal opinion.” 4) “Whether all asymptomatic diabetic patients should be tested remains debatable and unlikely to be financially affordable for society. To make asymptomatic screening more affordable at least one of the following conditions should be present…”

The tone of our writing was more one of hope for improvement in risk assessment than a call for unnecessary expenditure. Unfortunately, the prevailing argument used by Drs. Rutter and Nesto, that atherosclerosis imaging leads to unnecessary invasive diagnostic and interventional procedures, is a bit trite and not supported by substantial literature. On the contrary, some of us have shown that the performance of calcium screening in symptomatic patients at low-intermediate pretest probability of disease reduces the rate of normal cardiac catheterizations (hence unnecessary) and increases the number of “necessary” procedures, with a net 30–35% saving compared with a traditional diagnostic pathway (2). It was far from our intention to instruct physicians on doing unnecessary procedures; it was our desire to educate the readers as to what is currently known regarding coronary artery disease imaging in diabetes. The summary is that ischemia imaging is useful in some subgroups of diabetic patients, but it fails to completely define risk in a sizable portion of individuals and for any prolonged period of time. The enormous burden of disease inherent in diabetes deserves, therefore, better risk assessment. Evidence is accumulating that atherosclerosis imaging may help this task progress. Large amounts of calcium or an increased intima-media thickness actually adds useful prognostic information in diabetes (3,4), and absence of calcium is a good marker of low risk in diabetic and nondiabetic patients alike (3). Our appeal is for a conscientious application of imaging techniques while we learn more about their risk and benefit, as we use them daily.

Rutter MK, Nesto RW: Ischemia imaging and plaque imaging in diabetes: complementary tools to improve cardiovascular risk management (Letter).
Diabetes Care
Raggi P, Callister TQ, Cooil B, Lippolis NJ, Russo DJ, Patterson RE: Evaluation of chest pain in patients with low to intermediate pre-test probability of coronary artery disease by electron beam computed tomography.
Am J Cardiol
Raggi P, Shaw LJ, Berman DS, Callister TQ: Prognostic value of coronary artery calcium screening in subjects with and without diabetes.
J Am Coll Cardiol
Bernard S, Serusclat A, Targe F, Charriere S, Roth O, Beaune J, Berthezene F, Moulin P: Incremental predictive value of carotid ultrasonography in the assessment of coronary risk in a cohort of asymptomatic type 2 diabetic subjects.
Diabetes Care