Coronary Calcium Screening and the American Heart Association News Embargo
Coronary calcium imaging with computed tomography (CT) for the detection of coronary artery disease has emerged as one of several novel measures of cardiovascular risk. These measures, which also include C-reactive protein, homocysteine, lipoprotein-a, the ankle-brachial index, and carotid intimal-medial thickness, have been the subject of considerable interest on the part of the medical profession and the media for a number of years. Their role in the primary prevention of cardiovascular disease has not been firmly established, however, and hence the American Heart Association (AHA) has not recommended their implementation on a population-wide basis.
The AHA’s current position on CT scanning for coronary calcification has been articulated in 3 statements dating from 2000.1–3 When a physician is faced with a patient at intermediate risk, selected use of coronary calcium scores may be appropriate if the results have the potential to alter the treatment of the patient. The published literature does not yet, however, clearly define whether long-term patient outcomes can be improved by modifying treatment on the basis of coronary calcium scores. Thus, which asymptomatic individuals require or will benefit from CT scanning has not yet been determined with certainty. These statements pertain equally to the other emerging measures of risk noted above.
Coronary scanning with CT has received increased media attention over the past few months, perhaps in the wake of reports of cardiovascular procedures performed on noteworthy public figures. Recent reports in the lay press suggested that the AHA’s position on this subject was about to change and that the Association would endorse this technology for atherosclerosis screening in asymptomatic individuals. These reports have led to an unfortunate level of speculation by the public and the medical community, principally because the statement of imminent support is simply incorrect: The AHA does not endorse devices, equipment, or medications, and in no way has it stated or suggested otherwise for this or any other technology. In addition, the Association is not planning to alter its guidelines for the use of coronary calcium scanning.
How did this situation come about? We would like to review the events in detail because they inform readers about the complex relationships that exist among academicians, authors, the media, and commercial medical interests. More than 2 years ago, the AHA commissioned a panel of experts to write a Scientific Statement on the technical aspects of electron beam CT and multidetector CT to inform healthcare professionals about the differences in these competing imaging modalities as tools for the detection of coronary calcium. After lengthy discussion, peer review, and revision, the Scientific Statement was approved and submitted for publication to Circulation. The authors concluded that the use of these imaging technologies, although promising, will require corroborating data in larger clinical trials before the results of the small number of published studies can be used to change guidelines for coronary calcium screening. Most unfortunately, the topic of this Scientific Statement was discussed prematurely with the press and incorrectly interpreted to indicate that “[h]eart scans … are poised to win an endorsement from the American Heart Association, which has long been skeptical of their value.”4 There was, of course, no such endorsement for the reasons discussed above. In fact, the clinical information contained in this Scientific Statement did not differ significantly from the 3 previous AHA-commissioned position papers on the same topic.1–3 One of us (A.K.J.) wrote a letter to the editor of the newspaper in which this story appeared, explaining the AHA’s position on this topic and emphasizing that this position has not changed at this time. The newspaper in question promptly published a correction.5
Because information contained in the Scientific Statement had been prematurely released to and published by the lay press, the editors of Circulation decided not to publish the article. The editors made this decision because the lay publication of this information represented a breach of its time-honored news embargo (see below), and, more importantly, because publishing an article the message of which was misinterpreted in the lay press could have a potentially adverse effect on the health of the public. Interestingly, 2 days after the editors’ decision, 2 of us (J.L. and R.O.B.) received an unsolicited letter as part of a mass mailing to cardiologists extolling the virtues of electron beam CT. Citing the article in the lay press, the letter/advertisement claimed that “the American Heart Association is currently repositioning their [sic] statements to reflect the overwhelming evidence supporting” its use. The letter also offered the addressee the opportunity to obtain more information on preowned electron beam CT scanners “at a fraction of their original selling price,” given the “positive impact this [article] will have on insurance reimbursement.” Clearly, the impact that a news story of this sort can have on commercial interests in modern medicine and the cost of health care cannot be overestimated.
Many of the articles that appear in Circulation have a direct impact on the health and medical care of the public and are thus deemed newsworthy by the media. The conventional scientific format for presenting this information in the journal often can make interpretation of the results and the clinical implications of a study or Scientific Statement difficult for the lay public. For this reason, the News Media staff of the AHA have established a close working relationship with the media to facilitate communication of information published in Circulation. The established policy that defines this relationship involves the delivery of embargoed materials to members of the media before publication in the journal. This embargo policy has been designed to promote accurate reporting of the information and is given with the expressed understanding that the reporters receiving it will not publish the material before its publication in Circulation. In addition, there are strict times for release of the embargoed information to which all participants adhere, giving no reporter an undue advantage over any other. Other journals have established similar embargo policies.6–8 In light of the embargo policy and its strict ground rules, we urge authors of manuscripts accepted for publication in Circulation to direct all prepublication inquiries from the media to the News Media staff of the AHA.
The concept of an embargo on publishing newsworthy information may appear to run counter to the very essence of the journalistic profession. Nevertheless, participating media representatives generally accept this restriction for the greater good of ensuring that the information they report is absolutely accurate, presumably because they take their responsibility to report information about matters of health most seriously. There is, however, a prevailing sense of competition and concern that one reporter can undermine another should he or she choose to break the embargo. Thus, trust is an essential component of a successful embargo policy.
The embargo of new information that may influence medical care serves several purposes that we believe benefit the public: By providing all reporters the full article for review, it ensures that the information published in the media is accurate, and it gives physicians and other caregivers access to the original information at the same time as their patients gain access to the lay press reports, allowing for reasoned responses to patients’ questions. These 3 principles—accuracy, access, and timeliness—are the cornerstones of the embargo policy and generally have served the public and media well.
As of the time of this writing, it is unclear how the embargo policy was breached and the information reported prematurely (and inaccurately). The source of the inaccurate information about support or endorsement of the technology by the AHA remains unknown. We do, however, acknowledge the prompt response of the journalist involved to correct the information available to the public as soon as the error was pointed out to him.5
It is unfortunate for the authors who participated in the drafting, editing, and revising of a commissioned Scientific Statement to have their manuscript withdrawn from publication. The editors made this decision after much deliberation and did so because not to do so (1) would send a message that breaking the embargo is of no consequence and (2) would be unfair to those members of the media who honored it. Some would argue that the embargo did not apply here because the AHA’s News Media staff had not yet delivered formal embargoed material to the press and because this was an official Scientific Statement of the Association and not an original scientific paper. The editors, however, believe that the spirit of the embargo is of utmost importance in maintaining the scientific integrity of the journal and that premature release of scientific content can lead to false speculation as to scientific results or Association policies, as was proven to be the case in this instance. Such speculation has the potential to influence unduly the hopes of individuals affected by cardiovascular disease, medical practice, and the marketplace. Thus, a manuscript scheduled for publication in Circulation, regardless of the prematurity of the release of information or the nature of its content, is still bound by the intention of the embargo.
For an embargo to serve the public effectively, all participants—authors, editors, and reporters—must take it seriously. It is unfortunate, indeed, that the multiple factors that can lead to premature publication of scientific information may overcome the greater purpose of reporting information that can affect patient care accurately. The editors of Circulation hope that they will not be forced to exercise this prerogative in the future but will if necessary to ensure that all participants honor this important policy.
Greenland P, Abrams J, Aurigemma GP, Bond MG, Clark LT, Criqui MH, Crouse JR III, Friedman L, Fuster V, Herrington DM, Kuller LH, Ridker PM, Roberts WC, Stanford W, Stone N, Swan HJ, Taubert KA, Wexler L. Prevention Conference V: Beyond secondary prevention: identifying the high-risk patient for primary prevention: noninvasive tests of atherosclerotic burden: Writing Group III. Circulation. 2000; 101: e16–e22.
O’Rourke RA, Brundage BH, Froelicher VF, Greenland P, Grundy SM, Hachamovitch R, Pohost GM, Shaw LJ, Weintraub WS, Winters WL Jr, Forrester JS, Douglas PS, Faxon DP, Fisher JD, Gregoratos G, Hochman JS, Hutter AM Jr, Kaul S, Wolk MJ. American College of Cardiology/American Heart Association Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation. 2000; 102: 126–140.
Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC Jr, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL; American Heart Association. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004; 109: 672–693.
Winslow R. Major medical group expected to support use of EBT test; measuring calcium build-up. Wall Street Journal. September 21, 2004: D1.
Winslow R. Paper on heart scans, calcium, won’t be published by group. Wall Street Journal. October 8, 2004: B4.