The skeptical cardiologist was contacted in June by a reader seeking my input to help tell a story.
He shared with me that he had recently undergone a coronary artery calcium (CAC) scan and was impressed with how simple yet beneficial the test was:
I’m 57 and I have always had borderline high cholesterol. Recently though, my doctor recommended that I find out my Coronary CT Calcium Score. I got one over at St. Lukes and it was a 54. What blows me away is that this highly informative test is virtually unknown to the general public. No one I’ve mentioned this to has ever heard of it. I want to help change that.
I was disappointed to hear that so few are aware of the test given that I have written extensively about CAC testing to help in deciding which patients benefit from lipid-lowering therapy. For an introduction to the test see my post entitled “The Ultimate Guide to the Coronary Artery Calcium Scan” post. For the latest on the prevention of coronary heart disease see my post on “The Importance of Imaging and Advanced Biomarkers.”
The reader went on to ask for my input in the animated story he wanted to make:
I can tell you much more, BUT I’m a partner in an information design firm here in St Louis and have decided to make a 3 minute animated story out of my experience in the hopes of helping more people. I want people to know that this test exists, who should consider getting one, and a little bit of the science that goes into it. I’m wondering if you would be interested in looking at the script and storyboard to make sure I’m telling an accurate, credible story.
The reader was Scott Matthews, a designer, illustrator, and storyteller, and co-founder of a St. Louis company called Tremendousness. His company has made videos for TED and has collaborated in the past with Gary Taubes and Dr. Robert Lustig on The Sugary Truth. Tremendousness “crafts highly visual stories that turn your ideas into amazing actions and outcomes. These stories help you humanize transformation and change, accelerate innovation, and power sales, marketing, and thought leadership.”
I was excited to give my feedback and input on the content and now Scott and his team’s video is freely available for your education and/or enjoyment:
Please feel free to share this video with your friends, patients, and loved ones, especially those who have a history of parents or siblings with sudden death, heart attacks, coronary stents, or bypass surgery before the age of 65 years. Individuals who are “on the fence” about taking a statin will also benefit from spending 3 minutes looking at this video.
Semitremendously Yours,
-ACP
N.B. Although the CAC test utilizes a CT scan it is not the same as a coronary CT angiogram or CCTA. The CCTA requires the injection of a dye material, involves more radiation, and is more expensive than the CAC scan.
N.B.2 See comment from Dr. Osborne who correctly points out that a CAC score of 54 is actually high for a 57 year old white male and is not cause for celebration. Part of my input to the video was to dispel the idea that a score <100 is low risk in a youngish person. The significance of the score is highly related to the individuals age and gender. This is best determined by using the MESA coronary calculator and risk estimator. Hopefuly, your PCP or cardiologist can put the score in the proper context.
36 thoughts on “Worried About Cardiovascular Disease or High Cholesterol? Check Out This Video”
Good grief Jim, Your report regarding your high CAC score is the most reasssuring I’ve read today. And, I’ve been reading all day long. I was shocked and surprised when I received a phone call telling me I scored a 1129 on my recent CAC test. Though I’ve been on statins for several years, I believe I take good care of myself, eat well and get plenty of exercise. To say I have anxiety, is an understatement. I’ve had annual stress echo tests and everything is reported to be fine. I’ll have another stress echo next week and am hesitant to complete my typical swim workouts in the interim. Not sure if I’ll need an angiogram to confirm my arteries are clear. Regardless, I do appreciate your report and glad to hear there is still some hope.
Dr P,
Thank you for answering my question and that makes a lot of sense.
I have been thinking about why statins are so effective at lowering risks of MI aside from lowering APOB levels by blocking a cholesterol synthesis pathway and to some degree up regulating hepatic clearance. One thought that came to mind was that as you have mentioned multiple times statins increase the Ca++ in endothelial lesions thereby increasing the stability of the lesion and lowering the chances of rupture. In looking at the conclusions of the SCOT-HEART trial, it appears again as you have stated previously before that low attenuation plaque burden in patients with stable chest pain is the strongest predictor of fatal and non fatal MI. Getting to my point, I wonder if early interventions of statins “buy patients time” to revascularize or develop more collateral arteries in cardiac tissue. From reading I have gleaned that the process of angiogenesis or the growth of these anastomotic channels takes many years and could be the body’s way of circumventing stenotic vessels. I have also read that younger MI patients have less of these anastomotic channels and therefore when confronted with occlusion by thrombus or stenosis sometimes have more ischemic cardiac tissue damage than there older counterparts do. So I wonder if statins also delay/prevent rupture of lesions which in the long term might allow for these anastomotic channels to develop, thereby providing an alternative perfusion pathway to cardiac tissue in the event of blockage in another part of the coronary artery.
Not much to add that others haven’t said about the video, good simple message to risk stratify the need for a statin. One limitation as mentioned is that CAC cannot quantify soft plaque, however I have read IVUS can quantify soft plaque based on the echogenicity of plaque images during a CA. Is this correct, and if so can they give an objective density of a coronary lesion or is it an estimate. Since IVUS would be invasive I know it would be impractical in many preventative applications, I was just curious what diagnostics were out there that can identify and quantify soft plaque and if there was anything on the horizon that was non invasive.
Christian,
Methods for quantitating soft plaque are not yet in the clinical realm. IVUS can be used to quantify and characterize plaque features including thickness of fibrous cap, amount of lipid, etc. at a single point in the artery. But to measure throughout all of the coronary artery length and in all 3 arteries would be a very tiresome and laborious process, one which would put the individual getting the test at high risk of complications.
OCT is another technique which is intravascular and therefore invasive.
CCTA is our best hope for a “noninvasive” method to fully characterize and quantify atherosclerotic plaque burden.
In the clinical realm, however, you are not going to get a “score” for overall soft plaque similar to the score we get for CAC.
Dr P
The CAC only measures hard plaque. The CT angiogram measures hard and soft plaque. Why not recommend that instead?
Tina,
It appears your exact question has been answered.
Dr P
The CAC only measures hard plaque. To see hard and soft plaque you need a CT angiogram. Why not recommend that instead?
Leanlulu,
I indicated earlier in the comments that the CCTA or CT angiogram of the coronary arteries is more expensive with more radiation and involves the administration of dye which carries risks of allergic reactions and kidney damage.
The CAC not typically covered by insurance should only cost around $100 and therefore works pretty well as a screening test for advanced atherosclerosis.
The CCTA would also not be covered for screening and costs vary wildly but I was able to get it for patients who were very affluent and very proactive about there health for $850. As I mentioned in earlier comments I’ll put a post together focusing on this topic soon which would cover the situations where I might recommend CCTA for screening (meaning patient has no symptoms or signs of CAD and no abnormal stress testing or ECG)
Thanks, I guess it varies by locale then as my CT angiogram was covered by insurance and I just paid a small co-pay. I was able to learn that all of my plaque was densely calcified, i.e., no soft plaque which is good I think? Not sure.
Leanlulu,
I am shocked that your insurance company covered the CCTA.
I’d be interested in knowing more details of their coverage. Can you email me details at drp@theskepticalcardiologist.com?
thanks
dr P
I turned 60 years old in 2020. During my annual physical, I asked my PCP if I should have my heart looked at because of my age. This was my idea, not my doctor’s. I am a male and a health nut. I eat well, have a BMI of 22, run half marathons several times a year and have normal cholesterol levels. My calcium score came in at 1,027. That is not a misprint. My calcium score was over one thousand! My cardiologist told me I was on borrowed time and was amazed I had not yet had a significant cardiac event. He performed an angiogram fully expecting to insert several stints. My angiogram, however, showed my arteries were clear. All of the accumulated calcium was on the outside of my arteries and “posed no health risk.” I continue to run approximately 40 miles per week, feel great and am completely asymptomatic for heart disease. This “off the chart” calcium score caused me a great deal of anxiety during the months I needed to wait for my dispositive angiogram. Moral? If you have a high score, schedule the angiogram to be certain. A $100 dollar test not covered by insurance should not alone alter your life style or place you on unneeded medications. Thank you for reading…
Jim
Thanks for your comments but I disagree strongly with your cardiologist’s comments and approach and with your conclusions.
First, I would never tell a patient they were living “on borrowed time” or that I’m surprised they haven’t had a cardiac event. My goal in communicating the results is to let the patient know they have a significant burden of atherosclerotic disease and that this is good to know because now we can work preventing future events.
Second, I’ve written a post on this blog that talks about cardiac events after so-called “clean angiograms.” This is not uncommon because the angiogram is not capable of visualizing early plaque disease due to positive remodeling. The plaques don’t protrude into the lumen of the artery they grow outward and can be quite sizeable. An invasive angiogram is the absolute worst test to do after a high CAC score in an asymptomatic individual because of the risks of the procedure, the possibility of inappropriate stenting and this failure to recognize early CAD. I’d suggest you get a second opinion from a cardiologist who specializes in preventive medicine and doesn’t jump to performing invasive nonindicated procedures.
Third, neither the cost of the test nor insurance coverage is relevant. CAC is incredibly useful for better determining patient’s risk.
Great thread, with great information. I am 61 yrs old, workout 5 days a week religiously and have been for 25+ years, don
t smoke, don't drink, eat super clean, no sugar, no starch except for lots of fruits, veggies and sweet potatoes. I over performed on my treadmill test, carotid artery looked fine and a heart scan showed no damage. My cholesterol was 215 without statins and 143 with a low dosage, LDL 97 and HDL was 48, but my LDL-P was 1420 and I have occasional PVCs. But the big one that has me concerned was my calcium score, it was 320! The doc didn`t seem alarmed, he just told me to start taking a stain, no other advice offered. Any thoughts?I have no idea why the font changed, that`s not how I submitted it.
Deano,
Thank you. Given that your lifestyle is sterling, I presume you inherited factors accelerating coronary artery plaque development. See the post I reference on advanced biomarkers.
Your CAC score is very high for a woman your age, especially one without lifestyle risk factors and thus your ASCVD risk is high.
It is appropriate to start a statin but based on your LDL post statin I’d say you are not on enough or not on a high intensity one.
For individuals in your category I like to see apo B and LDL <70. I haven’t been check LDLP since I moved to apo B but you want that <1000.
If you are interested in a more aggressive approach to lowering your ASCVD risk let your doctor know and start a discussion.
Dr P
Thanks Dr. P, just a side note, I`m a man. Do you see patients via telehealth?
Oops! Sorry about that. I will contact you about telehealth.
For a 61 year old man, that CAC score is at the 71 st percentile. Still quite high for age.
For a woman, I did not even need to make the calculation it is so high. It is at the 96th percentile
https://www.mesa-nhlbi.org/Calcium/input.aspx
Dr P
Would it be beneficial to do the Calcium test again, just to make sure it wasn`t way off?
Dr. Pearson,
As with many roadmaps and guidebooks for the human body, the more you get into the details, the more complex the picture becomes.
Three articles with different perspectives:
https://www.aafp.org/afp/2019/1215/p734.html#:~:text=Data%20from%20the%20MESA%20cohort,6%25%20of%20those%20without%20events
(Don’t use the test. There’s too much testing leading to harms already.)*
https://jamanetwork.com/journals/jamacardiology/fullarticle/2722746
(It’s all in the sort of physical activity that got you the CAC in the first place.)*
https://www.mdedge.com/cardiology/article/103427/imaging/esc-coronary-artery-calcium-score-gets-upgrade
(If it’s dense, you’re OK.)*
*My simplistic descriptions, for lack of engaging headlines.
Jeff,
If we dive into the weeds of coronary calcium we can find many confusing findings. Very high density plaques are more stable, most likely reflecting maturation/healing and transition from the lipid-rich/vulnerable state, something that statins accelerate. The relationship between exercise, calcium and ASCVD risk needs more study.
I strongly disagree with Dr. Mandrola on this issue although I almost always agree with him on the value of interventional cardiology procedures which carry high risk and expense.
Dr. Mandrola is an electrophysiologist which means he is not in the trenches which primary care docs and preventive cardiologists who have to daily make recommendations to patients on what their risk of heart attack is and how best to reduce it.
The vast majority of preventive cardiologists have embraced CAC in their practice because they recognize both from available data and their own experience how valuable a tool it is.
I would also point readers to my post on Eric Topol, arguably the most prominent cardiologist on social media who has his head in the sand regarding CAC. https://theskepticalcardiologist.com/2019/08/10/are-you-taking-a-statin-drug-inappropriately-like-eric-topol-because-of-the-mygenerank-app/
Dr P
Nice little video! People don’t generally know about this test and nope, insurance doesn’t pick it up. Cost to me: $250. Had a stroke in 2003 age 51. Familial hyperlipidemia had been untreated (no other factors; I am thin, don’t smoke, good diet etc. Only other issue is somewhat limited cardio exercise due to multiple sclerosis.) Thereafter a small dose of lovistatin kept/keeps lipids in check. Calcium scoring 16 years later: 0. Yippee! I’ve recently developed an arrhythmia, getting to the end of a month of a monitor. I’ve been reading your info on arrhythmias. I’ll see what the monitor says. All of this said, I don’t feel like I’m going to have a heart attack after the results of calcium scoring.
Thanks for this blog! ?
Dear Dr. Pearson, I certainly enjoy your articles and find them interesting and many times clinically useful. I completely agree that the CAC is an essential tool in primary prevention and is woefully underused in clinical practice.
However, endorsing this video and it’s conclusions for this individual is unfortunately misleading and quite possibly harmful to others who view it. Furthermore it underscores the all-too-common inappropriate interpretation of the CAC score, even when it is ordered.
I’ll assume that the lipid numbers, the patients age, and CAC score noted in the video are real and are this particular patient’s numbers. His LDL is quite high and we’ll over the median LDL of 120 mg/dL (in the untreated US adult population). Furthermore his non-HDL is also elevated at 175, but with a good HDL (for whatever that means, honestly) and his TGs (which are quite amenable and modifiable to diet and exercise, unlike LDL) are quite good, indicating that he probably is pursing a reasonable lifestyle approach. In this particular case, his most important aberrant lipid target is his LDL which is largely genetically determined and, as opposed to TG, not likely to significantly respond to lifestyle changes. In fact, any change or lowering in his LDL with diet and exercise (which alas, since it largely driven by genetics and NOT lifestyle is generally about 5 to 10 percent reduction in LDL on average and given his “good” TG and HDL numbers likely indicating he is following a heart-healthy lifestyle) is probably already reflected in his LDL of 157 mg/dL.
Most importantly his CAC was not zero and therefore, even by the somewhat insensitive – but far superior to any other non-invasive imaging test except Cardiac CT Angiography – tool of coronary artery calcium to detect preclinical atherosclerosis he has demonstrable coronary artery disease. His CAC at age 57 of 54 puts him at the 66th percentile with respect to his age and sex from the MESA cohort and his arterial age is 68, also from the MESA cohort. This indicates a significant burden of preclinical atherosclerotic disease and even the conservative 2018 AHA/ACC guidelines on the treatment of cholesterol recommend (in their highlighted top 10 points to remember from the guidelines) that a non-zero “CAC score of 1 to 99 favors statin therapy, especially when > 55 years”.
Clinical kudos to his primary care physician for ordering the CAC as a decision tool to understand the potential benefit of statins in primary prevention, but it also illustrates the very common mistakes made in interpreting the exam, the communication of the results to the patient, and, in my opinion (but also backed by the guidelines of the AHA/ACC), a poor decision with respect to not initiating a statin with this particular fact pattern.
I am certainly a huge fan of CAC in primary prevention and also of you and your insightful (and appropriately skeptical) blog, but I really feel that the conclusions of the video are inaccurate and that they could be (unintentionally) deceptive to the lay public who might view it.
Thank you for allowing my feedback and please keep up the fine work and skepticism, my esteemed colleague!
John Osborne
Dr. Osborne,
Thank you for making these excellent point. I made the exact point to Scott. I actually had him enter his CAC score into the MESA risk calculator and I agree with your comments that a statin should strongly be considered.
Part of my input was modifying his enthusiasm over a “low” score.
I was pondering writing a second post on the outcome for his case.
Dr P
Great minds think alike, Dr. Pearson, and so does mine! ?
John,
Your comment would serve as the bulk of any post I wrote as follow up.
Perhaps you’d like to write the entire post for me?
AP
Sure! I’ve honored, Dr. Pearson.
A “low” CAC score is like having “just a little bit of cancer”, IMHBAO.
I was on the fence about a statin even after learning that I have familial hypercholesterolemia. I learned this after losing about 34 lbs on a ketogenic way of eating and normalizing my blood pressure but my CHO, LDL-C, LDL-P, and apoB were off the charts. My CHO had been high all of my adult life but I never did anything about it until last year when, as part of my weight loss/health seeking journey, I had many tests done to assess my health. I’m a research nerd. I knew about the CAC from you, Taubes, Lustig and others associated with the Diet Doctor site. CAC tests are not covered by insurance but the cost is low enough and I was keen to do it, so when my cardiologist recommended it as a way of pushing me off the fence, I jumped on it. My score was 114 (I am a 70 yo female). That was enough for me to try a statin (rosuvastin 20 mg), therapeutic goal being to limit or prevent more plaque as well as try to resolve the very high numbers. My numbers dropped like a rock within 3 months, my lipidologist was stunned (and pleased). I think neither doctor had ever seen such a dramatic change in such a short time. I have had no side effects (my husband and my sister-in-law both are intolerant to statins so I was nervous! They have also both had heart attacks and stents. My husband takes Repatha, my sister-in-law takes a combination of meds and just tolerates the joint pain). I have maintained my weight loss and now only take the statin and 2.5mg of amlodipine daily (mostly for Raynaud’s syndrome). The CAC should be part of the standard of cardiac care in my opinion!
Anne,
Amen! Thanks for sharing your story.
Dr. P
Excellent information. Should be mandatory for every “family doctor” to discuss with patients. I work in Radiology Departments around the St. Louis area and “this” is a seriously overlooked topic. THANKS for sharing.
Agreed!!!
I had a calcium score of zero and got a stroke in the same month. Make sure you know what the calcium score does not tell you about risk
Absolutely. In the youngish , soft plaque can be present in significant amounts without calcification.
Also, there are a variety of causes of stroke, several of which have nothing to do with atherosclerotic plaque.
For example, strokes in patients with atrial fibrillation are not caused by atherosclerosis.
Strokes in patients with PFOs are not caused by atherosclerosis.
So, the mechanism matters.
Dr P
Excellent video and I hope that it gets the widespread distribution it deserves. Good Job, Tremendousness and Scott Matthews.
And, good job, Dr. P., on using this as an evaluation tool. It helped me understand my CAD picture as a part of a comprehensive evaluation. Definitely a good addition to patient education.
Money well-spent.
Bravo to all.
This is a wonderful video — thank you so much! Very clear, easy to understand, great info. Will definitely be sharing.
I have a question about the relationship between CAC and cardiac CT scan. I believe you are saying that the CAC is a CT scan but it is not the same as a cardiac CT scan, which involves contrast, etc. — but can you get the same info from a cardiac CT scan as from the CAC?
In other words and for example, Person A get a cardiac CT scan to assess an issue but in the course of the procedure, plaque in an artery is found. What, if any, information would a CAC add to this clinical picture?
Does a finding of plaque in an artery on a cardiac CT scan always indicate a need for medical intervention? Is there some similar gradient of risk as with CAC as described in the video?
I guess I am wondering if a cardiac CT scan is a bigger version of a CAC, or if the two tests measure different variables and could, in fact, be complementary.
Thank you for your continuing work to make what is complicated and sometimes scary into information that can be understood by the rest of us. Your efforts — and Scott’s — are so appreciated!
Mary-Ann,
thank you.
Your questions are common and good ones. Let me put together a post on the difference. I think I have written previously in the blog but I couldn’t find a specific post.