Category Archives: Cardiac Tests

Bernie Sanders Is Back: Is His Heart Healthy? Why Is His Ejection Fraction Not Reported?

While campaigning in Las Vegas last October, Vermont Senator Bernie Sanders began experiencing tightness in his chest. He was rushed to a hospital where he was diagnosed with a heart attack and had two stents implanted to open blocked arteries.

Despite little details about his cardiac condition, the event cast a cloud over his candidacy.

At the time I asked (and answered) a few questions): Is it appropriate for voters to lose confidence in Sanders at this point? He was already the oldest candidate in the race at age 78 years. Would he survive a 4 year term in the grueling position of head of the free world?

We now have more details to better answer these questions.

On December 30 of 2019, a letter from Brian P. Monahan, MD MACP on a letter head which reads in all caps “THE ATTENDING PHYSICIAN:Congress of the United States” to The Honorable Bernard Sanders was released.

This letter summarized Sanders’ “general health history and current medications” as Sanders had requested

Monahan, an oncologist by training, examined Sanders on 12/19/2019 at which time he found the senator was:

” 6 feet tall and 174 pounds. His blood pressure was 102/56, with a pulse of 62 beats per minute. His total cholesterol was 117 milligrams per deciliter of blood, HDL cholesterol (or “good” cholesterol) was 32 milligrams, and LDL cholesterol (or “bad” cholesterol) was 58 milligrams.”

With the exception of the low HDL these are good numbers and they indicate that Sanders LDL/bad cholesterol was at the appropriate goal post MI of <70 mg/dl. I would be a little concerned about the lowish BP of 102/56 in a 78 year old man but this likely reflects to some extent medications he is receiving to strengthen and protect his heart muscle.

Past Medical History

Next, Monahan summarizes Sanders’ past medical history

Over the years you have been treated for medical conditions including gout, hypercholesterolemia, diverticulitis, hypothyroidism, laryngitis secondary to esophageal reflux, lumbar strain, and complete removal of superficial skin lesions. Your colorectal cancer screening is up to date. Your past surgical history consists of repair of left and right-side inguinal hernias by laparoscopic technique and a right true vocal cord cyst excision. In November 2019, a follow-up ENT evaluation of your vocal cords for hoarseness was stable. You have no history of tobacco use, exercise regularly, and seldom drink alcohol.

Now we know some Bernie’s characteristic voice is due to a vocal cord cyst and that he is following a healthy lifestyle with regular exercise and no cigarette smoking.

What Happened In Vegas: The Myocardial Infarction

Monahan’s description of the heart attack (myocardial infarction or MI) Sanders suffered in Las Vegas gives more information than I had seen previously but is still lacking in details which I felt were important to know: troponin level and ejection fraction

The most significant event in your recent health was your admission to the Desert Springs Hospital in Las Vegas Nevada on October 19 2019. You experienced myocardial infarction due to an acute blockage of a coronary artery. In the initial hours of your evaluation, you were found to have an elevation of cardiac muscle proteins in your blood accompanied by diminished heart muscle strength and chamber wall motion reduction as determined by echocardiogram. You underwent prompt cardiac catheterization with identification of the narrowed segment of the midportion of the left anterior descending coronary artery. The narrowed segment was re-opened followed by the placement of two drug-eluting stents, a procedure that is referred to as primary percutaneous coronary intervention (Per). You received standard treatment with medications to improve your heart function and provide antiplatelet therapy required by your stents. You were released from the hospital three days later and returned home.

The exact elevation of the cardiac muscle protein, aka troponin, level is not reported.

He indicates “diminished heart muscle strength” determined by an echocardiogram and this is the ejection fraction (EF) but the exact percent EF is not given.

In my previous post on Senator Sanders I wrote

The size of Sanders’ heart attack is an important determinant of his prognosis. The more myocardial cells that died the larger the damage. We can detect and quantify heart attacks with a blood test using a cardiac specific protein called troponin.

Some heart attacks are tiny and only detected by very slight increases in the troponin in the blood whereas larger ones result in large increases in the troponin. What kind did Sanders have?

The more damage to the main pumping chamber of the heart, the left ventricle, the weaker the pumping action as measured by the ejection fraction.  The lower the ejection fraction the more likely the development of heart failure. What is Sanders ejection fraction? Does he have any evidence of heart failure?

Heart Failure?: Signs Or Symptoms?

Later in his letter Monahan indicates

You have never had symptoms of congestive heart failure

This is an interesting turn of phrase. The doctor is not stating clearly that Sanders did not have congestive heart failure (CHF)

We diagnose CHF by eliciting certain symptoms such as shortness of breath or fatigue and observing certain signs such as crackles in the lungs, distention of the jugular veins, or swelling in the legs. These findings are combined with lab tests (BNP or pro BNP) and imaging studies (chest x-ray, echocardiography).

Given Monahan’s phrasing I suspect there were signs and/or abnormal labs that suggested CHF  on his presentation with chest pain. The good news is that subsequent testing indicates no CHF.

Bernie’s Medications:

Monahan goes on to describe current medications:

Your current daily medications include atorvastatin, aspirin, clopidogrel, levothyroxine, and lisinopril

The aspirin and clopidogrel are anti-platelet agents which are standard after implantation of drug-eluting stents like the two Sanders received at the time of his MI.  They help keep the stents from stenosing or clogging up.

The atorvastatin is a statin/cholesterol lowering drug which should be given post MI in high dosages (40 to 80 mg daily) to reduce the risk of progression of the atherosclerotic plaque in Bernie’s coronaries which caused his MI. The atorvastatin has lowered his LDL to <70.

Lisinopril is an ACE inhibitor which is likely being utilized in this case to help strengthen and protect his heart muscle after the MI. Typically this would be used in conjunction with a beta-blocker however later in the letter, Dr. Monahan indicates Sanders was taken off a beta-blocker:

Several of the medications you initially required (blood-thinner, beta blocker) were stopped based on your progress. Your heart muscle strength has improved

Why Was The Beta-Blocker Stopped?

I see two possibilities, one portending a good prognosis and the other a bad prognosis.

Beta-blockers have been shown to significantly improve outcomes post MI in patients with depressed EF. The normal EF is >55%. Did Sanders’ EF improve to the point where the doctors felt beta-blockers would no longer be beneficial? This would be a good prognostic sign.

The other possibility is that Sanders’ blood pressure was so low on the beta-blockers that he was weak or dizzy. This would be a bad prognostic sign.

A third possibility seems less likely to me: excessive heart rate slowing on a beta-blocker. Given his resting heart of 62 bpm on no beta-blocker he should have been able to tolerate at least a low dose of beta blocker.

Cardiac Testing Post MI

After Sanders returned to his home in Vermont he saw his personal cardiologist Martin LeWinter and underwent further testing which according to Monahan showed the following

The heart chamber sizes, wall thickness, estimated pressures, and heart valves are normal.

I’m presuming this information comes from an echocardiogram. One of the key pieces of information that would come from this same echocardiogram is the ejection fraction. Why doesn’t he mention the EF?

Several 24-hour recordings of your heart electrical activity indicated no significant heat rhythm abnormality.

So Senator Sanders had at least two Holter monitors. This is not the norm post MI and I have to think he must have had some significant arrhythmias on telemetry while hospitalized to prompt these investigations. What rhythm abnormalities prompted multilple Holter monitor studies?

Sanders also underwent a treadmill stress test in December which is the norm post MI. Findings were  summarized by Monahana

a successful graded exercise treadmill examination monitoring your heart function, muscular exertion, and oxygen consumption that indicated a maximal level of exertion to 92% of your predicted heart rate without any evidence of reduced blood flow to your heart or symptoms limiting your exercise performance. Your overall test performance was rated above average compared to a reference population of the same age. The cardiac exercise physiologist who evaluated your results determined that you are fit to resume vigorous activity without limitation.

A  letter from Dr. Phillip Ades indicates this was a cardiopulmonary exercise test and it appears maximal aerobic capacity was measured directly but this number is not revealed.

However, this type of stress test is not capable of monitoring “heart function” and Monahan’s statement that there was no “evidence of reduced blood flow to your heart” can only mean there were no EKG changes as blood flow to the heart was not directly measured.

Fitness To Continue Campaigning And Serve As President

Senator Sanders’ doctors conclude based on all the evidence they have that he is fit and able.

In addition to the letters referenced above, Mr. Sanders’s personal cardiologist, Martin LeWinter wrote a letter (which I can’t locate) which states that Mr. Sanders had experienced “modest heart muscle damage” but that his heart function was now “stable and well-preserved.”

Once more, the two things I would like to know are not being precisely described.

Heart muscle damage would be precisely assessed by the maximal troponin level during his MI. Modest is defined as “not large” in the Cambridge English dictionary.

Heart function would be precisely assessed by the ejection fraction. Well-preserved is most frequently used to describe older things or people that are in good condition or don’t appear as old as they really are. It’s often used to describe left ventricular function but is vague. Why not just state the ejection fraction?

It would also be nice to know what coronary artery was stented and what was the status of the other coronary arteries that weren’t stented.

Dr. LeWinter concludes

“At this point, I see no reason he cannot continue campaigning without limitation and, should he be elected, I am confident he has the mental and physical stamina to fully undertake the rigors of the presidency,”

I have a lot of confidence in Dr. LeWinter’s (see below) integrity and judgement and therefore would agree with his conclusions. I’d feel even more confident if I had access to all of Senator Sanders’ relevant data.

Skeptically Yours,

-ACP

N.B. I recognized Dr. LeWinter’s name as he has been a prominent figure in the area of pericardial disease and heart failure research.

His CV is very impressive.

Dr. LeWinter is Professor of Medicine and Molecular Physiology and Biophysics and Director of the Heart Failure and Cardiomyopathy Program at the University of Vermont. He received his undergraduate degree from Columbia University, his M.D. from New York University and sub-specialty training in Cardiovascular Disease at University of California, San Diego.  In addition to heart failure, cardiac hypertrophy and myocardial dysfunction Dr. LeWinter has had a longstanding interest in pericardial disease. Dr. LeWinter has received continuous research support from the NIH for over 35 years and is the author of over 190 original research papers, over 60 book chapters and review articles, and the Editor of two books. He is a Fellow of the American Heart Association, the American College of Cardiology, the Cardiovascular Section of the American Physiological Society and the International Academy of Cardiovascular Sciences, and a member of the Association of University Cardiologists. Dr. LeWinter has served on numerous Editorial Boards and research review committees and is an Associate Editor of the journals Circulation and Coronary Artery Disease

Heartening News For The New Year! United Health Care Paid For This Patient’s Coronary Calcium Scan

Unless you live in Texas you will have to pay out of pocket for a coronary artery calcium (CAC) scan. Insurers and Medicare won’t pay a dime for this simple test which  progressive preventive cardiologists and primary care docs rely on to better determine who is at risk for heart attacks and sudden death.

But as we approach 2020 perhaps this failure to cover our best tool to detect subclinical atherosclerosis can be reversed. To my surprise, earlier this week, a patient of mine revealed to me that United Health Care had reimbursed him for the CAC he had done earlier this year.

It wasn’t easy or straightforward but his process may work for others so I asked him to email me the letter he sent that resulted in coverage which I have copied below.

As discussed in your office today, I was able to get my insurance company (United Healthcare) to reimburse me from the Cardiac Calcium Scoring costs of $125 after filing an appeal through my former employer. Below, as requested, is the simple write up I provided to them.

I visited a cardiologist (Dr. Anthony Pearson) in May 2019 regarding heart palpitations I had with increasing frequency. He performed a variety of diagnostic tests (blood work, Holter monitor, echo stress test), which were all covered by UHC. Because these tests did not show any issues, he suggested I have a Cardiac Calcium Scoring Test, which I completed on May 24, 2019. The test showed that I had serious coronary artery disease (score of over 800), which caused the cardiologist to prescribe a daily baby aspirin and a statin medicine (also covered by UHC). While I was told that the Cardiac Calcium Scoring Test cost is not covered by insurance, this is the one and only test that indicated I was at a severe risk for a coronary artery event (significant or total blockage) and, per the cardiologist, may have saved my life or perhaps avoided an unexpected significant cost (e.g. bypass surgery) by catching the issue early.

To recap, St. Luke’s Hospital did not submit a claim for the $125 cost of the Cardiac Calcium Scoring Test because they said no insurance company pays for this test. This test was ordered by my cardiologist, Dr. Anthony Pearson, and was performed at St. Luke’s Hospital in St. Louis. I am requesting reimbursement for the cost of this test for the reasons stated above

The United Health Care EOB contained this claims summary:

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It would appear the mighty wall that insurers and CMS have put up against paying for CAC scans is crumbling and can be breached.

I highly recommend all patients who have gotten an appropriately ordered CAC go through this process with their insurers to attempt to obtain reimbursement.

Happy Antiatherosclerotic New Year,

-ACP

Omron’s HeartGuide Wristwatch Blood Pressure Monitor Allows BP Monitoring During Daily Activities Unobtrusively: Can It Replace Ambulatory BP Monitors?

I’ve been evaluating a wearable wrist watch blood pressure monitor for the last week.

After a Twitter interaction with Omron stimulated by Dr. Wen Dombrowski, the Omron people loaned me one of their HeartGuide devices.

Omron’s website describes the device as follows:

Engineered to keep you informed, HeartGuide is a wearable blood pressure monitor in the innovative form of a wristwatch. In tandem with its companion app HeartAdvisor, HeartGuide delivers powerful new technology making tracking and managing your blood pressure easier than ever before. Proactively monitor your heart health by turning real-time heart data into heart knowledge and knowledge into action. With HeartGuide wherever you go, you’re in the know.

I and the AHA have  not recommended wrist BP devices.  My decision was based on my personal research in the 1990s on arterial waveforms and the influence of wave reflection.  Studies have clearly shown a change in the arterial wave form as it proceeds from the ascending aorta to the periphery.

Therefore, the skeptical cardiologist was skeptical of the value of the HeartGuide

After wearing the HeartGuide for a week and using it in a variety of situations to measure my blood pressure I am rethinking my recommendation against wrist blood pressure cuffs.

I’ll give my full analysis of the device after more evaluation but what I’ve discovered is that it can serve as an accurate and unobtrusive daytime ambulatory blood pressure monitor.

Ambulatory blood pressure monitoring (ABPM) utilizes a portable BP monitor which includes a brachial BP cuff and a device that inflates the cuff every 20-30 minutes, makes a measurement and stores all the recordings for off-line review. Studies have shown ABPM is a better predictor of CV mortality than either clinic BP or home BP monitoring.

It has not been widely utilized in the US because it is poorly reimbursed.

The HeartGuide sits on my wrist and whenever I feel like it, wherever I am, I can quickly and simply make a recording of my BP.

 

 

With the HeartGuide I have made  BP recordings in a variety of situations which I would never previously have considered.

For example, earlier this week I wore the HeartGuide to work. I measured my BP at home and it was 125/76. After dropping my gear off at my office I walked to the 6th floor of the hospital to see inpatients. This involved going down several flights of stairs, crossing to the hospital via a pedway and climbing several flights of stairs.

When I emerged on the 6th floor I stopped (because the Heart Guide does not like it if you are moving), triggered the Heart Guide and put my right hand over my heart (the Heart Guide likes you to put your hand on your heart). Within 90 seconds I knew my BP (it had increased to 143/81).

In order to do this unobtrusively I wandered into the patient waiting area and pretended to be watching NFL highlights on the TV.  Nobody seemed to notice I was taking my BP!

Subsequently, I was paged to do a transesophageal echo/electrical cardioversion and went downstairs to our “heart station” where a room full of RNs, a sonographer, an anesthetist and a patient awaited me. While talking to the patient about the procedure I triggered the Heart Guide and made another BP recording. Nobody noticed!IMG_5220

The Heart Guide BPs are displayed on the watch face for a few seconds and can be sent via BlueTooth to the OmronAdvisor smartphone app.

The graph above shows my BP was high at 807 AM while I was talking to the patient and still up after the procedure.

One day I wore the HeartGuide to the gym and made BP measurements under a variety of conditions.

HG leg press

The HeartGuide will not activate while walking on the treadmill no matter how hard I try to keep my arm still. It does not like motion of any kind.

But the first reading on the left was immediately after running on the treadmill. I then performed an isometric leg press hold on a weight machine and was able to obtain a recording during this maneuver of 140/88.  Shortly after the leg press I repeated the recording and it had dropped down to 104/69.

I have to say this is an abundance of BP information that is quite interesting and heretofore I had never been aware of. It opens up intriguing clinical possibilities.

I will have to spend more time analyzing the Heart Guide before writing my overall impression and recommendations but thus far I see it expanding our toolkit for understanding hypertension and personalizing cardiovacular medicine.

Try to imagine yourself standing like me outside a restaurant unobtrusively taking your blood pressure and ponder the possibilities!

Soon you may find that wherever you go, you’re in the know. But be aware of the possibility of being arrested for loitering while checking your BP.

ap-HG.jpeg

Omnimanometrically Yours,

-ACP

If you’d like to read a detailed description of the HeartGuide check out this review while eagerly awaiting my more serious and more complete analysis.

ISCHEMIA Shows Medical Therapy Outcomes As Good As Coronary Stents or Bypass For Most CAD Patients

The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical And Invasive Approaches) study presented at the AHA meeting this week provides further evidence that a conservative approach utilizing optimal medical therapy is an acceptable strategy for most patients with stable coronary disease (CAD).

Cardiologists have known for a decade (since the landmark COURAGE study) that outside the setting of an acute heart attack (acute coronary syndrome or ACS), coronary stents don’t save lives and that they don’t prevent heart attacks.

Current guidelines reflect this knowledge, and indicate that stents in stable patients with coronary artery disease should be placed only after a failure of  “guideline-directed medical therapy.”  Despite these recommendations, published in 2012, half of the thousands of stents implanted annually in the US continued to be employed in patients with either no symptoms or an inadequate trial of medical therapy.

Yes, lots of stents are placed in asymptomatic patients.  And lots of patients who have stents placed outside the setting of ACS are convinced that their stents saved their lives, prevented future heart attacks and “fixed” their coronary artery disease. It is very easy to make the case to the uneducated patient that a dramatic intervention to “cure” a blocked artery is going to be more beneficial than merely giving medications that stabilize atherosclerotic plaque, dilate the coronary artery or slow the heart’s pumping action to reduce myocardial oxygen demands.

Stent procedures are costly  in the US (average charge around $30,000, range $11,000 to $40,000) and there are significant risks including death, stroke and heart attack. After placement, patients must take powerful antiplatelet drugs which increase their risk of bleeding. There should be compelling reasons to place stents if we are not saving lives.

What Did ISCHEMIA Prove?

ISCHEMIA (paper unpublished but slides available here) showed that an invasive strategy (employing cardiac catheterization with resulting stenting or coronary bypass surgery (CABG)) offered no benefit over optimal medical therapy in preventing cardiovascular events in patients with moderate to severe CAD.

Screen Shot 2019-11-17 at 10.39.42 AM

Rates of all-cause death were nearly superimposable over the years studied, reaching 6.5% and 6.4% at 4 years for the invasive and conservative groups,

Screen Shot 2019-11-17 at 10.40.47 AM

Inclusions and exclusion criteria are listed below. Patients with unnaceptable angina despite optimal medical therapy were not included. These patients clearly benefit symptomatically from revascularization (as long as their chest pain is actually angina and not from another cause.)

All patients had stress imaging studies demonstrating moderate to severe amounts of ischemia. Such patients with very abnormal stress tests in the past have typically been sent immediately to the cath lab.

Based on ISCHEMIA we now know in these patients there is no need to do anything urgently other than institute OMT.

Screen Shot 2019-11-17 at 10.37.21 AM

These patients were on good medical therapy which likely explains the very good outcomes in both conservative and invasive arms. The “high level of medical therapy optimization” is what cardiologists should be shooting for with LDL<70, on a statin with systolic blood pressure <140 mm Hg, on an antiplatelet drugg and not smoking.

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Interestingly coronary CT angiography (CCTA) was utilized prior to patients receiving catheterization. I’ve been  utilizing this noninvasive method for visualizing the coronary arteries increasingly prior to committing to an invasive approach.

Quality Of Life 

Finally, in a separate presentation the ISCHEMIA trial showed that the invasive strategy did improve symptoms and quality of life modestly. It did not improve quality of life in those without angina symptoms.

The ORBITA study (which I wrote about here) showed that a large amount of the symptomatic improvement in patients following stenting may be a placebo effect.

Importance Of ISCHEMIA

Hopefully the results of ISCHEMIA will cut down on the number of unnecessary catheterizations, stents and bypass operations performed. This, in turn, will save our health system millions of dollars and prevent unnecessary complications.

Outside the setting of an acute heart attack the best approach to patients with blocked coronary arteries is a calm, thoughtful, and measured one which allows ample time for shared decision-making between informed patients and knowledgeable physicians. Such decisions should carefully consider the ISCHEMIA, COURAGE and ORBITA results.

Nonischemically Yours,

-ACP

N.B. Ischemia is a fantastic acronym for this study. Doctors use it a lot to describe the absence of sufficient blood flow to tissues.

N.B.2 Although I deplore the number of unnecessary caths and stents performed in the US, especially in patients without symptoms and those with noncardiac chest pain, I still utilize them in my patients with flow-limiting coronary stenoses and unacceptable anginal chest pain with symptoms despite optimal medical therapy and have noticed outstanding results. This angiogram shows a tight, eccentric LAD blockage in such a patient who now, post stent, has had complete resolution of the chest pain that limited him from even short walks.

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How Common Are Inaccurate Coronary Artery Calcium Scans?

One reason the  skeptical cardiologist has been so enthusiastic about coronary calcium (CAC) scans is that I have found them to be highly reproducible and highly accurate.

Unlike most  imaging tests in cardiology if we perform a CAC on the same individual in the CT scanner of hospital A and then repeat it within a few days in the CT scanner of hospital B we expect the scores to be nearly identical.

Also, unlike most other imaging tests we don’t expect false negatives or false positives. If the CAC score is zero there is no coronary calcification-high sensitivity. If the score is nonzero there is definitively calcium and therefore atherosclerotic plaque in the coronaries-high specificity.

This is  because calcium as defined in the Agatson score is literally black and white-a pixel is either above or below the cut-off. Computer software automatically identifies on the scan. A reasonably trained CT tech should be able to identify the calcium that is residing in the coronary arteries based on his or her knowledge of the coronary anatomy as registered on CT slices. Using software the total Agatson score is calculated.

A physician reader (either cardiologist or radiologist) (who should have a very good understanding of the cardiac and coronary anatomy ) should review the CT techs work and verify accuracy.

A recent case report, however, has demonstrated that the above  assumptions are not always true.

Franz Messerli, a pre-eminent researcher in hypertension and a cardiologist describes in fascinating detail a false-positive CAC scan he underwent in 2013.  He was told he had a score of 804 putting him in a high risk category consistent with extensive plaque formation.

After consulting with cardiologist friends and colleagues he decided to put himself on a statin and aspirin despite having an excellent lipid profile.

Messerli assumed that the CAC score was not a false positive (although later in his article he indicates he had questioned the reading) writing:

“although one can always quibble with ST segments or wall motion abnormalities, on the CAC the evidence is rock-hard, you actually with your own eyes can see the white calcium specks! ‘Individuals with very high Agatston scores (over 1000) have a 20% chance of suffering a myocardial infarction or cardiac death within a year’—although I did not quite classify, this patient information coming from esteemed Harvard cardiology colleagues3 was hardly reassuring.

(His reference 3 for the 20% risk of MI or cardiac death in a year for CAC score >1000 is suspect. It is a 2003 “patient page” on coronary calcium in Circulation which does not have a reference for that statistic.)

A more recent study found patients with extensive CAC (CAC≥1000) represent a unique, very high-risk phenotype with CVD mortality outcomes (0.80%/yr) commensurate with high-risk secondary prevention patients (0.77%/yr) from the FOURIER trial)

Six years after the diagnosis Messerli was at a Picasso exhibition, “leisurely ambling between his Blue and Pink Period “when he developed chest pain.

To further evaluate the chest pain he underwent a coronary CT angiogram and this demonstrated pristine and normal coronary arteries, totally devoid of calcium.

He did have a lot of mitral annular calcification (MAC). The CCTA images below show how close the MAC is to the left circumflex coronary artery (LCX).


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The slice above shows how the MAC would appear on the CT scan designed to assess coronary calcium.  It’s position is very close to that of the circumflex but an experienced reader/tech  should have known this was not coronary calcification.

MAC is a very common finding on echocardiograms, especially in the elderly and it is likely that this error is not an isolated one.

Dr. Messerli writes

After relating these findings to the cardiologist who did the initial CAC, he indicated that most likely someone mistook mitral annular calcification as left circumflex calcium. This was hardly reassuring, since I specifically had asked that obvious question after receiving the initial CAC

Around the time I read Messerli’s case report I encountered a similar, albeit not as drastic case. A CAC scan showed a significant area of calcification near the left circumflex coronary artery which was scored as circumflex coronary calcification.

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The  pattern of this calcification is not consistent with the known path of the circumflex coronary in this case. When it was eliminated from the scoring the patient had a zero score. The difference between a nonzero score and a zero score is hugely significant but for patients with scores >100 such errors are less critical.

I have also encountered cases where extracardiac calcium mimics right coronary calcification.

There are some important take-home points from my and Dr. Messerli’s experience.

  1. False positive CAC scans do occur. We don’t know the frequency. If the scans are not overread by a competent cardiologist or radiologist with extensive experience in cardiac CT these mistakes will be more common

When I asked Dr. Messerli about this problem he responded

I am afraid you are correct in that CAC scores are generated by techs and radiologists and cardiologist simply sign the report without verifying the data. Little doubt that MAC is most often missed.
     2. Like other cardiac imaging tests (such as echocardiography) having an expert/experienced/meticulous  tech and reader matters.
    3. Dr. Messerli and I agree that a research project should be done to ascertain how often this happens and to evaluate the process of reading and reporting CAC.
4. Patients should look at the breakdown of the calcium in the CAC by coronary artery. Whereas it is not uncommon to see most of the calcium in the LAD it is rare to see a huge discrepancy in which the circumflex coronary artery score is very high and the LAD score zero. Such a finding should warrant a review of the scan to see if MAC was included in error.
Skeptically Yours
-ACP
N.B. Dr. Messerli’s report can be read for free and makes for entertaining reading.
I was very intrigued by two comments he made at the end:
  1. “Had my CHD been diagnosed a decade earlier, guidelines might well have condemned me to taking beta-blockers for the reminder of my days.6 This, as Philip Roth taught us in ‘The Counterlife’, might have had rather unpleasant repercussions.7

Until recently I had never read anything by Philip Roth but when he died last year I read his Pulitzer Prize winning  1987 novel American Pastoral and liked it. Given this Roth reference involving beta-blockers I felt compelled to get my hands on “The Counterlife.” The book is a good read (much better IMHO than American Pastoral) and one of the main plot points relates to the side effects (see my post on feeling logy) a character suffers from a beta-blocker. Stimulated by a desire to be able to perform sexually if taken of the medication, the character undergoes coronary bypass surgery and dies.

2. “As stated by Mandrola and true in the present case, ‘given the (lucrative) downstream testing that often occurs when coronary calcium is found in asymptomatic people, the biggest winners from CAC screening may be the testers rather than the tested’.”

I feel the CAC in the right hands should not lead to (lucrative or inappropriate) downstream testing in the asymptomatic (see my discussion on this topic here.)

 

 

Which Ambulatory ECG Monitor For Which Patient?

The skeptical cardiologist still feels that KardiaPro has  eliminated  use of long term monitoring devices for most of his afib patients

However not all my afib patients are willing and able to self-monitor their atrial fibrillation using the Alivecor Mobile ECG device. For the Kardia unwilling and  many patients who don’t have afib we are still utilizing lots of long term monitors.

The ambulatory ECG monitoring world is very confusing and ever-changing but I recently came across a nice review of the area in the Cleveland Clinic Journal of Medicine which can be read in its entirety for free here.

This Table summarizes the various options available. I particularly like that they included relative cost. .

The traditional ambulatory ECG device is the “Holter” monitor which is named after its inventor and is relatively inexpensive and worn for 24 to 48 hours.

The variety of available devices are depicted in this nice graphic:

For the last few years we have predominantly been using the two week “patch” type devices in most of our patients who warrant a long term monitor. The Zio is the prototype for this but we are also using the BioTelemetry patch increasingly.

The more expensive mobile cardiac outpatient telemetry (MCOT) devices like the one below from BioTel look a lot like the patches now. The major difference to the patient is that the monitor has to be taken out and recharged every 5 days. In addition, as BioTel techs are reviewing the signal from the device they can notify the patient if the ECG from the patch is inadequate and have them switch to an included lanyard/electrode set-up.

The advantage of the patch monitors is that they are ultraportable, relatively unobtrusive and they monitor continuously with full disclosure.

The patch is applied to the left chest and usually stays there for two weeks (and yes, patients do get to shower during that time) at which time it is mailed back to the company for analysis.

Continuously Monitoring,

-ACP

A Patient’s Confusing Journey Into The Quagmire Of Cardiac Imaging: A Cautionary Tale

Mary-Ann, a reader from the north,  provides today’s post. Her story illustrates how easily medical care can veer off the rails while it is simultaneously railroading patients.  It is a cautionary tale with wisdom that can help most patients.

In this post I’ll just present Mary-Ann’s perspective and solicit responses.  Down the line I’ll provide some perspective on the processes, the problems and the solutions.


It started innocently enough. I showed up for a regular visit with my cardiac provider, a mid-level professional. She noted I was flushed and had a high pulse — about 100. 

Starbucks, I explained, and I flush easily — always have. She looked skeptical.

That is how I went from a half-caf Americano to a 48-hour holter monitor.

I went back for results — the usual ectopic beats but nothing scary or new. But again, she noted I had a fast heart rate and I was flushed.

And once again I explained: Starbucks — it is right down the street and okay, I might have a problem.

That is the short — but highly accurate — version of how I wound up getting a stress echo. 

I showed up for the results of the echo and that is where the runaway train started down the tracks.

“…possible inferoapical wall hypokinesis with lack of augmentation of systolic function, which are abnormal findings and may be indicative of ischemia due to underlying coronary artery disease. EF was 56% at rest and 40-50% at stress.” 

Wait — what?!

I was marched down the hall and scheduled for a cardiac angiography — and told not to run any marathons in the intervening two days. 

Marathon?! I was terrified I was going to drop dead at any moment. I contemplated just sitting the waiting room for 48 hours — just to be safe.

Then I started reading the professional literature and things were not adding up. An EF at stress of 40 – 50% is not good — in fact, it can be heading into heart failure land.

But I was active and fine — it did not make any sense.

I called the office; my provider was not available. I explained that I was worried there was a mistake. Oh no, I was assured, they are very careful to not make mistakes.

I wrote my will. I cried a lot. 

And when the person called to remind me of the procedure (like I could forget!?) I once again explained that I was worried there had been a mistake, and once again — reassurance. No mistake.

Nevertheless, she (aka me) persisted!

I sat on the hospital bed in nothing but a gown and handed the nurse my two-page letter; it started like this:

“I am reminded that what is normal and ordinary for a professional is never that for a patient. I am terrified.

First, I want to be really sure that there is not any chance of a mix-up in the stress echo test results. This is not simple denial or wishful thinking…” 

And that nurse paid attention, which is how I wound up not having a cardiac angiography. 

The cardiologist scheduled to do the procedure — we shall call him Doc #2 — wrote: 

“She has some concerns regarding the results of the stress echo study … I reviewed the most recent stress echo and it appears to me that the results for the resting versus the stress echo ejection fractions have been transposed…”

Translation: A Typo.

I was elated! Jubilant! We went to Starbucks to celebrate.

The giddy joy quickly turned to something along the lines of WTH just happened here? I read the original echo report written by Doc #1 — that lit the tinder. There were two different values for EF at stress documented in the report, and another sentence that was repeated. 

The professorial side of me was deeply affronted — in a subsequent meeting with hospital administrators I confess to saying that someone who is making hundreds of thousands of dollars a year doesn’t get to write such a sloppy ass report — and about someone’s heart, no less! 

But the best part of that meeting was learning that Doc #1 denied there was a typo — he stood by his findings. 

Oh dear.

And Doc #2 stood by his findings as well. And Doc #3 got involved somewhere along the way and he agreed with Doc #2. And the mid-level Provider also agreed with Doc #2.

The majority rule seems like an odd way to make health care decisions — wouldn’t you think all those smart people could talk among themselves and agree?

Apparently not.

That first meeting with the hospital folks included all manner of solicitous apologies and an attitude of collaboration. Of course, they said, we can send the echo to an outside cardiologist — at our expense — and get an answer.

And then I made the unthinkable mistake — and I blame the Skeptical Cardiologist for this — of asking informed questions.

“Are the cardiologists involved in reading my echo Level III echo specialists?”

“I understand that there can be variance in estimated EF between cardiologists — what level of variance is considered acceptable?”

The hospital team responded to my questions by calling a meeting — and the tone had changed considerably (Thanks a lot, Corporate Legal).

The offer to pay for an outside opinion was off the table — after all, they said, you would not have a patient-provider relationship with the cardiologist reading the echo. Ahem, I noted — I have zero relationship with the first cardiologist who read the echo and would not know him if I bumped into him at Starbucks. And you all did offer to pay for that outside opinion…

Oh never mind those minor details. No outside opinion on their dime. They would do a Lexiscan at their expense as a tie breaker. Final Offer.

Tiebreaker — really?! Is this a soccer game?

And seriously — should I have to have an invasive test to settle THEIR disagreement?! [Note: If it involves needles, it is invasive.]

Because there were not enough cardiologists involved already, I saw yet another one — from a different practice. He offered that the EF at stress looked more like 55%, placing his bet smack in the middle, and recommending a CT Angiography Coronary Arteries with Contrast as the tiebreaker.

Tiebreaker. That word implies both sides are equivalent or equal. However, my heart is not actually a game and the two teams cannot both be right — there is no equivalency in play here. What we are really trying to do involves accuracy — not breaking a tie score.

But I digress.

It doesn’t seem like you should have to make a chart to keep track of what cardiologists say about the same echo but in this case, it seemed necessary.

 And in the meantime, yet another cardiologist weighed in that the quality of the echo was poor — and no wonder they could not agree.

Deep breaths.

And so, for the past four months I have tried to navigate all this, and to understand what this actually means about cardiology and medicine and so many things. My confidence and my mind have been blown. Resources – and time – have been wasted. 

Ectopic heartbeats are typically benign in a structurally normal heart — I thought I was safe. But I have not felt safe since that day when I learned that Doc #1 and Docs #2, 3, and so on had decided to have a stand-off at the OK Corral that is my heart.

Except, I do not know if it is okay. And that is the problem. 


Unfortunately, Mary-Anne’s tale is not uncommon. It touches on many of the areas that patient’s should be aware of including

-Undergoing diagnostic imaging testing when you are free of symptoms

-Inadequate quality control in diagnostic imaging and how that leads to false positive results

-Variance in imaging performance and interpretation-how the same test can be read as normal by one doctor and markedly abnormal by another.

-The tendency of some cardiologists to recommend invasive testing when it is inappropriate and likely to cause more harm than good

-The importance of second opinions, especially if invasive testing is recommended

-The importance of patient’s doing their own research and asking good questions based on that research.

Transparently Yours,

-ACP

Are You Taking A Statin Drug Inappropriately Like Eric Topol Because of the MyGeneRank App?

The skeptical cardiologist was listening to a podcast discussion between Sam Harris and Eric Topol recently and became  flabbergasted.

Topol, the “world-renowned cardiologist” who is seemingly everywhere in media these days was discussing what he considers the overuse of imaging technology during the podcast which Harris’s website describes as follows:

In this episode of the Making Sense podcast, Sam Harris speaks with Eric Topol about the way artificial intelligence can improve medicine. They talk about soaring medical costs and declining health outcomes in the U.S., the problems of too little and too much medicine, the culture of medicine, the travesty of electronic health records, the current status of AI in medicine, the promise of further breakthroughs, possible downsides of relying on AI in medicine, and other topics.

Personally, I have been amazed at the hype and promotion that artificial intelligence (AI) has been getting given the near total absence in cardiology of any tangible benefits from it and I wanted to hear what the man who wrote ” Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again ” had to say about it.

About 28 minutes into the podcast, Harris, who has lately been preoccupied with promoting meditation as a cure for all ills, begins describing a procedure he underwent:

I’ve had a few adventures in cardiology. CT scan, calcium score scan.

Harris, who in neuroscience and philosophy might speak precisely, here is very vague. Did he get a coronary calcium scan (CAC) or a coronary CT angiogram? There is a huge difference and he is conflating the two imaging procedures.

Apparently he is unhappy with having undergone it but:

I might be telling a different story if my life was saved by it.

And his doctor’s rationale  for getting the scan was lacking:

The way this was dispensed to me. We now have this new tool, let’s use it.

Let me just say at this point that if your doctor’s rationale for performing a test is that he has a machine that performs the test just say no. Or demand an explanation of how the results will change your management or prognosis.

Apparently the scan that Harris had didn’t turn out either horrifically worse than expected or remarkably better and didn’t change management:

In my case at the end it didn’t make sense.

Now, I can forgive Sam Harris for being somewhat naive and misguided when it comes to coronary artery scans or coronary CT angiograms but Eric Topol , the world’s leading talking cardiology head should fully understand the value of coronary artery calcium scans.

This is where I first become flabbergasted.

Topol says in response at this point that coronary artery calcium scans are “terribly overused” and that “I’ve never ordered one.”

Eric, you cannot be serious!

Are you telling me that you wouldn’t order one on your 60 year old airline pilot friend whose father dropped dead of a massive MI at age 50 but whose lipids look fine?

Why doesn’t Eric order CACs?

Because “There are so many patients who have been disabled by the results of their calcium score even though they have no symptoms.”

This is where the degree of my flabbergastment increased by an order of magnitude.

Our job as preventive cardiologists is to identify those at high risk and lead them to lifestyle choices and medicine that dramatically lowers that risk.  We educate them that the large build up of subclinical atherosclerosis we identified does not have to result in sudden death, crippling heart attacks or strokes. We reassure them that with the right tools we can help them live a long, productive and happy life.

Eric, what do you tell these people? The calcium score is irrelevant? You’re fine. You shouldn’t have gotten it. Surely not! This would be the preventive cardiology equivalent of sticking one’s head in the sand.

This is not the first time Topol has opined on the dangers of CAC. An excerpt from his book, ‘The Patient Will See You Now: The Future of Medicine Is in Your Hands” posted on Scientific American describes the ills created in a 58 year old man who had a CAC score of 710.

My patient was told that he had a score of 710—a high calcium score—and his physician had told him that he would need to undergo a coronary angiogram, a roadmap movie of the coronary anatomy, as soon as possible. He did that and was found to have several blockages in two of the three arteries serving his heart. His cardiologists in Florida immediately put in five stents (even though no stress-test or other symptoms had suggested they were necessary), and put him on a regimen of Lipitor, a beta-blocker, aspirin and Plavix.

This case is not an example of inappropriate usage of CAC it is an example of really bad doctoring and failure to utilize the CAC information properly.

One should never order a cardiac catheterization/coronary angiogram solely on the basis of a high CAC score. Even ordering a stress test in this situation is debatable as I discuss here.

And Topol’s patients symptoms were most likely related to a beta-blocker that he didn’t need (see here).

My Gene Rank

Later in the podcast I reached maximum flabbergast  levels when Topol announced that as a result of a high score for CAD risk he received using an iPhone app called MyGeneRank he had started taking a statin drug.

He enthusiastically promoted the app which his Scripps Translational Science Institute developed and urged listeners to utilize this approach to better refine the estimate of their risk of heart attack and stroke.

Per the Scripps website:

The MyGeneRank mobile app is built using Apple’s ResearchKit, an open source framework that enables researchers and programmers to build customized mobile apps for research purposes. With user permission, the app connects with the 23andMe application program interface and automatically calculates and returns a genetic risk score for coronary artery disease.

In addition, the app calculates a 10-year absolute risk estimate for an adverse coronary event, such as heart attack, using a combination of genetic and clinical factors. Users are able to adjust behavioral risk factors to see the influence of lifestyle habits on their overall risk.

Elsewhere, Topol, has stated

“We are excited to launch a unique study that combines an iOS app and genomics to help guide important health decisions,” says Eric Topol, MD, Founder and Director of the Scripps Translational Science Institute and Professor of Molecular Medicine at The Scripps Research Institute. “Not only does participating in the study arm individuals with their own data, but it also gives them the opportunity to participate in new type of research – one that is driven by and for patients.”

Curious, I downloaded the MyGeneRank app, answered some questions and gave it permission to access my 23 and Me data. After requiring me to complete a survey on my health it then  yielded  my coronary artery disease risk score.

 

 

 

 

 

 

 

Oh, no! My genetic risk score was at the 81st percentile! In the red zone.  According to Eric Topol I should take a statin like him. Based on these results I probably should be incredibly anxious and crippled by fears of cardiac death.

Fortunately, I have superior information to allay my fears. I’ve had CAC scans in the past which are well below average for men my age. Despite my dad’s history of early CAD, a recent coronary CT angiogram showed minimal plaque. I know exactly where I stand risk-wise.

How many cardiac cripples has Topol’s MyGeneRank inappropriately created?

Is the data that MyGeneRank utilizes superior to that from CAC scans?

For coronary artery calcium scanning there is a wealth of data supporting improved risk prediction and we are looking directly at the atherosclerotic process that eventually causes the diseases we want to prevent.

It’s interesting that a recent study looking at a polygenetic risk score’s ability to predict cardiac events was comparing the risk score’s ability to predict subclinital atherosclerosis:

Each 1-SD increase in the polygenic risk score was associated with 1.32-fold (95% CI, 1.04-1.68) greater likelihood of having coronary artery calcification and 9.7% higher (95% CI, 2.2-17.8) burden of carotid plaque.

In the Scientific American article Topol quotes Mark Twain:, “To a man with a hammer, a lot of things looks like nails that need pounding.”

Topol’s hammer is artificial intelligence. We eagerly await the day he discovers a nail that he can bang on that  significantly advances medical care.

In the meantime I and the vast majority of progressive preventive cardiologists will be utilizing CAC scores intelligently to identify both those patients at high risk for cardiovascular events who need more aggressive treatment and those at low risk who can be reassured and have treatment de-escalated.

Polygenetic CAD risk scores do show promise to improve our predictive powers but more study is needed in this are before we make clinical treatment decisions based on the results.

Astoundingly Yours,

-ACP

The Ultimate Guide To The Coronary Artery Calcium Scan (Score) Circa 2019

The skeptical cardiologist’s first post on coronary artery calcium (CAC) scan was posted in 2014 and had the wordy title “Searching for Subclinical Atherosclerosis: Coronary Calcium Score-How Old Is My Heart?”

This post still serves as a good introduction to the test (rationale, procedure, risks) but in the 5 years since it was published there has been a substantial body of data published on CAC and in 2018 it was embraced by major organizations.

Overall, I’ve written 20 posts in which CAC plays a predominant role since then and I feels it’s time to put the most important changes and concepts  in one spot.


Detection Of Subclinical Atherosclerosis: What’s Your Risk of Dropping Dead?

First, the rationale for using CAC (also known as a coronary calcium score or heart scan) is detection of “subclinical atherosclerosis”, a non-catchy but hugely important process which I describe in an early post on who should take aspirin to prevent heart attack or stroke:

We have the tools available to look for atherosclerotic plaques before they rupture and cause heart attacks or stroke. Ultrasound screening of the carotid artery, as I discussed here, is one such tool: vascular screening is an accurate, harmless and painless way to assess for subclinical atherosclerosis.

In my practice, the answer to the question of who should or should not take aspirin is based on whether my patient has or does not have significant atherosclerosis. If they have had a clinical event due to atherosclerotic cardiovascular disease (stroke, heart attack, coronary stent, coronary bypass surgery, documented blocked arteries to the legs) I recommend they take one 81 milligram (baby) uncoated aspirin daily. If they have not had a clinical event but I have documented by either

  • vascular screening (significant carotid plaque)
  • coronary calcium score (high score (cut-off is debatable, more on this in a subsequent post)
  • Incidentally discovered plaque in the aorta or peripheral arteries (found by CT or ultrasound done for other reasons)

then I recommend a daily baby aspirin (assuming no high risk of bleeding).


Help In Deciding Who Needs Aggressive Treatment

Second, CAC is an outstanding tool for further refining risk of heart attack and stroke and helping better determine who needs to take statins or undergo aggressive lifestyle reduction, something I described in detail in my post “Should All Men Over Sixty Take a Statin Drug”.

The updated AHA/ACC Cardiovascular Prevention Guidelines came out in 2013.

After working with them for 9 months and using the iPhone app to calculate my patients’ 10 year risk of atherosclerotic cardiovascular disease (ASCVD, primarily heart attacks and strokes) it has become clear to me that the new guidelines will recommend statin therapy to almost all males over the age of 60 and females over the age of 70.

As critics have pointed out, this immediately adds about 10 million individuals to the 40 million or so who are currently taking statins.

By identifying subclinical atherosclerosis, CAC scoring identifies those who do or don’t need statins.


This is particularly important for patients who have many reservations about statins or who are “on the fence” about taking them when standard risk factor calculations suggest they would benefit.


The Widowmaker

In 2015 I wrote about a documentary entitled “The Widowmaker” (see here and here) which is about the treatment and prevention  of coronary artery disease and what we can do about the large number of people who drop dead from heart attacks, some 4 million in the last 30 years:

The documentary, as all medical documentaries tend to do, simplifies, dumbs down and hyperbolizes a very important medical condition. Despite that it makes some really important points and I’m going to recommend it to all my patients.

At the very least it gets people thinking about their risk of dying from heart disease which remains the #1 killer of men and women in the United States.

Perhaps it will have more patients question the value of stents outside the setting of an acute heart attack. This is a good thing.

Perhaps it will stimulate individuals to be more proactive about their risk of heart attack. This is a good thing.

Although CAC has some similarities to mammography (both utilize low dose radiation, 0.5 mSV) I concluded that CAC was not “the mammography of the heart” as the documentary proclaims.

What We Can Learn From Donald Trump’s CAC?

In 2018 I noted that “Donald Trump Has Moderate Coronary Plaque: This Is Normal For His Age And We Already Knew It.”

In October, 2016 the skeptical cardiologist predicted that Donald Trump’s coronary calcium score, if remeasured, would be >100 .  At that time I pointed out that this score is consistent with moderate coronary plaque build up and implies a moderate risk of heart attack and stroke.

Trumps’ score gave him a seven-fold increase risk of a cardiovascular event in comparison to Hilary Clinton (who had a zero coronary calcium score) .

Yesterday it was revealed by the White House doctor , Ronny Jackson, that Trump’s repeat score  was 133.

I was able to predict this score because we knew that Trump’s coronary calcium was 98 in 2013 and that on average calcium scores increase by about 10% per year.

What is most notable about the Trump CAC incident is that Trump, like all recent presidents and all astronauts underwent the screening. If the test is routine for presidents why is it not routine for Mr and Mrs Joe Q Public?

At a mininum we should consider what is recommended for aircrew to the general public:

A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation.

The 2018 guidelines Take A Giant Step Forward

In late 2018 I noted that CAC had been embraced by major guidelines:

I was very pleased to read that the newly updated AHA/ACC lipid guidelines (full PDF available here) emphasize the use of CAC for decision-making in intermediate risk patients.

 

 

 

For those patients aged 40-75 without known ASCVD whose 10 year risk of stroke and heart attack is between 7.5% and 20% (intermediate, see here on using risk estimator) the guidelines recommend “consider measuring CAC”.

If the score is zero, for most consider no statin. If score >100 and/or >75th percentile, statin therapy should be started.

A Few Final Points On CAC

First, it’s never too early to start thinking about your risk of cardiovascular disease. I have been using CAC more frequently in the last few years in  individuals <40 years with a strong family of early sudden death or heart attack and often we find very abnormal values (see here for my discussion on CAC in the youngish.)

coronary calcium scan with post-processing on a 45 year old white male with very strong history of premature heart attacks in mother and father. The pink indicates the bony structures of the spine (bottom) and the sternum (top). Extensive calcium in the LAD coronary artery is highlighted in yellow and in the circumflex coronary artery in ?teal. His score was 201, higher than 99% of white male his age.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If heart disease runs in your family or you have any of the “risk-enhancing” factors listed above, consider a CAC, nontraditional lipid/biomarkers, or vascular screening to better determine were you stand and what you can do about it.

Included in my discussions with my patients with premature ASCVD is a strong recommendation to encourage their brothers, sisters and children to undergo a thoughtful assessment for ASCVD risk. With these new studies and the new ACC/AHA guideline recommendations if they are age 40-75 years there is ample support for making CAC a part of such assessment.

Hopefully very soon, CMS and the health insurance companies will begin reimbursement for CAC. As it currently stands, however, the 125$ you will spend for the test at my hospital is money well spent.

The Importance of Proactivity

In “The MESA App-Estimating Your Risk of Cardiovascular Disease With And Without Coronary Calcium Score” I recently wrote that:

If you want to be proactive about the cardiovascular health of yourself or a loved one, download the MESA app and evaluate your risk.  Ask your doctor if a CACS will help refine that risk further.

There are many other questions to answer with regard to CAC-should they be repeated?, how do statins influence the score?, is there information in the scan beyond just the score that is important? Is a scan helpful after a normal stress test?

I’ve touched on some of these in the past, including the really tough  question “Should All Patients With A High Coronary Calcium Score Undergo Stress Testing?

Like most things in cardiology we have a lot to learn about CAC. There are many more studies to perform. Many questions yet to be answered.

A study showing improved outcomes using CAC guided therapy versus non CAC guided therapy would be nice. However, due to the long time and thousands of patients necessary it is unlikely we will have results within a decade.

I don’t want to wait a decade to start aggressively identifying who of my patients is at high risk for sudden death. You only get one chance to stop a death.

Apothanasically Yours,

-ACP


 

A Voodoo Coronary Calcium Scan Could Save Your Life

The skeptical cardiologist received this reader comment recently:

So I went and got a Cardiac Calcium Score on my own since my cardiologist wouldn’t order one because he says they are basically voodoo.. Family History is awful for me.. I got my score of 320 and I’m 48 years old.. Doc looked at it and basically did the oh well.. so I switched docs and the other doc basically did the same thing.. I try so very hard to live a good lifestyle..I just don’t understand why docs wait so long to actually take a look at your heart.. I would have thought a score of 320 would have brought on more testing.. It did not..

I was shocked that a cardiologist practicing in 2019 would term a coronary artery calcium (CAC) scan (aka, heart scan or calcium score) “voodoo.”

I’m a strong advocate of what I wrote in a recent post with the ridiculously long title, “Prevention of Heart Attack and Stroke-Early Detection Of Risk Using Coronary Artery Calcium Scans In The Youngish“:

It’s never too early to start thinking about your risk of cardiovascular disease. If heart disease runs in your family or you have any of the “risk-enhancing” factors listed above, consider a CAC, nontraditional lipid/biomarkers, or vascular screening to better determine where you stand and what you can do about it.

Here’s what I told this young man:

If your cardiologist tells you coronary calcium scores are voodoo I would strongly consider changing cardiologists.

A score of 320 at age 48 puts you in a very high risk category for stroke and heart attack over the next 10 years.

You need to find a physician who understands how to incorporate coronary calcium into his practice and will help you with lifestyle changes and medications to reduce that risk


Let’s analyze my points in detail and see if these off the cuff remarks are really justified

1,  Changing cardiologists.

Recent studies and recent guideline recommendations (see here) all support utilization of CAC in this kind of patient. If you have a strong family history of premature heart disease or sudden death you want a cardiologist who is actively keeping up on the published literature in preventive cardiology,  Such cardiologists are not dismissing CAC as “voodoo” they are incorporating it into their assessment of patient’s risk on a daily basis.

2. High risk of CAC score 320  at age 48

I plugged normal numbers for cholesterol and BP into the MESA risk calculator (see my discussion on how to use this here) for a 48 year old white male.

As you can see the high CAC score puts this patient at almost triple the 10 year risk of heart attack and stroke.

Immediate action is warranted to adjust lifestyle to reduce this risk! This high score will provide great motivation to the patient to stop smoking, exercise, lose excess weight, and modify diet.

Hidden risk factors such as lipoprotein(a),  hs-CRP and LDL-P need to be assessed.

Drug treatment should be considered.

3. Find physician who will be more proactive in preventing heart disease

This may be the hardest part of all my recommendations. On your own you can get a CAC performed and advanced lipoprotein analysis.

However, finding progressive, enlightened, up-to-date preventive cardiologists can be a challenge.

We need a network of such cardiologists.

I frequently receive requests from readers or patients leaving St. Louis for recommendations on cardiologists.

If you are aware of such preventive cardiologists in your area email me or post in comments and I will keep a log and post on the website for reference.

Voodoophobically Yours,

-ACP