Case study: A 48 year-old man, athletic and highly successful in his career, enjoys a day of surfing. While walking back to his car, he collapses and cannot be revived. A heart attack is to blame for his sudden death. Rare? Unfortunately, this is neither rare nor hypothetical as the world lost a good man recently and my heart goes out to his young family.
How can this happen? Although I did not know this man, I imagine he saw doctors and had checkups. Perhaps he even had a stress test along the way. There is a disconnect in the identification of early heart disease that is not true of some other important ailments. For example, consider the fact that when you turn 50 you are asked to have a colonoscopy to look directly at the colon for masses. Women are asked to have a mammogram to look directly at the breast for growths. But heart artery blockages, the number 1 cause of sudden death over age 30, are still not looked at directly. The standard recommendations at a physical exam include measuring blood pressure and cholesterol and maybe performing an ECG, all of which are indirect and inadequate examinations of the status of the coronary arteries.
I know there is a better approach, the coronary artery calcium scan (CACS). It is endorsed by the Society for Heart Attack Prevention and Eradication (SHAPE), the American College of Cardiology, and hundreds of peer reviewed research studies. The American College of Cardiology has given a high endorsement (IIA) to the use of CACS in persons with known risk factors for silent coronary disease.
The "mammogram" of the heart, as the CACS is known, is low-cost ($80 in my community) and offers a direct examination of the heart arteries. There is no contrast or IV injection and the test takes about 1 minute.
Who should not have a CACS?
If someone already knows they have coronary artery disease such as a previous cardiac catheterization showing blockage, a previous heart stent, or a previous heart bypass surgery, there would be no need for a CACS. People who know that they have blockage in other parts of the body, like an artery of the brain called the carotid artery or the arteries of the leg, remain debatable candidates for the CACS.
What about risks of the CACS?
Other than a small out of pocket cost (insurance covered in a few states like Texas), other concerns are the possibility of creating undue stress, missing soft plaque without calcium, and the dose of radiation. For decades, cardiologists have relied on exercise nuclear testing using treadmill examinations. One measure of the dose of radiation is called a milliSievert or mSv. An exercise test with Cardiolite may expose a patient to 12 to 15 mSv of radiation. By comparison, a cardiac catheterization done in an efficient manner may expose a patient to about 10 mSv of radiation. In centers with the most advanced multislice scanners, the imaging has gotten so fast that the radiation dose of a CACS is less than1 mSv and on par with a mammogram.
Furthermore, a new research study has demonstrated that a CACS over 400 adds independent prognostic information even over the most advanced nuclear stress test.
Why do a CACS?
A CACS may provide life-changing information. For example, the European Society of Cardiology said that "there is overwhelming evidence that coronary calcification represents a strong marker of risk for future cardiovascular events in asymptomatic individuals and have prognostic power above and beyond traditional risk factors." The same position statement indicated that in asymptomatic individuals a calcium score of zero was associated with a very low risk of heart events over the next 3 to 5 years (less than 1 percent per year). Individuals with a coronary calcium score greater than 1000 have an eleven-fold increase in risk of major events even if they are without symptoms. This is a huge difference.
No one should be surprised by heart disease. A CACS at age 40 or 45 can identify if there is a burden of silent calcified atherosclerotic plaque. If silent heart disease is found, a range of measures from plant based reversal diets, exercise, stress management, supplements, and monitoring can be implemented. In my clinic, I monitor patients with abnormal CACS and work on reversing their plaque with all of these strategies. Yes, $80 can save a life (perhaps $150 in your community). Do not wait. Call your local hospitals to see if it is offered, find out the cost, get a Rx from your health care provider, and schedule a CACS today. Finding out your score can help you ride the waves knowing the true status of your heart health.