Coronary Calcium Scoring
It is time to turn off the faucet instead of just mopping the floor.
All health insurance companies acknowledge that asking a woman a list of questions, doing blood test and breast examination will not reveal the presence of early breast cancer. They follow the guidelines and pay for routine mammography. It saves lives.
All health insurance companies know that asking a person a list of questions, doing blood test, EKG and even an expensive nuclear stress test will not reveal the presence of multiple plaques in the coronary arteries before a heart attack, which is fatal in 1 in 4 cases. The American College of Cardiology and the American Heart Association approved and gave Coronary Calcium Scoring a Class IIb recommendation in 2012. During all this time, health insurance companies, including Medicare, continue to refuse to pay for this $100 test while many tens of thousands of us die needlessly every year.
If you have not watched our 15-minute introductory video, please take the time to watch it now.
Patient John ask a question: Doc, what is my risk of having a non-fatal heart attack, stroke or sudden cardiac death in the next 10 years?
The Best Guess Method
Patient John replies: Doc, that is not reassuring. I don't want to take medications that have no benefits if I don't have plaques. And if I have many plaques, I want to take the optimal medications that will keep me healthy. How can we stop guessing? It my life.
The Calcium Scoring Method - High Calcium Score
The Calcium Scoring Method - Zero Calcium Score
Calcium Scoring is not just for Presidents, Astronauts and Executives - It is for You Too.
Lesson Learned: Even White House and NASA doctors were wrong and updated their protocol for heart disease and heart attack prevention to include coronary calcium scoring: Watch this video.
In a systematic review and meta-analysis of 11,256 patients from six studies, Coronary Calcium Score greater than zero was associated with higher likelihood of physician initiating and patient complying with heart attack and stroke preventive medical therapy and positive lifestyle intervention.
Insisting on adding the 10 year Framingham Risk assessment only detracts from the superior predictive value of calcium scoring and confuses the primary care providers leading to no risk assessment at all and therefore no treatment. No treatment means more preventable deaths and higher healthcare cost.
About 620,000 Americans suffer a first heart attack every year which is fatal in 1 in 4 cases, Identifying them earlier by calcium scoring gives them access to effective and inexpensive medical treatment. We can save more of our fellow Americans if we all agree to give them access to coronary calcium scoring. Some don't.
Coronary Calcium Scoring Test Explained:
For patients and primary care providers, click here.
For patients, click here.
Correction: Radiation exposure is now much lower using improved technique at about .5 milliSievert - comparable to or even lower than screening mammography.
For physicians, click here.
The Framingham Risk Scoring is an algorithm that predicts the likelihood of developing a non-fatal heart attack, stroke and sudden cardiac death from a fatal heart attack due to the development of atherosclerosis and subsequent plaque rupture within the next 10 years. The data collection started in 1948 by recruiting an Original Cohort of 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts, who had not yet developed overt symptoms of cardiovascular disease or suffered a heart attack or stroke. There are several versions with updated data but they have the same fundamental limitations - it does not answer the questions that patients and physicians want to know;
A patient with a risk score of 25% which is high and you are about to prescribe a statin. You tell the patient that his/her Risk Score is 25% - meaning there is a 1 in 4 chance within the next 10 years of suffering a heart attack, a stroke or sudden cardiac death.
Patient asks: Do I have plaques in my coronary arteries? If I do, how much?
Doc replies: I don't know. The score does not say. But it predicts that within the next
10 years, you will develop plaques and that one will rupture causing a heart attack, stroke or sudden death.
Patient asks: It is possible that I don't have plaques right now?
Doc replies: Yes. It is possible that you don't have any.
Patient asks: If I don't have plaques right now, are you still going to prescribe statin?
Doc replies: Probably not.
It is clear that this old traditional and unreliable 10-year risk scoring is not the ideal tool winning the war against heart attack and stroke. Long term compliance to medical treatment is poor and physicians don't routinely perform this scoring method routinely.
Several studies have shown that a non-zero calcium score is the best method for making sure that physicians initiate appropriate medical therapy and patients comply with both positive lifestyle intervention and medical therapy long term.
The Alternative Approach - Look for the Disease, Stop Guessing if there is or there will be Disease in 10 Years.
The conversation with the patient goes differently.
This is what I said to this patient: "This is your calcium scan. We are looking at your disease - not your risk of getting it. You already have the disease and here it is. Your calcium score is 746, which is high. You have many calcified plaques in three major arteries, including the left main coronary artery. This is just the tip of the iceberg. You have other plaques that have no calcification yet and we don't see them. We know how to treat your condition very well. Medical treatment is very effective and you don't need to have stents or heart bypass surgery."
This is a real patient and the medical treatment was initiated 15 years ago with excellent compliance. He is now 65 and doing well. I expect that he will continue to remain healthy without any cardiovascular events and without need for stents or heart bypass surgery.
If you already had a heart attack, stent or heart bypass, there is no need for coronary calcium scoring because it is already known that you have many plaques and the test will not provide any new useful information that will change your medical management. You should already be on plaque-directed optimal medical therapy.
There is no need to have CT angiography and cardiac catheterization if you have no cardiac symptoms even if your calcium score is high.
Unlike screening mammography which is done repeatedly at certain intervals, calcium scoring is done only once or twice during a lifetime. It only costs around $100 and we want all health insurance companies to pay for it. But in the mean time, $100 out-of-pocket expense is a very good investment on your health. Do it. Radiation exposure is low and about the same for mammography and calcium scoring.