Measuring your Heart Attack Risk: Coronary Calcium Score: History, Risk Adjustment

Measuring your Heart Attack Risk: Coronary Calcium Score: History, Risk Adjustment


So, comment below if you recognize this
picture. I’ll give you a hint: This is a heart. This is a coronary artery calcium
score. So guess what? Those white dots are – we’re going to talk a little bit more
about coronary artery calcium score for this video. There’s a lot of topics. We’re
going to cover. One is a movie called the Widowmaker. If you haven’t seen it, you
should. and if you have someone who may have some risk for heart attack and
stroke, and they haven’t seen it – have them take a look. This is a – this was
funded by a thin athletic Irish businessman who was very wealthy who ran 4 or 5 miles – I mean 4 or 5 times a week and then found out that he
had significant plaque – calcified plaque by getting a coronary artery calcium
score. I’ve commented in several towns. I don’t use the coronary artery calcium
score as much as I do the CIMT because the literature behind – following
sequentially – is not as good as it is for CIMT but it’s there. In fact, speaking of
which, a lot of this conversation came up when John published his article on
decreasing his coronary artery calcium scores. This is it, by the way, this is the
image that he used and you saw that he had a 59% decrease after his
massive changes in lifestyle. That generated a lot of discussion. A lot of
attention – one of them was whether or not radiation was an issue. The reality is – we
talked about that. I did a separate video on that. You get, what’s called about a
milli – I think a separate series or a millisievert. It’s basically equivalent
to the risk of one lifetime in a sow or one in a thousand lifetime.
When you consider and that’s for the older technology about ten years ago –
when you consider the – the fact that untreated plaque is more like a 40-80% 10-year risk, again, the risk for a coronary artery calcium score radiation
is not (to me) significant. It would be, if you decided
you wanted to do it on 30-year olds all the time, which could be done by CIMT
but nobody’s going to be doing repetitive coronary calcium scores on 30
year olds. We’re also going to talk a little bit more about the – there’s some
very interesting stories within this. Besides the ones I’ve just mentioned,
another story is this article – this is the definitive first statement by the
American Heart Association. It’s on – it was a scientific statement on
cardiovascular imaging using calcium scan. One of the things that’s very
interesting about – and that’s the full – the full text. If we get time in this
video, I’ll go back and cover some of the key points in it. The – another side story
has to do with a big fella that developed the – the best scoring for the coronary
artery calcium test. You may recognize the name Arthur Agatston, cardiologist
that, again, wrote the – developed the Agatston score – also wrote the book on
the South Beach diet. Interestingly enough, if you go back and you look at
the original American Heart Association article. This one. You’ll see a thing
about embargoes. Jolla Scalzo was the editor of circulation magazine in 2004. A
lot of information had been developed and research had been developed
regarding coronary artery calcium or the American Heart Association
commissioned a group led by Matthew Budof to come up with the scientific
statement. Laskowza was then the author – I mean the editor, embarked – basically
said “Look, I’m not gonna publish this.” He held it off for over – for about a year
but it still came out. His point was “How did this situation come about?” He said
“Look, they’ve been two men – too much information coming out about this
article before we published it.” These reports have led to an unfortunate level
of speculation by the public and the medical community. Principally because
the statement of imminent support is simply incorrect, No, his statement of
lack of support was incorrect and, sure enough, the article did come out a year
later. Before I go on and before I get into depth on that article, let me just
cover something very quickly. The Agatston score itself – zero. It was a
pretty reliable negative test, 1-10 is minimal, 11-100 is mild coronary atherosclerosis with calcification. 100-400 is
moderate and over 400 is high and I will routinely see patients with out – with
over a thousand. As you saw back with John’s, he never really got that high but
he did have moderate risk, according to to that Agatston score. Now, let’s
get back to the – to the circulation article. Basically, the scientific
statement – it covers a lot of very interesting points. Some of which have
been updated. For example, we will see in this article that they didn’t – that the
jury was still out on sequential coronary calcium scores.
Budof. the head of that policy committee actually published
something in 2013. This is a 20-what.. 2006 yeah, 2006 publication. In 2013, Budof come out with some research supporting use of sequential. The jury is
still out. You’ll still see a lot of debate, as you may have during some of
our comments, but again, as I’ve mentioned, I think it’s a it’s a viable solution,
especially when you get really messy confusing CIMT scores. Now, here’s the
executive summary reviews: the scientific data on cardiac CT, related to coronary
artery disease and atherosclerosis. It describes what it is. Gets into some
discussion about limitations. It uses the natural contrast. For those of you who
are wondering, yes – there are some – some studies where you can use radioactive
contrast but that’s not what this is. Majority of published studies have
reported using the Agatston score and, you remember, we talked about Dr.
Agatston of South Beach dieting. Now, here’s where it starts to become
very important. You have people that have low to moderate Framingham risk scores
but there’s a question – these folks should have a coronary artery calcium
score and, as I’ve pointed out before, there’s no radiation associated with CIMT. CIMT shows a better sequential thing. So these folks should have a CIMT.
Again, one of the biggest problems is access. So I think both of these studies
are far better than a stress test, as I’ve mentioned a few times,
the problem with stress test is that there are way too many
false negatives and now, when – if that sounds a little bit technical, let’s just
think through what happened. There was a very celebrated case – Tim Russert. He had
a negative stress test in what- March of 2008, and then in June of 2008, he died with a heart attack in the newsroom. You don’t get so many false negatives with these
studies. Now, back to the cardiac CT article. The American Heart Association
position on it: they strongly recommend using a low dose technique. They go into
talk about, again, radiation associated with it which, again, I’ve said is minimal
compared to the risk associated with having a plaque in your coronary
arteries. Use of coronary artery calcium score in symptomatic patients has
already been shown. That wasn’t really a part of their policy decisions. They did
go on and talk quite a bit about EB CT which is electron beam CT versus multi
source CT – not going to get into that discussion. There’s still a little bit of
research and, back and forth – going on with that – at this point, the cardiac CT
technology is rapidly evolving and, again, that means better studies, less radiation. Again, a good study – the – and, again, a
little bit of a moving target in terms of trying to nail some of these things
down but, no question, better than a stress test for predicting risk and
disease. The A – the American Heart Association had done two prior
statements on coronary artery calcium screening. 1 in 1996 and the – another one
in 2000. So this was not the first. And again, there’s been a ton of research going on around this. Oh, one of the key things
– again, another key thing for me is if you go back to the in terms of comparison
between CIMT and coronary artery calcium score,
besides the radiation but – besides some of the the problems with the – with
scoring is this: As you can see, you’ve got very broad ranges here one 0, 1-10,
11-100, 100-400, and then above 400. And it’s really difficult to
get clarity between the risks at those levels. You go back to CT and, I mean. CIMT – CIMT gives you a much better clarity regarding sequential studies. Now,
I say that and we – one of the things we presented was that CIMT technology is
changing as well. Todd had doubled the sensitivity of his tests between John Lorscheider’s most recent – most recent tests and the tests before that, indicating a
potential doubling and plaque burden. Again, as you – as you get deeper into
interpreting it, that was not – that was not the case but you see this with both
of these studies. There is no study out there that’s perfect. You see the same
kind of things with glucose tolerance tests – oral glucose tolerance test vs
Hayashi formula vs Kraft insulin survey. All have their own problems and
challenges and John’s already done a good video on showing some of the
challenges in terms of continuous glucose monitoring
and finger stick mechanisms – blood strips. So, again, if going through all of these
details on these screening tests gives you the heebie jeebies, welcome to my
world. I’ve not been afraid of it. I just
understand. I’ve studied – part of what epidemiologists do in medicine is study
the pros and the kinds of tests and if you have questions for me regarding
those, please just put them down under the – in the comment section on the video.
Also, again, I’ve gotten – I’ve gone into things like predictive value of a
positive, predictive power of a test, things like that. On other tests, such as
screening for colorectal cancer, back to the American Heart Association position
on coronary calcium, again, they’ve already said (long before 2006) it’s good
for symptomatic patients itself. It helps classify – the big thing was to point to
here on the mid right-hand side of the of the screen. That was the big focus and,
as you’ll see, they’ve got over a page of discussion about it. That’s where it
really does help. Now, let’s get to an example. We got – we dealt with a whole lot
of maybe cold hard facts except for the stories in the beginning but let’s talk
about patient examples and it’s worth reading this one potential risk
stratification whether calcium or other other tests first requires calculation
of the Framingham risk. For example, a 45 year old man with a total cholesterol of
225, an HDL of 45, and systolic blood pressure of 140 has a 10-year risk of 4%
if he is not a smoker. Again, that’s talking about Framingham. If the same
individual has a systolic blood pressure of 160, his tenure risk is still only 5%. At least by the data that we have and I
think most of us would say “No. The – the latter individual, where the blood
pressure of 160 has higher risk in this study. Greenland data studies similar to
this – Greenland and associates demonstrated this utility of calcium
scanning when the Framingham risk is less than 10%. Again, that’s not a
disadvantage that you see with the CIMT. Now, modifying this case though illustrates how non-invasive test-testing could
influence patient treatment and does on a regular basis. In an intermediate risk
patient, consider that patient – 5 years later. He’s 50-year old years old. Now
with blood pressure of 140 over 85, cholesterol to total cholesterol 220, HDL
of 145. The – his risk is now intermittent. An intermediate with a bout a 10% risk
by Framingham. A positive current area of calcium of greater than 169. The
physician would be able to say “Look, now he’s got at least a 20% risk” So, at that
point, what do you do? There’s a lot of Statin haters out there that will say no.
No – don’t use statins. That’s where you’re going. The statin haters and the statin lovers can have their debate. I do use
them. I use very low low amounts, not driven by LDL but driven more by
cardiovascular inflammation, which you’ll see – but here’s one thing that you don’t
see in these studies because it wasn’t there in the science at 2006. Lifestyle –
it has been shown that individuals with with CIMT and with coronary artery
calcium scores that indicate risk – they have a far
better uptake of doing what they need to do, in terms of improving their lifestyle,
dropping the weight they need to drop, improving their diet, exercising, doing
the things they need to do. So, at the end of the day, these two studies are very
good. And, again, neither one of them has the false negative – false negative rate
that you see with stress tests. So, bottom line – I would recommend either one of
them. I recommend CIMT, if you can get access to a good provider. I’m actually
having some discussions with Todd and a couple of friends that have done this
before looking at the potential of providing CIMT at different cities in
the country. Now, back to this – to the coronary calcium discussion and maybe,
hopefully, just put a bow on it. Here’s the thing: EB CT, that’s one of the versions.
Basically, coronary calcium has undergone a 20-year period of testing for reliability and validity. It’s now established. This was back in 2006. It’s
now established as a useful technique in identifying individuals with or at risk
for coronary heart disease and they were right. As much politics and anger and
frustration and editors like – loves cows, Oh, pulling the information for another
year and people not watching the movie – the Widowmaker – This is a good test and,
again, as I’ve added a couple of times, I don’t use it that much because I’ve got
great access to a high-quality CIMT. I know there have been comments coming
from England and Australia. Some folks having (what they consider) good access, some with not so good access. So, again, if I didn’t have CIMT access, I
would clearly be using coronary calcium scores. I have covered a lot of
waterfront here, a lot of details – and I hope it hasn’t been too confusing. I hope
some of it’s been entertaining, especially when you go back and connect
some dots like this one and John’s dots about what he did and
please go watch that video and recommend it to others. Thanks for your
interest.