(Heartscan | Calcium Scoring)
Every 25 seconds in the USA, someone has a coronary event. Every minute, someone dies from one. Nearly half of these heart attack victims will have no prior symptoms, or warning, at all. Moreover, statistics show that nearly 75% of those hospitalized with heart attacks have normal cholesterol levels; so, how is a person to know if they are really at-risk? Now, there is a fast, simple, more-reliable way to find out.
Medicine’s understanding of the risk factors and disease process that are responsible for these sudden, fatal events has changed much over the last 15 years. We once attributed them primarily to a clogging of the coronary arteries from gradual plaque buildup, and pointed to diet and lack of exercise as the culprits; but, it turns out to be not so simple. While there may be some truth to the old way of thinking, we now understand that the vast majority of fatal attacks are caused by the rupture of a plaque, resulting in a blood clot. (See picture to left.) Moreover, even a relatively small plaque can become inflamed and vulnerable to rupture. Compounding this issue is the fact that traditional cardiac screening & diagnostic exams, such as an ECG stress test, echocardiogram, or even a cardiac catheterization, often do not identify the presence of plaque until it is quite advanced; creating a false sense of security.
In the late 90’s, a technology called Intravascular Ultrasound (IVUS), finally allowed us to understand how traditional testing methods could fail to identify so many of these patients at high risk. With IVUS, we were able to see from cross-sectional (down-the-bore) images of the coronary arteries that these vessels can remodel, or widen, to accommodate plaque buildup. Referred to as the Glagov Effect, this means that an artery could be plaque-lined, and at risk of fatal rupture, yet still be coursing with an ample supply of oxygenated blood. As a result, the person could feel, and test, as completely normal. This finally explained how an apparently healthy person could pass an exercise test, and yet subsequently die of a sudden heart attack. The bottom line is that plaque in the coronary arteries puts a person at-risk; and in general, more plaque equals more risk. Although calcified lesions are generally considered stable, their presence is highly-associated with the concurrent presence of soft plaque, which in turn can then become infected (vulnerable) and potentially rupture. (Note: it is the vulnerable soft plaques, not the calcified plaques, which rupture.) While the soft plaque is difficult to detect, the calcified plaque is not. The Heartscore is a measurement by CT scan of the amount of calcified plaque; which by correlation is a superb indicator of risk to the patient.
Historically referred to as coronary calcium scoring, the Heartscore exam is accomplished by use of an extremely fast CT scanner, which can create motion-free images of the coronary arteries. There are no needles or dyes, and only a minimal change of dress. The use of ECG leads is needed to ensure ideal timing of the scan, but the entire acquisition takes less than 15 seconds. From the resultant images, the amount of calcified plaque is then measured, and the results correlated to a normal range for age & gender. While the average scores increase with age, and male scores are usually higher than female scores, the only truly “normal” score is zero.
Those who smoke, have high blood pressure, diabetes, or a family history of coronary disease are the most-likely to have plaque. Other good candidates for the Heartscore study are those who have high cholesterol and/or triglyceride levels; or inflammatory diseases, such as arthritis or lupus. The Mayo Clinic even goes so far as to link atherosclerosis to “infections, or inflammation of unknown cause.” (That really widens the field.) Paradoxically, even some who are very fit, with no apparent risk factors, can have plaque. In fact, a 2015 study showed that one-fifth of middle-aged athletes are at previously-undiagnosed cardiac risk based upon the presence of plaque. (One well-known example of this was Jim Fixx, author of the Complete Book of Running, who died at 52 while jogging.)
So, although it can vary slightly from provider-to-provider, the Heartscore procedure is generally recommended for all persons without previously-diagnosed heart disease, and after these age minimums:
While the Heartscore procedure was once available only at specialized centers, the proliferation of ultrafast CT scanners in recent years has made it not only much more accessible, but also easily affordable. In addition, primary care physicians continue to become better-educated as to the value of the procedure and the risk management of patients based upon their results. Providers listed on this website have an active screening program, with ample experience, and can provide clinical follow-up if appropriate. If you want to know whether you are one of the vast multitudes with silent (undiagnosed) heart disease, neither cost nor availability should be an excuse any longer.
Abnormal findings that are outside-the-scope of the procedure, but which are nevertheless revealed, are considered incidental. When those findings are clinically-significant, which happens occasionally with wellness imaging, this can prove to be serendipitous for the patient. In the case of a Heartscore, although it is not a part of the procedure, the image quality and field of view of the CT scan can be such that the radiologist might notice clinically-significant findings outside of the heart. There is no guarantee that these will be noticed, or interpreted, but this is not an uncommon occurrence. Examples of such findings are:
- Lung cancer (centrally-located)
- Liver nodules or tumors
- Aneurysm of the aorta
- Enlargement of the heart (cardiomegaly)
- Hiatal hernia
While the potential for ruling out these issues may not be a viable reason to schedule a Heartscore, such findings are valuable, and some can even save your life. For patients who have had such findings, it has often proven to be a very “beneficial occurrence.”