Cardiac CT angiography ( CTA) can be very useful in the evaluation of patients who have a strong family history of early-onset heart disease to determine if their coronary arteries are blocked or narrowed by the buildup of plaque or to rule out abnormal coronary artery anatomy.
Calcium scoring can help better assess their risk of heart disease and can help tailor medical therapy.
Listen in as Robert Pelberg, MD., explains these diagnostic procedures and when to refer to a specialist.
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The Importance of Calcium Scoring & Cardiac CT Angiogram
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Learn more about Robert Pelberg, MD
Robert Pelberg, MD
Robert Pelberg, MD specializes in general cardiology, preventive cardiology and cardiac imaging; including cardiac CT angiography and calcium scoring, nuclear cardiology and echocardiography. He is board certified in cardiovascular diseases, cardiac CT angiography, nuclear cardiology and echocardiography.Learn more about Robert Pelberg, MD
Transcription:
The Importance of Calcium Scoring & Cardiac CT Angiogram
Melanie Cole (Host): Cardiac CTN geography can be very useful in the evaluation of patients who have a strong family history of early onset heart disease. To determine if their coronary arteries are blocked or narrowed by the buildup of plaque, or to rule out abnormal coronary artery anatomy, calcium scoring can help better assess the risk of heart disease and can help tailor medication therapy. My guest today is Dr. Robert Pelberg. He’s a cardiac imaging and clinical cardiologist specialist with the Christ Hospital Health network. Welcome to the show. Why is coronary calcium important? Tell the listeners what you want them to know about this.
Dr. Robert Pelberg (Guest): Thank you for having me. I’ll start by saying that coronary calcium is in fact a marker for coronary atherosclerosis. Coronary calcium is not a normal part of aging and basically it indicated an abnormal coronary artery. Coronary calcium is extremely strong as a risk factor for coronary events. In addition, it’s a pretty good diagnostic test as well. Coronary calcium has been shown to have a much more significant and independent prognostic implication than that for any Framingham risk factor alone and it’s very additive to the Framingham risk factors. In addition, Framingham risk factors don’t account for family history, and as you pointed out, family history is a very important point. Coronary calcium is very good for both a diagnostic standpoint, a risk stratification standpoint, and to potentially help us in determining how aggressive we need to be to treat these folks with secondary preventive medications by style measures, etc.
Melanie: What if they're an asymptomatic patient? How are you using it to assess cardiovascular risk based on Framingham, which is more lifestyle prevention and not even necessarily asymptomatic?
Dr. Pelberg: Truthfully, coronary calcification is in fact a test only for the asymptomatic frankly. That’s not to say I never use in patients who are symptomatic, but for the purposes of this discussion, it should be considered a risk stratifying type test. In other words, it’s not a diagnostic test for someone already presenting with chest pain. I use it mainly in the asymptomatic population who are intermediate in their risk or who might be intermediate in their risk and have something that pushed me over the edge like a family history that’s significant. Basically, it tells me if they have significant coronary artery disease or if they do not. In other words, if a person has a calcium score of 0, and they're over age 40 or so, the chances of them having significant coronary atherosclerosis is low and I would tell them at that point we’re good to go and repeat it in five years or so, let’s do some conservative measures such as lifestyle, etc., but I wouldn’t necessarily recommend a baby aspirin or a statin for those patients. On the other hand, if we determine they do have coronary calcium in this asymptomatic population, it pushed me over the edge to treat them very aggressively with high intensity statin therapy, aspirin therapy, etc., smoking cessation, all of those things – of course, smoking cessation in everyone – but it helps me to convince them. In addition, it’s very good for the patient who is not really sure. They're saying to me ‘do I really need this statin; do I not need this statin?’ Having a picture of the diagnosis and the pathological process directly is much more powerful than the associative findings as suggested in the Framingham risk.
Melanie: Does insurance recognize this screening?
Dr. Pelberg: I think it’s a class 2A indication by the American College of Cardiology, so it’s recognized in the guidelines. The data supporting it are far in advance of what insurance has come to accept at this point, and the short answer to your question is some insurance companies do not, some insurance companies do. You have to see; however, most hospitals are providing this service for a very affordable cost. For example, at the Christ Hospital, we charge $99 for this screen, which is really a bargain.
Melanie: When’s the right time for patients to get this screening and how frequently would you like them to get them?
Dr. Pelberg: I think that a very good indication for this is you're a middle aged person – we’ll say over 40 – who has some risk factors for coronary artery disease, but is not necessarily high risk clinically, the person should be asymptomatic and I think it should be done very routinely is of the information that it provides and the potential treatment that it might suggest. It might avoid the need for statin and aspirin therapy in a lot of patients and it might force the issue in many different patients. Once a patient is diagnosed with coronary atherosclerosis via calcium score, there are equivocal opinions concerning whether or not to repeat this test. There are lots of complicated issues regarding the use of statin therapy and the promotion of coronary calcification or healing, which does not necessarily mean worsening of the atherosclerotic process, but might manifest itself as a higher calcium score despite healing and perhaps even regression of non-calcified plaque.
Point being, if you repeat a calcium score and you're on high dose statins, you may see a rise in the calcium score, which does not necessarily mean an advancing of the atherosclerotic process. Having said that, a rise in calcium score in 18 months of 15% or greater does portend a bad prognosis, which suggests maybe even the need for more aggressive therapy. My philosophy depending on age is that I don’t necessarily routinely recommend repeating unless I'm trying to convince a patient to be compliant, but I will on certain instances repeat it in 18 months or so just to see if we’re having any kind of effect in preventing that increase in calcium score by 15%. It’s equivocal. Many people don’t choose to repeat it because if you're doing everything that you can for the patient to treat the process from a secondary prevention standpoint, then knowing what that calcium score does may not in fact change management.
Melanie: What about the score itself, the coronary artery calcium score? Does it increase with advancing age? Is it generally higher in men? Are you seeing an ethnic difference in that coronary calcification? Speak about the score itself.
Dr. Pelberg: The score itself is definitely seen to increase with age. There is a very beautiful study with multiple sub-studies called the Mesa Study, which went over the ethnic nature, so it certainly increases with age. We see it greater in men than females, although females reach that of men after menopause, higher in African Americans, higher in lower socioeconomic status folks, but it’s very important to understand that calcium is not a normal part of aging. In populations of patients around the world that do not eat a Western diet, they don’t necessarily develop calcium with age. I don’t want people to come away with the thought ‘as I get older, I'm going to develop calcium, it’s inevitable.’ It is very common in the population of patients in the Western society, but it’s not an inevitable thing. It can be regressed. It can be prevented. Calcium score, definitely though, portends significantly increased risk as it rises.
Melanie: How do physicians encourage patients to understand the importance of knowing their numbers and knowing this calcium score, and then following through with adherence? What do you want other physicians to know about communication with their patients on the importance of knowing these?
Dr. Pelberg: The first thing is I do a lot of primary prevention and I think that one has to dedicate their practice to a belief in primary and secondary prevention. First thing is you got to schedule a good amount of time to talk to these patients. This is not a five-minute follow-up visit – I schedule 30 minutes for my patients when I'm discussing calcium score results because I want to talk about all of these things. I think it takes education – I provide handouts to these patients regarding the process itself, the questions we’re trying to answer, the prognostic implications, how to determine depending on the calcium score whether a patient might have a type of stenosis or not, independent of symptoms, what can be down with diet, what can be diet with exercise, what can we expect, the importance of medication such as statins and aspirin, the importance of compliance and the importance of regular follow-ups, smoking cessation, diabetic control and just discussing with them the actual data. When they see these numbers and they see this on paper, sometimes I find that they're more aware. I also try to tell these patients to tell everybody they know. Discuss knowing your numbers with your patients because hypertension is a silent killer, often not found until a symptom ensues – heart attacks can be a silent killer – and often silent until significant atherosclerosis develops. Knowing your blood pressure, knowing your glucose, knowing your cholesterol, knowing your family history is critical important and I stress this with these patients. In regard to calcium scoring, if you can identify the disease on paper with a picture and not just the image of the possibility of the disease or a risk of the disease, but you're actually showing them that they have the disease, I think you can make an impact in these asymptomatic patients in regard to secondary prevention before symptoms develop.
Melanie: At what point is the right time to refer a patient into cardiology?
Dr. Pelberg: I think a primary care physician is certainly within their realm to order a calcium score in an intermediate risk asymptomatic patient in order to further risk stratify them into high or low. If the calcium score is positive, in my mind, any of those patients should be seen at least once by a cardiologist.
Melanie: What can a physician expect from your team at the Christ Hospital Health network after referral in so far as communication with the referring physician and your team approach?
Dr. Pelberg: They will get an extremely detailed note and/or phone call regarding this patient’s risk stratification, anatomical considerations of calcium, further testing and a treatment plan regarding secondary prevention, which includes lifestyle measures, dietary concerns, exercise prescriptions, medication concerns and a detailed description of the follow-up that would be recommended in regard to continued testing and monitoring.
Melanie: Thank you so much for being with us today. You're listening to Expert Insights Physician Views and News with the Christ Hospital Health network. More information on Dr. Pelberg and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
The Importance of Calcium Scoring & Cardiac CT Angiogram
Melanie Cole (Host): Cardiac CTN geography can be very useful in the evaluation of patients who have a strong family history of early onset heart disease. To determine if their coronary arteries are blocked or narrowed by the buildup of plaque, or to rule out abnormal coronary artery anatomy, calcium scoring can help better assess the risk of heart disease and can help tailor medication therapy. My guest today is Dr. Robert Pelberg. He’s a cardiac imaging and clinical cardiologist specialist with the Christ Hospital Health network. Welcome to the show. Why is coronary calcium important? Tell the listeners what you want them to know about this.
Dr. Robert Pelberg (Guest): Thank you for having me. I’ll start by saying that coronary calcium is in fact a marker for coronary atherosclerosis. Coronary calcium is not a normal part of aging and basically it indicated an abnormal coronary artery. Coronary calcium is extremely strong as a risk factor for coronary events. In addition, it’s a pretty good diagnostic test as well. Coronary calcium has been shown to have a much more significant and independent prognostic implication than that for any Framingham risk factor alone and it’s very additive to the Framingham risk factors. In addition, Framingham risk factors don’t account for family history, and as you pointed out, family history is a very important point. Coronary calcium is very good for both a diagnostic standpoint, a risk stratification standpoint, and to potentially help us in determining how aggressive we need to be to treat these folks with secondary preventive medications by style measures, etc.
Melanie: What if they're an asymptomatic patient? How are you using it to assess cardiovascular risk based on Framingham, which is more lifestyle prevention and not even necessarily asymptomatic?
Dr. Pelberg: Truthfully, coronary calcification is in fact a test only for the asymptomatic frankly. That’s not to say I never use in patients who are symptomatic, but for the purposes of this discussion, it should be considered a risk stratifying type test. In other words, it’s not a diagnostic test for someone already presenting with chest pain. I use it mainly in the asymptomatic population who are intermediate in their risk or who might be intermediate in their risk and have something that pushed me over the edge like a family history that’s significant. Basically, it tells me if they have significant coronary artery disease or if they do not. In other words, if a person has a calcium score of 0, and they're over age 40 or so, the chances of them having significant coronary atherosclerosis is low and I would tell them at that point we’re good to go and repeat it in five years or so, let’s do some conservative measures such as lifestyle, etc., but I wouldn’t necessarily recommend a baby aspirin or a statin for those patients. On the other hand, if we determine they do have coronary calcium in this asymptomatic population, it pushed me over the edge to treat them very aggressively with high intensity statin therapy, aspirin therapy, etc., smoking cessation, all of those things – of course, smoking cessation in everyone – but it helps me to convince them. In addition, it’s very good for the patient who is not really sure. They're saying to me ‘do I really need this statin; do I not need this statin?’ Having a picture of the diagnosis and the pathological process directly is much more powerful than the associative findings as suggested in the Framingham risk.
Melanie: Does insurance recognize this screening?
Dr. Pelberg: I think it’s a class 2A indication by the American College of Cardiology, so it’s recognized in the guidelines. The data supporting it are far in advance of what insurance has come to accept at this point, and the short answer to your question is some insurance companies do not, some insurance companies do. You have to see; however, most hospitals are providing this service for a very affordable cost. For example, at the Christ Hospital, we charge $99 for this screen, which is really a bargain.
Melanie: When’s the right time for patients to get this screening and how frequently would you like them to get them?
Dr. Pelberg: I think that a very good indication for this is you're a middle aged person – we’ll say over 40 – who has some risk factors for coronary artery disease, but is not necessarily high risk clinically, the person should be asymptomatic and I think it should be done very routinely is of the information that it provides and the potential treatment that it might suggest. It might avoid the need for statin and aspirin therapy in a lot of patients and it might force the issue in many different patients. Once a patient is diagnosed with coronary atherosclerosis via calcium score, there are equivocal opinions concerning whether or not to repeat this test. There are lots of complicated issues regarding the use of statin therapy and the promotion of coronary calcification or healing, which does not necessarily mean worsening of the atherosclerotic process, but might manifest itself as a higher calcium score despite healing and perhaps even regression of non-calcified plaque.
Point being, if you repeat a calcium score and you're on high dose statins, you may see a rise in the calcium score, which does not necessarily mean an advancing of the atherosclerotic process. Having said that, a rise in calcium score in 18 months of 15% or greater does portend a bad prognosis, which suggests maybe even the need for more aggressive therapy. My philosophy depending on age is that I don’t necessarily routinely recommend repeating unless I'm trying to convince a patient to be compliant, but I will on certain instances repeat it in 18 months or so just to see if we’re having any kind of effect in preventing that increase in calcium score by 15%. It’s equivocal. Many people don’t choose to repeat it because if you're doing everything that you can for the patient to treat the process from a secondary prevention standpoint, then knowing what that calcium score does may not in fact change management.
Melanie: What about the score itself, the coronary artery calcium score? Does it increase with advancing age? Is it generally higher in men? Are you seeing an ethnic difference in that coronary calcification? Speak about the score itself.
Dr. Pelberg: The score itself is definitely seen to increase with age. There is a very beautiful study with multiple sub-studies called the Mesa Study, which went over the ethnic nature, so it certainly increases with age. We see it greater in men than females, although females reach that of men after menopause, higher in African Americans, higher in lower socioeconomic status folks, but it’s very important to understand that calcium is not a normal part of aging. In populations of patients around the world that do not eat a Western diet, they don’t necessarily develop calcium with age. I don’t want people to come away with the thought ‘as I get older, I'm going to develop calcium, it’s inevitable.’ It is very common in the population of patients in the Western society, but it’s not an inevitable thing. It can be regressed. It can be prevented. Calcium score, definitely though, portends significantly increased risk as it rises.
Melanie: How do physicians encourage patients to understand the importance of knowing their numbers and knowing this calcium score, and then following through with adherence? What do you want other physicians to know about communication with their patients on the importance of knowing these?
Dr. Pelberg: The first thing is I do a lot of primary prevention and I think that one has to dedicate their practice to a belief in primary and secondary prevention. First thing is you got to schedule a good amount of time to talk to these patients. This is not a five-minute follow-up visit – I schedule 30 minutes for my patients when I'm discussing calcium score results because I want to talk about all of these things. I think it takes education – I provide handouts to these patients regarding the process itself, the questions we’re trying to answer, the prognostic implications, how to determine depending on the calcium score whether a patient might have a type of stenosis or not, independent of symptoms, what can be down with diet, what can be diet with exercise, what can we expect, the importance of medication such as statins and aspirin, the importance of compliance and the importance of regular follow-ups, smoking cessation, diabetic control and just discussing with them the actual data. When they see these numbers and they see this on paper, sometimes I find that they're more aware. I also try to tell these patients to tell everybody they know. Discuss knowing your numbers with your patients because hypertension is a silent killer, often not found until a symptom ensues – heart attacks can be a silent killer – and often silent until significant atherosclerosis develops. Knowing your blood pressure, knowing your glucose, knowing your cholesterol, knowing your family history is critical important and I stress this with these patients. In regard to calcium scoring, if you can identify the disease on paper with a picture and not just the image of the possibility of the disease or a risk of the disease, but you're actually showing them that they have the disease, I think you can make an impact in these asymptomatic patients in regard to secondary prevention before symptoms develop.
Melanie: At what point is the right time to refer a patient into cardiology?
Dr. Pelberg: I think a primary care physician is certainly within their realm to order a calcium score in an intermediate risk asymptomatic patient in order to further risk stratify them into high or low. If the calcium score is positive, in my mind, any of those patients should be seen at least once by a cardiologist.
Melanie: What can a physician expect from your team at the Christ Hospital Health network after referral in so far as communication with the referring physician and your team approach?
Dr. Pelberg: They will get an extremely detailed note and/or phone call regarding this patient’s risk stratification, anatomical considerations of calcium, further testing and a treatment plan regarding secondary prevention, which includes lifestyle measures, dietary concerns, exercise prescriptions, medication concerns and a detailed description of the follow-up that would be recommended in regard to continued testing and monitoring.
Melanie: Thank you so much for being with us today. You're listening to Expert Insights Physician Views and News with the Christ Hospital Health network. More information on Dr. Pelberg and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.