Transcription:
A Coronary Calcium Scan Can Save Your Life

Prakash Chandran: Your doctor may order heart scans to get a better understanding of your risk of heart disease or if your treatment plan is uncertain. Today, we'll learn about coronary calcium scans and joining us to discuss is Dr. Alon Gitig, an attending cardiologist at St. John's Riverside Hospital.

This is Riverside Radio Healthcast, the podcast from St. John's Riverside Hospital. My name is Prakash Chandran. So Dr. Gitig, thank you so much for joining us today. I really appreciate your time. What exactly are coronary calcium scans?

Dr. Alon Gitig: Great. Thank you for having me on. It's a pleasure to talk to you. Coronary calcium scans are a type of CAT scan that is very low dose, meaning it's a very low amount of radiation. The purpose of it is to try to detect if you have any cholesterol plaque building up in your arteries. The problem with imaging cholesterol plaque of the heart arteries is that you can't really see it with any testing, unless you do very expensive contrast CAT scans, meaning with dye or invasive tests. But a calcium scan just looks for areas of very bright white signal, which is emanated by calcium when there's a CAT scan done, which is very easy to see, even with a low-dose image quality. If there's calcium in the artery walls, it tells us that there's cholesterol plaque because cholesterol plaque initially forms as cholesterol in the artery walls. But after some time, it typically calcifies gradually, and it allows us to see a marker that tells us there is plaque there. And that's what these tests are most valuable to tell us plaque has started forming in the arteries of the heart.

So there's actually a few differences. One is that an angiogram is invasive. So catheters are going up through the patient's arteries, including the major artery of the body called the aorta and injecting dye into the heart arteries. And anywhere along the way, there's a very, very, very small, but non-zero risk of having some damage to an artery wall or breaking off plaque that goes in the wrong location.

A calcium scan is completely noninvasive. In addition, it's far less radiation that is required than an angiogram or other higher quality imaging CAT scans. And so when the radiation physicists who study potential health effects of radiation, principally the chances of having a cancer developed from a certain dose of radiation, when those folks looked at this test, this is the type of test that is felt to be very negligible amount of radiation as far as lifetime risk of cancer. It comes to approximately the amount of a handful of chest x-rays, probably somewhere around 10 chest x-rays and really does not move the needle much. It's also much less expensive. Well, I'll just say that because of the fact that it's noninvasive and extremely low radiation, it offers the ability to do this in lower risk people who are earlier in the process, often younger and aren't expected to have blockages yet, but we want to see if they're early in the process and if we could head it off. So an angiogram is going to show you if you have a blocked artery, whereas a calcium scan is going to tell us has the process started and where are you along the path, which leads me to a final point. The calcium score is actually a very well-studied and validated in many different populations piece of information. And we have tables that tell us the percentile ranking for men and women of different ethnicities at different ages. So it's actually quantifiable, unlike an angiogram that says there's plaque there or not, it looks like it's narrowing an artery or not this, this tells us how much plaque have you developed at this age at this point in your life and where do you stand compared to age-matched peers. Are you far accelerated or are you well behind the curve? Are you right smack in the middle?

Prakash Chandran: Yeah, it's fascinating to hear about. And actually, I have a family history of heart disease. You know, my grandfather died at 42. My dad had a heart incident, but thankfully he's okay now and he is 83 years old. But it is something that I personally think about. How can I be proactive and get ahead of this? And one of the things that you mentioned is, because of the accessibility, people can do it younger and they can start that process sooner. So who do you recommend should be getting this test done? Is it people with a family history like myself? Like what does that profile look like?

Dr. Alon Gitig: That's a great question. And I would argue that there's no one-size-fits-all way to answer that. There are professional societies that have issued guidelines on using calcium scans. But at the end of the day, pretty much every society recommendations will say that it needs to be individualized on a patient by patient basis.

The factors that come into play, so you mentioned picking things up early, that is the biggest reason to do a calcium scan test. But it really depends on what the doctors and, more importantly, in my opinion, what the patient's goals are. When you talk about prevention, there are, you know, are a couple ways to look at it. At the extreme, some people say, well, If I have some risk factors that are known to associate with an increased risk of heart disease, such as what you mentioned, you have a family history. I'm going to just assume that I have the process going on and that, if I let it sit long enough, I'll have a problem and I'm going to get proactive early and do everything I can to optimize my blood pressure, my cholesterol, my blood sugar, my exercise, my weight, et cetera, and live my life as healthy as possible. That's one end of the spectrum and I see lots of patients who want to do that. At the other end are people who say, you know, just because these risk factors increase the risk of heart disease, they're far from a definitive destiny, and "I'm not going to take medications that might improve my numbers or change my lifestyle in radical ways unless I develop a problem." If you develop a problem, that's what we call secondary prevention. You now are getting aggressive to prevent a second episode. And in the middle are where the most people fall. They're willing to do a lot of things to prevent disease, but they have limits of how much they feel they can take on at a time or how comfortable they are with taking prescription medication when they don't have disease yet. So what we're really talking is primary prevention.

The other big piece of information is what are you trying to do? Are you trying to prevent disease from occurring in your 40s, 50s and 60s, but you're okay with developing heart disease or a stroke in your 70s or are you saying, "I want to live to 90, 95, which is very common these days, and I want to be fully functional with no disease," because they require different approaches. But I would argue that if your goal is to try to live an entire normal life expectancy in the modern era and really minimize the chance that you're going to ever have disease, then it is a good idea to have a calcium scan done earlier rather than later, because the moment you detect even one tiny fleck of calcium, meaning your score is no longer zero, it means the process has started and it started a while ago because it takes some time before the cholesterol plaque begins to calcify. We don't have the magic bullet test to tell us now your score is high enough that you're really likely to have a problem. All we know is you either have no evidence of the disease process or it started. And I would argue that if you want to be aggressive with prevention, the only approach is to say, once you find evidence of plaque, that's when you get aggressive.

So in terms of your question about who would be appropriate candidates, when there's a strong genetic history of heart disease, I think most people, once they're over the age of 40 especially for men, women tend to track about 10 years later than men in terms of disease with the arteries, so you could argue 50 years old is a good time to get a baseline done. Again, this is minimal amount of radiation and the benefits are very great if you're going to act on lifestyle changes and possibly prescriptions. I will say though that I have some patients who really are clear about their goals and they want to avoid disease for an entire lifetime and they have very strong family histories or other blood tests that speak to genetic abnormalities and cholesterol, meaning it's been there for many years and potentially wreaking havoc with the arteries. And in some of those patients, even in their 30s, I will do a baseline test because in those high risk patients, we find disease.

Now, the other argument is just treat everybody aggressively. You don't need the test. But as I say, it's a patient-doctor informed decision discussion because patients are different in what they want to do in terms of lifestyle and what medications they're willing to take. So if somebody's treatment is going to change based on the answer, then I think it's reasonable to do it quite early in life. But most people, we're talking around sort of 40s to 50s.

Prakash Chandran: Yeah, I think there's a lot of nuance in that answer. And I'm really glad that you went into detail there. It seems like broadly speaking, if you want to be proactive and live the longest life possible, then doing a scan like this sooner than later is always a good thing. And there's actually a final point that you made that I wanted to really drive home. And that is that if you get one of these scans done and the calcium score is greater than zero, then that means that the disease process has started, and it can't really recede without intervention. Is that fair to say?

Dr. Alon Gitig: That's exactly right. And there is more nuance to the number. There are certain absolute numbers, the actual score that's reported, that are considered low intermediate or high, which associate with lesser or greater risk within the next five years of having a heart attack or stroke. However, in general, those numbers, the amount it changes your five-year risk of having something happen, in general, in absolute numerical terms tends to be small. You might go from having thought at baseline your risk was less than 1% in five years to it being 3% or something along that line. It's a big, you know, several factors higher. But in real terms, the numbers are quite low. But what is not low is when you say, "You now have the disease process, your 20-year outlook has changed dramatically. You are quite likely to develop progression and end up with a problem in 15, 20, 30 years," because this is a slow-moving process, a very slow-moving process. And so if you're looking at this at a wider lens, that's when the biggest change in risk occurs.

Prakash Chandran: That makes a lot of sense. So let's talk about when someone gets the test, their score is non-zero, and I know there's a range there. But you know, kind of thinking about that 20-year outlook, what can that person start to do knowing that a disease process is starting within them?

Dr. Alon Gitig: So that's a complicated answer and there's a ton of information if you get really into all of the details. But in general, I would summarize it as saying this, the person, if they are really aggressive, should try to optimize everything that we know, has a reasonable amount of evidence that it's related to risk of disease of the arteries, meaning heart attacks and strokes, that has really extremely little or no downside to them of trying. And what that boils down to is optimizing the status of all of the lifestyle factors is first and foremost.

People need to try to achieve and maintain a better body weight than where they are, if they're overweight or obese, according to medical criteria, but specifically to minimize the amount of belly fat and their waist circumference, which is a major predictor of bad events when it comes to cardiology. People need to optimize their muscle mass by doing exercise, strength training, and their cardiovascular fitness by doing cardio exercise, movement, whether it's walking or jogging or cycling or gym equipment. And people need to optimize their diets, which doesn't always go hand in hand with weight loss, but usually it does. And that means, for the most part, really cutting back on the amount of processed foods that we eat, because those are endemic in our society and have a big part to play in chronic disease, including cardiac disease; minimizing the amount of products with added sugar; products made from flour, which is a refined grain and not a natural food and focusing as much as possible on healthy foods that come from natural sources, whether it's plants or animals; healthy unprocessed foods. You can get into some more detail about whether it should be more plant, less plant, but that's the general principle.

You want to make sure that you're getting your blood pressure into optimal ranges either with those diet changes and exercise or medications. I should mention that controlling stress and improving sleep, which are huge problems at baseline and became even more huge since the pandemic started is a very important thing for heart health and often shows up in blood pressure being elevated. You want to get your cholesterol into optimal ranges and you want to be absolutely sure that any blood test that show signs of prediabetes or the beginning stages that eventually lead to prediabetes, which we call insulin resistance, that all of those things look ideal. These are markers of blood sugar, markers of insulin levels in your body and markers of inflammation.

So all of these things can be addressed potently with lifestyle changes including stress, exercise and diet management. But in some cases, medications are certainly favored as the benefit goes up when somebody has plaque starting and if the risks are low enough of side effects.

Prakash Chandran: Yeah, I know I'm kind of asking these more general broad questions, but I think you're doing a really good job answering them. And I know a lot of the answers are nuanced. You know, I think part of this is there's just a lack of awareness around the scan itself, right? I've done a lot of these conversations and I think this is the first time I'm hearing about a coronary calcium scan. So, just as we close, my first question is why do you think that is? Like, why is there the lack of that awareness? And secondly, if people are now convinced that they wanna be proactive and get a scan done, how can they do that?

Dr. Alon Gitig: Right. So I think part of the awareness issue is that the test is done with CAT scans, which most doctors' offices don't have, right? Cardiologists have echo machines to do ultrasounds of the heart. They have stress testing equipment. They usually don't have CAT scans and doctors tend to do what they know and what's at their fingertips. So this requires sending somebody out to an imaging facility like St. John's Hospital, which offers it, and getting a test done. So it just tends to be talked out less and done less. But the power of the result in terms of risk prediction is clearly recognized now by all cardiology societies as being extremely potent and among the most potent variables that impacts risk.

So, it is, you know, now clear cut established in guidelines that this test is often useful when somebody is on the border. Now, when I say on the border, again, if someone's blood pressure is high, it makes sense to give medications to lower it. Same if their cholesterol is quite high. So. There's an argument not to do the test in those people, unless the person, the patient, has a compelling need to just want to know what's going on with them. But in general, there are many, many people who want the information to guide their decision on whether or not to take drug X, Y, or Z. So if you wanna have this test done, your best bet is to speak to your doctor. Many primary care doctors have started understanding this test and being comfortable ordering it. I would say in my experience still the majority are not, they would refer you to a cardiologist to have their opinion on whether they think it's required or not. And then, if you feel that it's a test you want to have and, you know, there's issues with insurance coverage, you can purchase it out-of-pocket. You can go to a place that does it and ask them to perform it on you. They will require a prescription, so you'll have to work with a doctor around that. But most places that offer this test do so for $200 or less, it's often around a $100 to $150 out of pocket. So I think it's money very well spent.

Prakash Chandran: Absolutely. Well, Dr. Gitig, really appreciate your time and the education today.

Dr. Alon Gitig: It was an absolute pleasure. I enjoyed it. Thanks for having me on.

Prakash Chandran: That was Dr. Alon Gitig, an attending cardiologist at St. John's Riverside Hospital. Thanks for checking out this episode of Riverside Radio Healthcast. For more information, you can call our physician referral service at 914-964-4DOC or email us at findadoc@riversidehealth.org. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been Riverside Radio Healthcast, the podcast from St. John's Riverside Hospital. Thanks so much, and we'll talk next time.