Buildup of calcium, or calcifications, are a sign of atherosclerosis and coronary heart disease. Coronary calcium scoring is one of the most advanced cardiac diagnostic tests available today. A simple, noninvasive test, the calcium test is one of the best tools used to detect early signs of heart disease, greatly reducing a patient’s risk of a sudden heart attack.
Listen to this podcast as Jack Tighe, MD, Medical Director of St. Luke’s Cornwall Hospital Cardiovascular Institute, discusses this important test as an easy, noninvasive exam used to detect coronary artery disease in its early stages.
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Coronary Calcium Scoring for Early Detection of Heart Disease
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Learn more about Jack Tighe, MD
Jack Tighe, MD
Dr. Jack Tighe received his bachelor's degree from the University of Michigan and his medical degree from Loyola University- Stritch School of Medicine. He completed a residency in internal medicine at the Walter Reed Army Medical Center in Washington, D.C., where he also completed fellowship training in cardiovascular disease. During his training at Walter Reed Medical Center he received the outstanding resident award, the outstanding fellow award and was inducted into the alpha omega alpha medical honor society. Dr. Tighe has presented at national and international conferences including the American Heart Association and the American College of Cardiology. Dr. Tighe has also co- authored numerous studies that have been published in peer reviewed journals including the New England Journal of Medicine. Dr. Tighe is a member of the American College of Cardiology, American Society of Echocardiography and the Society for Cardiovascular Computed Tomography. Dr. Tighe is also the Director of the Cardiovascular Institute at St. Luke's Cornwall Hospital.Learn more about Jack Tighe, MD
Transcription:
Coronary Calcium Scoring for Early Detection of Heart Disease
Melanie: Like so many of us, are you worried about heart disease? If you are, you might want to consider a test that could be a precursor that could let you know whether you are at a higher risk of developing coronary artery disease. My guest today is Dr. Jack Tighe. He’s the medical director at St. Luke’s Cornwall Hospital’s Cardiovascular Institute. Welcome to the show. Let's speak about some of the risk factors for heart disease because we hear about things like smoking and genetics and all of these kinds of things, but there are other risk factors as well that we might not be aware of, like cholesterol and stress. Speak about some of those.
Dr. Jack Tighe, MD: First of all, thank you for having me on the show today. Certainly, what we want to do in finding coronary heart patients is identify those patients that are at risk. As you point out, there are risk factors that are well recognized – smoking is a pretty good example of that, diabetes, high blood pressure – these are risk factors that are pretty well-known. There are newer risk factors that are emerging. We know that cholesterol in it of itself is a risk factor, there are sub-fractions of cholesterol disorders that are also risk factors as well too and some inflammatory things that may be going on as well too, so there are risk factors. What we’re also interested in getting at are patients who have already established coronary artery disease that they may not know. Many of our patients, as it turns out, may not have a lot of obvious risk factors for heart disease development, and yet, may have coronary disease already developing. It’s those people that we’re interested in getting after.
Melanie: You're also looking at inflammatory markers, correct? You're looking at things that people think inflammation like arthritis, but we’re talking different kind of inflammation that could put somebody at risk that you're looking for as well.
Dr. Tighe: Exactly. We’re talking about vascular information and there are markers, and this has been looked at for quite some time now, looking at the reactive protein, which is the measure of inflammation within the vascular space that correlates with coronary events, homocysteine which can be elevated and be a market for inflammation as well too, so there are other inflammatory cytokines that contribute to abnormal coronary physiology, at least coronary artery disease and certainly those things are active areas of interest. This is something that's a different topic. From what we're looking at, we're looking at trying to identify those patients that already have heart disease developed. I guess the easiest way to think about this is to think about who the at-risk patients are. We’re pretty good clinically at picking out who are the people who are likely to have heart disease. We have just our eyeballs. We know the risk factors. We know that people with diabetes and people who smoke and overweight and underactive and have high blood pressure and high cholesterol, those are pretty high-risk people that are likely to have coronary artery disease.
We see people who are fit, active, don’t smoke, don’t have cholesterol issues, don’t have blood pressure issues that are generally low risk. We have tools that we can use to measure this and we can use risk factor predictors, something called a Framingham Risk Index, which is a marker, a tabulated way of adding up risk and figuring out what is your risk of having a coronary event in the next 10 years. This can be projected so that at the high-risk people, the people with lots of risk factors, they have a 20% chance of having a coronary event in the next 10 years. People who are low risk have a less than 10% risk of having a coronary event in the next 10 years. The problem is that when you use these tools, they're pretty good at picking out the high risk and the low-risk patients, but they're not so good at parsing out those people in between, people who maybe who one or two risk factors for heart disease. They don't have any symptoms, they're pretty active. I think about guys in their mid-40s who do triathlons who have high cholesterol and they look at me thinking ‘why do you want to treat my cholesterol, I'm young I'm fit, I don’t have any other risk factors, I don’t smoke, I don’t really need a statin medication,’ but it turns out that many of those people already have heart disease under development. If you don’t look for it with a test like this, then you don’t find it.
Melanie: Let's talk about the test like this, the coronary calcium scoring. What is this test? How does it work?
Dr. Tighe: It’s very basic. It’s looking at the coronary arteries with x-rays and seeing if coronary calcium is already developing in the arteries of the heart. It identifies the coronary disease in not the earliest, but its earliest identifiable state. Coronary disease starts off really early in our lives before we're 10. We're already starting to work on the coronary plaque. Those plaques are basically soft, they're made out of cholesterol, they're not visible by any technology – we really can't find those. When people mature in their 40s in men and into their 50s in women, the plaques that are under development start to calcify. They’ve been there so long, they start to actually harden. That’s what atherosclerosis means – hardening of your arteries. We can see that hardening by doing an x-ray. A CAT scan is more or less just an x-ray in the round. What we can see with this test is we can see the coronary arteries in a stop-motion format laying across the surface of the heart and we can see if calcium is developing in those arteries and that's the market that proves that have plaque.
Melanie: Why wouldn’t everybody want this test? If it can get some of the pretty early stages, is it considered great screening? Why wouldn’t everyone want this?
Dr. Tighe: Seems like a good thing. I understand the reservations. The reservations are such that the argument is if you do this test and you find there's coronary calcium in the arteries of the heard, are you going to increase the amount of downstream testing that takes place after that? In other words, they have a positive calcium score, they have coronary artery disease, should we do a stress test? Should we do a catheterization? Should we put in a stent in this person who’s completely asymptomatic who has no problems and they're physically fit and active? Now it turns out they have coronary disease – how far do we go? That’s always been the concern, that this will lead to an increase in downstream testing. It’s been studied. It turns out it does not. We know very well based on how much coronary calcium is there what's the likelihood of an obstructed lesion is.
You can break it down into four different groups. A calcium score of less than 100 means that there's virtually no obstructive stenosis. Someone with a calcium score from 100 to 400, there's about a 4% chance of having an abnormal stress test. If the calcium score is between 400 and 1,000, there's about a 15% chance of having an abnormal stress test. If it’s over 1,000, then the risk is higher. It can be approaching 50% of having abnormal stress test. You can get an idea the amount of calcium, the likelihood of having an abnormal stress test.
Melanie: That does come into play with people, the additional testing and is it going to make people concerned then and start to be worried or will it be a positive thing where they can start doing some of these lifestyle behavior changes that might change this?
Dr. Tighe: The worry is, go back a few years, we used to do PSAs, prostate-specific antigen testing on pretty much everybody, and that lead to a lot of prostate biopsies, a lot of prostatectomies and all the complications that can come from prostate surgery and a life was saved. No change in mortality from prostate cancer despite all this aggressive testing and treatment. You certainly would see in calcium scoring, a screening testing that finds coronary disease, is it going to lead to more testing? Is it going to lead to better outcomes? The problem with calcium scoring is that the outcomes data is not there. We know that there is evidence of coronary disease, and for many people, that can be very helpful as a positive motivator to maybe get them to make some lifestyle changes or to begin taking an aspirin or maybe if they're on the fence about taking that statin and not sure they want to do that, sometimes knowing that they have coronary artery disease is a motivator to undergo treatment, but what we don’t have is enough data to say that if they do these things that they're going to do better, that they're going to have less heart attacks, and that they're going to survive longer.
Melanie: Does insurance cover this?
Dr. Tighe: Insurance does not cover and that's the reason why insurance doesn't cover this. There are no outcomes data. Colonoscopy. If you have a colonoscopy, you can show that people are less likely to have colon cancer. They cover that. Calcium scoring, we don't have that kind of data yet.
Melanie: I was going to bring up colonoscopy as a perfect example of some of these kinds of things that do work specifically for the purpose of screening and even prevention.
Dr. Tighe: Screening testing is a very complicated issue in medicine. Does the screen test really help? This is where mammography and colonoscopy, there's proven benefits of these tests, but calcium scoring is a test that you have to have that data to prove that it does improve outcomes.
Melanie: What would you like listeners to take away from this, patients to take away, if they're going to ask their cardiologist or if they even have seen a cardiologist if they're going to ask their primary care provider what about a calcium score? Should I get that? Who would they ask and when would they ask that question?
Dr. Tighe: I think it’s a great question to ask, even at the internal medicine at their primary care level. Primary care doctors are the doctors where arteries errode. We see patients in our offices usually after they've already had a coronary event or they're already at risk or they already got coronary disease under development. It would be nice to know before they get to that point and that's where the primary care doctor becomes so valuable. When they're sitting and having that conversation about high cholesterol and wonder if we should treat this, that's a great time to think about a calcium score. There's a little bit of an age disparity between men and women in terms of when coronary calcium develops. Usually, in women, it's about 10 years later, so I think guys start developing coronary calcification in their later 30s or 40s or early 50s and then you want to frame that to maybe 40s or 50s or 60s. If your calcium score is 0 and a lady in her 40s, it might not be true 10 years later.
Melanie: That’s right and we’ve learned that women have different signs of heart attacks, different symptoms of heart disease and all those things.
Dr. Tighe: A corollary of that would be, say you're a woman in your 50s, should you take an aspirin every day? If you have high cholesterol or high blood pressure, should you be on an aspirin? The data would say for the women study that maybe women in their 50s not so much; they may be more likely to have an ulcer from an aspirin than they would a heart attack. But if they have coronary disease, that’s different. Those patients do benefit from being on an aspirin. The problem is that when you treat everybody with the same treatment, a lot of people you're treating you don’t need to treat.
Melanie: Wrap it up, your best advice about all of this confusing information, but a really interesting and neat test that people should ask their doctors about.
Dr. Tighe: I think this is a test that is very helpful in defining what your personal risk is. We see a lot of patients in the office who come in with chest pain and they're concerned about the chest pain, but what I'm also concerned about is you're 50, maybe a little overweight, do you have heart disease? We could do a stress test, and the stress test is normal and the chest pain is not their heart, but maybe they already have heart disease and that's not the cause of their chest pain but something that’s just going to be a problem for them in the future. This is something that we want to look at as well too. For me, when I see people in the office, and in terms of just thinking the same way, we want to understand what is the symptom that brought them to our attention, but we also want to look deeper and say what is your risk for heart disease, should we know more about your heart health, and this is a very simple way combined with a good physical examination, a good history and laboratories to look at their cholesterol, to look at their A1C to see if they're diabetic, and to what extent. This is a nice part of that work up to get an idea of what coronary risk is going forward.
Melanie: Thank you so much for being with us today. What an interesting segment. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That's stlukescornwallhospital.org. I'm Melanie Cole. Thanks for listening.
Coronary Calcium Scoring for Early Detection of Heart Disease
Melanie: Like so many of us, are you worried about heart disease? If you are, you might want to consider a test that could be a precursor that could let you know whether you are at a higher risk of developing coronary artery disease. My guest today is Dr. Jack Tighe. He’s the medical director at St. Luke’s Cornwall Hospital’s Cardiovascular Institute. Welcome to the show. Let's speak about some of the risk factors for heart disease because we hear about things like smoking and genetics and all of these kinds of things, but there are other risk factors as well that we might not be aware of, like cholesterol and stress. Speak about some of those.
Dr. Jack Tighe, MD: First of all, thank you for having me on the show today. Certainly, what we want to do in finding coronary heart patients is identify those patients that are at risk. As you point out, there are risk factors that are well recognized – smoking is a pretty good example of that, diabetes, high blood pressure – these are risk factors that are pretty well-known. There are newer risk factors that are emerging. We know that cholesterol in it of itself is a risk factor, there are sub-fractions of cholesterol disorders that are also risk factors as well too and some inflammatory things that may be going on as well too, so there are risk factors. What we’re also interested in getting at are patients who have already established coronary artery disease that they may not know. Many of our patients, as it turns out, may not have a lot of obvious risk factors for heart disease development, and yet, may have coronary disease already developing. It’s those people that we’re interested in getting after.
Melanie: You're also looking at inflammatory markers, correct? You're looking at things that people think inflammation like arthritis, but we’re talking different kind of inflammation that could put somebody at risk that you're looking for as well.
Dr. Tighe: Exactly. We’re talking about vascular information and there are markers, and this has been looked at for quite some time now, looking at the reactive protein, which is the measure of inflammation within the vascular space that correlates with coronary events, homocysteine which can be elevated and be a market for inflammation as well too, so there are other inflammatory cytokines that contribute to abnormal coronary physiology, at least coronary artery disease and certainly those things are active areas of interest. This is something that's a different topic. From what we're looking at, we're looking at trying to identify those patients that already have heart disease developed. I guess the easiest way to think about this is to think about who the at-risk patients are. We’re pretty good clinically at picking out who are the people who are likely to have heart disease. We have just our eyeballs. We know the risk factors. We know that people with diabetes and people who smoke and overweight and underactive and have high blood pressure and high cholesterol, those are pretty high-risk people that are likely to have coronary artery disease.
We see people who are fit, active, don’t smoke, don’t have cholesterol issues, don’t have blood pressure issues that are generally low risk. We have tools that we can use to measure this and we can use risk factor predictors, something called a Framingham Risk Index, which is a marker, a tabulated way of adding up risk and figuring out what is your risk of having a coronary event in the next 10 years. This can be projected so that at the high-risk people, the people with lots of risk factors, they have a 20% chance of having a coronary event in the next 10 years. People who are low risk have a less than 10% risk of having a coronary event in the next 10 years. The problem is that when you use these tools, they're pretty good at picking out the high risk and the low-risk patients, but they're not so good at parsing out those people in between, people who maybe who one or two risk factors for heart disease. They don't have any symptoms, they're pretty active. I think about guys in their mid-40s who do triathlons who have high cholesterol and they look at me thinking ‘why do you want to treat my cholesterol, I'm young I'm fit, I don’t have any other risk factors, I don’t smoke, I don’t really need a statin medication,’ but it turns out that many of those people already have heart disease under development. If you don’t look for it with a test like this, then you don’t find it.
Melanie: Let's talk about the test like this, the coronary calcium scoring. What is this test? How does it work?
Dr. Tighe: It’s very basic. It’s looking at the coronary arteries with x-rays and seeing if coronary calcium is already developing in the arteries of the heart. It identifies the coronary disease in not the earliest, but its earliest identifiable state. Coronary disease starts off really early in our lives before we're 10. We're already starting to work on the coronary plaque. Those plaques are basically soft, they're made out of cholesterol, they're not visible by any technology – we really can't find those. When people mature in their 40s in men and into their 50s in women, the plaques that are under development start to calcify. They’ve been there so long, they start to actually harden. That’s what atherosclerosis means – hardening of your arteries. We can see that hardening by doing an x-ray. A CAT scan is more or less just an x-ray in the round. What we can see with this test is we can see the coronary arteries in a stop-motion format laying across the surface of the heart and we can see if calcium is developing in those arteries and that's the market that proves that have plaque.
Melanie: Why wouldn’t everybody want this test? If it can get some of the pretty early stages, is it considered great screening? Why wouldn’t everyone want this?
Dr. Tighe: Seems like a good thing. I understand the reservations. The reservations are such that the argument is if you do this test and you find there's coronary calcium in the arteries of the heard, are you going to increase the amount of downstream testing that takes place after that? In other words, they have a positive calcium score, they have coronary artery disease, should we do a stress test? Should we do a catheterization? Should we put in a stent in this person who’s completely asymptomatic who has no problems and they're physically fit and active? Now it turns out they have coronary disease – how far do we go? That’s always been the concern, that this will lead to an increase in downstream testing. It’s been studied. It turns out it does not. We know very well based on how much coronary calcium is there what's the likelihood of an obstructed lesion is.
You can break it down into four different groups. A calcium score of less than 100 means that there's virtually no obstructive stenosis. Someone with a calcium score from 100 to 400, there's about a 4% chance of having an abnormal stress test. If the calcium score is between 400 and 1,000, there's about a 15% chance of having an abnormal stress test. If it’s over 1,000, then the risk is higher. It can be approaching 50% of having abnormal stress test. You can get an idea the amount of calcium, the likelihood of having an abnormal stress test.
Melanie: That does come into play with people, the additional testing and is it going to make people concerned then and start to be worried or will it be a positive thing where they can start doing some of these lifestyle behavior changes that might change this?
Dr. Tighe: The worry is, go back a few years, we used to do PSAs, prostate-specific antigen testing on pretty much everybody, and that lead to a lot of prostate biopsies, a lot of prostatectomies and all the complications that can come from prostate surgery and a life was saved. No change in mortality from prostate cancer despite all this aggressive testing and treatment. You certainly would see in calcium scoring, a screening testing that finds coronary disease, is it going to lead to more testing? Is it going to lead to better outcomes? The problem with calcium scoring is that the outcomes data is not there. We know that there is evidence of coronary disease, and for many people, that can be very helpful as a positive motivator to maybe get them to make some lifestyle changes or to begin taking an aspirin or maybe if they're on the fence about taking that statin and not sure they want to do that, sometimes knowing that they have coronary artery disease is a motivator to undergo treatment, but what we don’t have is enough data to say that if they do these things that they're going to do better, that they're going to have less heart attacks, and that they're going to survive longer.
Melanie: Does insurance cover this?
Dr. Tighe: Insurance does not cover and that's the reason why insurance doesn't cover this. There are no outcomes data. Colonoscopy. If you have a colonoscopy, you can show that people are less likely to have colon cancer. They cover that. Calcium scoring, we don't have that kind of data yet.
Melanie: I was going to bring up colonoscopy as a perfect example of some of these kinds of things that do work specifically for the purpose of screening and even prevention.
Dr. Tighe: Screening testing is a very complicated issue in medicine. Does the screen test really help? This is where mammography and colonoscopy, there's proven benefits of these tests, but calcium scoring is a test that you have to have that data to prove that it does improve outcomes.
Melanie: What would you like listeners to take away from this, patients to take away, if they're going to ask their cardiologist or if they even have seen a cardiologist if they're going to ask their primary care provider what about a calcium score? Should I get that? Who would they ask and when would they ask that question?
Dr. Tighe: I think it’s a great question to ask, even at the internal medicine at their primary care level. Primary care doctors are the doctors where arteries errode. We see patients in our offices usually after they've already had a coronary event or they're already at risk or they already got coronary disease under development. It would be nice to know before they get to that point and that's where the primary care doctor becomes so valuable. When they're sitting and having that conversation about high cholesterol and wonder if we should treat this, that's a great time to think about a calcium score. There's a little bit of an age disparity between men and women in terms of when coronary calcium develops. Usually, in women, it's about 10 years later, so I think guys start developing coronary calcification in their later 30s or 40s or early 50s and then you want to frame that to maybe 40s or 50s or 60s. If your calcium score is 0 and a lady in her 40s, it might not be true 10 years later.
Melanie: That’s right and we’ve learned that women have different signs of heart attacks, different symptoms of heart disease and all those things.
Dr. Tighe: A corollary of that would be, say you're a woman in your 50s, should you take an aspirin every day? If you have high cholesterol or high blood pressure, should you be on an aspirin? The data would say for the women study that maybe women in their 50s not so much; they may be more likely to have an ulcer from an aspirin than they would a heart attack. But if they have coronary disease, that’s different. Those patients do benefit from being on an aspirin. The problem is that when you treat everybody with the same treatment, a lot of people you're treating you don’t need to treat.
Melanie: Wrap it up, your best advice about all of this confusing information, but a really interesting and neat test that people should ask their doctors about.
Dr. Tighe: I think this is a test that is very helpful in defining what your personal risk is. We see a lot of patients in the office who come in with chest pain and they're concerned about the chest pain, but what I'm also concerned about is you're 50, maybe a little overweight, do you have heart disease? We could do a stress test, and the stress test is normal and the chest pain is not their heart, but maybe they already have heart disease and that's not the cause of their chest pain but something that’s just going to be a problem for them in the future. This is something that we want to look at as well too. For me, when I see people in the office, and in terms of just thinking the same way, we want to understand what is the symptom that brought them to our attention, but we also want to look deeper and say what is your risk for heart disease, should we know more about your heart health, and this is a very simple way combined with a good physical examination, a good history and laboratories to look at their cholesterol, to look at their A1C to see if they're diabetic, and to what extent. This is a nice part of that work up to get an idea of what coronary risk is going forward.
Melanie: Thank you so much for being with us today. What an interesting segment. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That's stlukescornwallhospital.org. I'm Melanie Cole. Thanks for listening.