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Calcium Scoring
Did you know that, for typically less than $100, there's a test that predicts your likelihood of having a heart attack? Dr. Neel Khanna discusses calcium scoring, how the calcium test works, and who is considered a potential candidate for this test.
Featured Speaker:
Neel Khanna, MD, MPH
Dr. Neel Khanna, MD, MPH, is a Crystal Run Healthcare interventional cardiologist. He is the Medical Director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall. He is also board certified in Cardiovascular Disease, Interventional Cardiology, Echocardiography, Internal Medicine, Nuclear Cardiology, and Vascular Imaging. Transcription:
Calcium Scoring
Scott Webb: Did you know that for typically less than a hundred dollars, there's a test that predicts your likelihood of having a heart attack? It's true in joining me today to tell us about how the calcium score test works and who's a good candidate for the test is Dr. Neel Khanna. He's the medical director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall. This is Doc Talk presented by Montefiore St. Luke's Cornwall I'm Scott Webb. Doctor. Thanks so much for your time today. I know there are a few ways to predict the likelihood of us having a heart attack in the future. And one of them is with our calcium scores. So let's start here. How has the score calculated or how has the test performed?
Dr. Neel Khanna: So basically a calcium score is a low resolution CT scan, and it's a CT scan that's gated and directed only towards the heart in other areas. As a result, what we've learned over time is that plaque, often the outer layer of plaque is a layer of calcium. So cat scans with the way that they operate are designed to pick up calcium. And so what we've realized, if someone gets a simple, low resolution cat scan, that's directed to their heart, we can actually calculate based on the amount of razor sent out how much calcium is in those arteries. And we can directly relate that to then how much plaque is in their arteries.
Scott Webb: Yeah. And so at the end of that test, which sounds pretty amazing a score is arrived at or calculated if you will. So for all of us, for people who might be having this CAT scan, what's the score we're hoping for? Maybe you can sort of take us through the range.
Dr. Neel Khanna: One of the big take homes of this is that. The score is age dependent and it's risk factor dependent also. So, it's very different for a 40 year old person who's otherwise healthy to get a calcium score versus a 70 year old person who has high blood pressure and diabetes. We expect different scores. And so one thing that's done with calcium scores is you get a gross number. Obviously you can relate to any other person at any other age and compare it, but then probably more importantly, we give a percentile rank. That percentile rank, meaning let's say you get a percentile rank of 50%.
That's saying that basically 50% of people have a calcium score that is lower than yours or less plaque than you do. And 50% have higher than you do. You're right in the middle. , the important thing is that percentile rank is age match to people exactly your age. So, it goes within the age categories. If you're a 70 year old, you're roughly compared to other patients who are 70 years old, because obviously as we get older, we expect a certain amount of plaque to form in the arteries. The question is, are you at much more increased risk than an age match person that you know, or that you don't know?
And,, so we percentile ranked that per [inaudible]. Generally speaking, the score is important where the calcium is particularly, there are three arteries of the heart, is all the calcium and all the score in just one artery versus evenly distributed in all three. And the last thing is what is your percentile rank? Are you at much higher risk than other patients your age? Those are the three major issues. When you get a calcium.
Scott Webb: I see what you mean, thinking about, who's a good candidate for this test. I'm assuming age risk factors, family history, or at least some of the considerations. And I'm sure there are some others as well.
Dr. Neel Khanna: One of the things that I tell patients. I have some patients who come to me who have a very strong family history. They carry that with them. They're very concerned about their heart health. And honestly, before we really started using calcium scores, there is not a good test to say, okay, your family history is playing a role in your heart health, or either that, or it's not. People would traditionally do stress, tests, stress tests are great tests that test, whether you have obstructive blockages in the heart arteries.
But it basically is for people who are symptomatic, meaning people who are having symptoms of chest pain, having significant shortness of breath. That's when you do a functional test, like a stress test, and that's when your physician, your cardiologist will prescribe a test like that. Generally speaking, calcium scores are for people who are asymptomatic or maybe very mild symptoms. And they're concerned about their risk, whether they should be on certain medications, like a baby aspirin or statin medications to lower their cholesterol.
Maybe they're very resistant to starting one of those medications and they ask their physician, I really don't wanna start that medication. How do I know if I'm at a really increased risk? and whether I would really benefit from a medication like that, calcium scores have really been instrumental in helping patients like that. Generally speaking, to just go back to the previous question you asked, if I have a young, healthy patient, maybe they have some family history, , age around 40 years old. I have plenty of patients who come like that.
And they asked me they're very concerned about their family history and their risk. We generally would expect their score to be close to zero. Meaning at that age to have very little calcified plaque at their age. And then, if their score is even 15 or 20, that's somewhat unexpected for their age. Whereas, someone age matched who's 65. It may be a little different. A 10 or a 15 for their age is, more significant. And I didn't mention this prior, but the scores mean a lot, obviously if someone has a. Regardless of age above a thousand, they have a greater than 90% chance of having a blockage in their heart arteries.
That's blocking a significant amount of blood flow. Whereas if they have a score less than 50, for example, that's more unlikely. So, the percentile rank is important. The score that we get is actually important. And the people that we screen for this type of a test is also important. A Calcium score is not for people who we already know have significant blockages or who have stents in their heart already. Those are patients who have to be followed very closely by a heart doctor. Anyway, it's a great test for people who based on their risk factors are at intermediate risk for having heart disease.
Meaning, they may have high blood pressure. They may have borderline diabetes. And so they're at a higher risk of developing coronary disease, but not high risk. Like they don't actually have disease that we've found out. And so this will really help us guide their treatment going forward.
Scott Webb: Are there occasions where someone's score is so high, so alarming that almost immediate action is needed?
Dr. Neel Khanna: Yeah, but we can't trust enough, a calcium score is not a functional test, meaning it's not like a stress test, as I've said where it's like, okay, if it's positive, we need to act on this right now. But your question is well taken in the fact that there's really two sets of people who we can give definitive answers or close definitive answers. It's that patient who comes in, who's worried about their risk, who has a score of zero, where I can reassure them that at this point they have no calcified plaque. They can take a deep breath. And just focus on their future health.
It's not a license to do whatever they want, but at this point with their heart health things look good. That's a reassuring patient. And I could tell you, your score is totally zero. You don't have to worry about anything at this point. Versus that patient who has a score in the 90th percentile. That patient who has a score in the 90th percentile, we take their symptoms even more seriously, even mild symptoms. And often when someone has a score greater than the 90th percentile. We treat them very intensively and often they will require further testing to see is there something underlying?
I can tell you for me personally, I have seen, some patients who are referred to me who have relatively vague complaints, they get a calcium score with their primary care doctor. The score is well above the 90th percentile and much higher than what they should have at their age. And we often find through further testing that they have severe blockages in their heart. And we're able to fix that before they have a major cardiac event. And that type of a patient often would've been missed and would only come to our attention unfortunately, when they're coming to the hospital with either acute coronary event or chest pain or something like that. Often we're able to catch them a little before that. And that is really the holy grill of cardiology and medicine.
Scott Webb: It really is. I mean, that's the dream, that's the goal to catch these things before they have those events. And I think that, folks are gonna want to know, because it sounds like people, often are asked. For this test or volunteering for this test, they're gonna want to know how does insurance handle the calcium scores.
Dr. Neel Khanna: That's a really good question. And it's been a little bit of a frustration for heart doctors and primary care doctors who order this test. It's not a definitive test in the sense, as I've said multiple times, that it's gonna tell us that this needs to be acted on right away. Which has allowed it not to be covered widely, meaning it's often an out of pocket expense for a patient. The good news is that it's a low resolution CT, it's gated only to the heart. So people have been able to roughly subsidize the cost. I know for the practice I work for, it's about. $90 out of pocket expense, out of pocket expense, not covered by any insurance.
And at other sites, I think it's even maybe a little less than that. And so, obviously it depends on what your finances are, but it's not a disabling cost. There is some. good news on the horizon, where there are some insurance carriers who at this point have started in 2022 to cover this test. And I think insurance companies have realized its importance in preventative care and in preventing major things from happening. And so some are starting to cover it. Whereas a couple years ago nobody was covering it.
So, often what's done now is we submit it through the insurance. We see if it's covered. If it's not covered, then you know, it's usually a charge of $90 or less, which I think. Is money well spent. If someone is truly at intermediate risk and truly worried about their heart health or their possibility of having coronary disease.
Scott Webb: I think you're so right, and I know next time when we speak, we're gonna talk about heart healthy diets and exercise and so on. Today has been, really educational as we wrap up here, doctor. Are your final thoughts about the calcium scores and the value for, as you say, people who are at at least intermediate risk.
Dr. Neel Khanna: I think patients at intermediate risk, a calcium score, and especially if they're relatively asymptomatic, a calcium score is a great test to predict their future risk of having in a coronary event or even it can be related to stroke risk also because all vascular disease happens very similarly. So, it's really a great test to help us identify those patients who are gonna present to us prematurely that we're surprised about, that they are surprised about. And, there's definitely changes in the management of these patients that we can make before they have a major cardiac event to really help prevent that stuff.
So, I really stress to patients. If you're concerned about your heart health, if you have a strong family history, if your doctor determines that you're at intermediate risk or they recommend at a younger age, that you have a cholesterol medication, you should ask your doctor about a calcium scoring and whether it would be beneficial for you. And, you can make joint decision and potentially get some very important information.
Scott Webb: Yeah. Some very important information. So, talk to you next time. Thanks so much. And you stay well
Dr. Neel Khanna: Thank you so much.
Scott Webb: And visit Montefioreslc.org for more information about the Cardiovascular Institute. And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.
Calcium Scoring
Scott Webb: Did you know that for typically less than a hundred dollars, there's a test that predicts your likelihood of having a heart attack? It's true in joining me today to tell us about how the calcium score test works and who's a good candidate for the test is Dr. Neel Khanna. He's the medical director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall. This is Doc Talk presented by Montefiore St. Luke's Cornwall I'm Scott Webb. Doctor. Thanks so much for your time today. I know there are a few ways to predict the likelihood of us having a heart attack in the future. And one of them is with our calcium scores. So let's start here. How has the score calculated or how has the test performed?
Dr. Neel Khanna: So basically a calcium score is a low resolution CT scan, and it's a CT scan that's gated and directed only towards the heart in other areas. As a result, what we've learned over time is that plaque, often the outer layer of plaque is a layer of calcium. So cat scans with the way that they operate are designed to pick up calcium. And so what we've realized, if someone gets a simple, low resolution cat scan, that's directed to their heart, we can actually calculate based on the amount of razor sent out how much calcium is in those arteries. And we can directly relate that to then how much plaque is in their arteries.
Scott Webb: Yeah. And so at the end of that test, which sounds pretty amazing a score is arrived at or calculated if you will. So for all of us, for people who might be having this CAT scan, what's the score we're hoping for? Maybe you can sort of take us through the range.
Dr. Neel Khanna: One of the big take homes of this is that. The score is age dependent and it's risk factor dependent also. So, it's very different for a 40 year old person who's otherwise healthy to get a calcium score versus a 70 year old person who has high blood pressure and diabetes. We expect different scores. And so one thing that's done with calcium scores is you get a gross number. Obviously you can relate to any other person at any other age and compare it, but then probably more importantly, we give a percentile rank. That percentile rank, meaning let's say you get a percentile rank of 50%.
That's saying that basically 50% of people have a calcium score that is lower than yours or less plaque than you do. And 50% have higher than you do. You're right in the middle. , the important thing is that percentile rank is age match to people exactly your age. So, it goes within the age categories. If you're a 70 year old, you're roughly compared to other patients who are 70 years old, because obviously as we get older, we expect a certain amount of plaque to form in the arteries. The question is, are you at much more increased risk than an age match person that you know, or that you don't know?
And,, so we percentile ranked that per [inaudible]. Generally speaking, the score is important where the calcium is particularly, there are three arteries of the heart, is all the calcium and all the score in just one artery versus evenly distributed in all three. And the last thing is what is your percentile rank? Are you at much higher risk than other patients your age? Those are the three major issues. When you get a calcium.
Scott Webb: I see what you mean, thinking about, who's a good candidate for this test. I'm assuming age risk factors, family history, or at least some of the considerations. And I'm sure there are some others as well.
Dr. Neel Khanna: One of the things that I tell patients. I have some patients who come to me who have a very strong family history. They carry that with them. They're very concerned about their heart health. And honestly, before we really started using calcium scores, there is not a good test to say, okay, your family history is playing a role in your heart health, or either that, or it's not. People would traditionally do stress, tests, stress tests are great tests that test, whether you have obstructive blockages in the heart arteries.
But it basically is for people who are symptomatic, meaning people who are having symptoms of chest pain, having significant shortness of breath. That's when you do a functional test, like a stress test, and that's when your physician, your cardiologist will prescribe a test like that. Generally speaking, calcium scores are for people who are asymptomatic or maybe very mild symptoms. And they're concerned about their risk, whether they should be on certain medications, like a baby aspirin or statin medications to lower their cholesterol.
Maybe they're very resistant to starting one of those medications and they ask their physician, I really don't wanna start that medication. How do I know if I'm at a really increased risk? and whether I would really benefit from a medication like that, calcium scores have really been instrumental in helping patients like that. Generally speaking, to just go back to the previous question you asked, if I have a young, healthy patient, maybe they have some family history, , age around 40 years old. I have plenty of patients who come like that.
And they asked me they're very concerned about their family history and their risk. We generally would expect their score to be close to zero. Meaning at that age to have very little calcified plaque at their age. And then, if their score is even 15 or 20, that's somewhat unexpected for their age. Whereas, someone age matched who's 65. It may be a little different. A 10 or a 15 for their age is, more significant. And I didn't mention this prior, but the scores mean a lot, obviously if someone has a. Regardless of age above a thousand, they have a greater than 90% chance of having a blockage in their heart arteries.
That's blocking a significant amount of blood flow. Whereas if they have a score less than 50, for example, that's more unlikely. So, the percentile rank is important. The score that we get is actually important. And the people that we screen for this type of a test is also important. A Calcium score is not for people who we already know have significant blockages or who have stents in their heart already. Those are patients who have to be followed very closely by a heart doctor. Anyway, it's a great test for people who based on their risk factors are at intermediate risk for having heart disease.
Meaning, they may have high blood pressure. They may have borderline diabetes. And so they're at a higher risk of developing coronary disease, but not high risk. Like they don't actually have disease that we've found out. And so this will really help us guide their treatment going forward.
Scott Webb: Are there occasions where someone's score is so high, so alarming that almost immediate action is needed?
Dr. Neel Khanna: Yeah, but we can't trust enough, a calcium score is not a functional test, meaning it's not like a stress test, as I've said where it's like, okay, if it's positive, we need to act on this right now. But your question is well taken in the fact that there's really two sets of people who we can give definitive answers or close definitive answers. It's that patient who comes in, who's worried about their risk, who has a score of zero, where I can reassure them that at this point they have no calcified plaque. They can take a deep breath. And just focus on their future health.
It's not a license to do whatever they want, but at this point with their heart health things look good. That's a reassuring patient. And I could tell you, your score is totally zero. You don't have to worry about anything at this point. Versus that patient who has a score in the 90th percentile. That patient who has a score in the 90th percentile, we take their symptoms even more seriously, even mild symptoms. And often when someone has a score greater than the 90th percentile. We treat them very intensively and often they will require further testing to see is there something underlying?
I can tell you for me personally, I have seen, some patients who are referred to me who have relatively vague complaints, they get a calcium score with their primary care doctor. The score is well above the 90th percentile and much higher than what they should have at their age. And we often find through further testing that they have severe blockages in their heart. And we're able to fix that before they have a major cardiac event. And that type of a patient often would've been missed and would only come to our attention unfortunately, when they're coming to the hospital with either acute coronary event or chest pain or something like that. Often we're able to catch them a little before that. And that is really the holy grill of cardiology and medicine.
Scott Webb: It really is. I mean, that's the dream, that's the goal to catch these things before they have those events. And I think that, folks are gonna want to know, because it sounds like people, often are asked. For this test or volunteering for this test, they're gonna want to know how does insurance handle the calcium scores.
Dr. Neel Khanna: That's a really good question. And it's been a little bit of a frustration for heart doctors and primary care doctors who order this test. It's not a definitive test in the sense, as I've said multiple times, that it's gonna tell us that this needs to be acted on right away. Which has allowed it not to be covered widely, meaning it's often an out of pocket expense for a patient. The good news is that it's a low resolution CT, it's gated only to the heart. So people have been able to roughly subsidize the cost. I know for the practice I work for, it's about. $90 out of pocket expense, out of pocket expense, not covered by any insurance.
And at other sites, I think it's even maybe a little less than that. And so, obviously it depends on what your finances are, but it's not a disabling cost. There is some. good news on the horizon, where there are some insurance carriers who at this point have started in 2022 to cover this test. And I think insurance companies have realized its importance in preventative care and in preventing major things from happening. And so some are starting to cover it. Whereas a couple years ago nobody was covering it.
So, often what's done now is we submit it through the insurance. We see if it's covered. If it's not covered, then you know, it's usually a charge of $90 or less, which I think. Is money well spent. If someone is truly at intermediate risk and truly worried about their heart health or their possibility of having coronary disease.
Scott Webb: I think you're so right, and I know next time when we speak, we're gonna talk about heart healthy diets and exercise and so on. Today has been, really educational as we wrap up here, doctor. Are your final thoughts about the calcium scores and the value for, as you say, people who are at at least intermediate risk.
Dr. Neel Khanna: I think patients at intermediate risk, a calcium score, and especially if they're relatively asymptomatic, a calcium score is a great test to predict their future risk of having in a coronary event or even it can be related to stroke risk also because all vascular disease happens very similarly. So, it's really a great test to help us identify those patients who are gonna present to us prematurely that we're surprised about, that they are surprised about. And, there's definitely changes in the management of these patients that we can make before they have a major cardiac event to really help prevent that stuff.
So, I really stress to patients. If you're concerned about your heart health, if you have a strong family history, if your doctor determines that you're at intermediate risk or they recommend at a younger age, that you have a cholesterol medication, you should ask your doctor about a calcium scoring and whether it would be beneficial for you. And, you can make joint decision and potentially get some very important information.
Scott Webb: Yeah. Some very important information. So, talk to you next time. Thanks so much. And you stay well
Dr. Neel Khanna: Thank you so much.
Scott Webb: And visit Montefioreslc.org for more information about the Cardiovascular Institute. And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.