Evo Terra (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm your host, Evo Terra. And today, we have the pleasure of speaking with Dr. Abid Fakhri, a cardiologist at UM Baltimore Washington Heart Associates. He specializes in heart health and will shed light on a crucial diagnostic tool, cardiac calcium scoring.

Dr. Fakhri, thank you very much for joining me today. I like to start these conversations at the base level. Can you tell me what is cardiac calcium scoring, and how does it help assess heart health?

Abid Fakhri, MD: Well, thanks for having me on to discuss this very important topic. Calcium scoring is a relatively new screening test that's been made available for the detection of heart disease. So, just to give our listeners a little bit of background, coronary arteries are the arteries that feed our heart muscle with oxygen and nutrients. As we age, atherosclerosis, which is plaque buildup in those arteries, starts to clog those vessels, starving the heart of oxygen and nutrients. If it becomes critical, that could lead to a heart attack or weakening of the heart muscle.

So traditionally, we've relied on screening methods like blood pressure and cholesterol to help understand patients' risk. But the question is what if there was a way rather than through abstract means, understanding people's heart disease risk? What if we could actually visualize that plaque and give a number that can help guide doctors and patients to make better decisions about their heart health. So, calcium scoring takes a CT scan of the heart, measures the amount of atherosclerosis in the vessels, and gives a number of the atherosclerosis that's present in those vessels. So, it's a basic, safe, non-invasive way of understanding heart disease risk.

Host: That's great information. So, it sounds like it's something everybody should do, but I don't actually think that's true. So, who should consider getting their cardiac calcium scoring test? And at what age, I guess, is it most beneficial?

Abid Fakhri, MD: Yeah. That's a great question. So, we understand that heart disease risk goes up as you get older, and we know that there's a difference for men and women. Typically, women don't experience an increase in heart disease risk until menopause. So, we recommend that men over the age of 38 and women over the age of 45 may be the right category to consider screening if they've got risk factors such as high blood pressure, abnormal cholesterol, diabetes, history of tobacco use, and my favorite is family history of heart disease. Because many of us have loved ones, parents, mother, father, brothers, sisters who have had heart disease and the question often comes up is, "Well, if it happened to dad, could it happen to me?" And I think that that's something that you can't measure in a blood test. So if you have those risk factors and you're over the age of 38, male, or over the age of 45, female, this is the right test for you.

Host: That's great. My family does have that history, which is why I need to do this quickly, apparently. Let's talk about that score. I assume it's like golf in that a lower score is better than a high score. Can you explain the calcium score, how it's calculated, and what different score ranges might mean?

Abid Fakhri, MD: Absolutely. So, if you can think through conceptually old plaque that builds up in those arteries, that calcium, the plaque that builds up hardens and becomes calcified almost to the density of bone. So, when we do a CT scan, we see these calcium deposits, and we know that there's no bones inside the heart. So, the technologist basically traces out the calcium deposits, and the computer is able to give us a number of how much calcium is deposited in those vessels. A score of zero is great. That means there's no calcium deposits. One to 100 is low, 101 to 300 is considered intermediate, and 300 and above I would consider high.

Host: Excellent. So, thinking about this scoring technology, what are some of the types? I mean, is it just once or there different ways this can be done? What's better than others? Give us a rundown of our options.

Abid Fakhri, MD: Absolutely. So, the technology to detect coronary calcification exists on any CT scan. In fact, I've made it a habit for any patient that I see in consultation, I'll actually pull up old CT scans and review them just for subjective evidence of atherosclerosis. So, I can pull up the CT scan when I'm in the office with the patient, and I can show them there is atherosclerosis in the vessels. And if we don't start taking the necessary preventative steps, then this has a potential to become something more. So, the technology exists on any CT scanner to detect this. However, if you get the scan done at a facility that has the software and expertise, we can actually quantify that for you and that number can help make better decisions. As I said, there's cutoffs that we can give you when we know the number. So, the scan can be done at any facility, but there are certain facilities where the scan can be done with the proper measurements.

Host: And how accurate is this technology in predicting heart risk, heart disease specifically? Any limitations?

Abid Fakhri, MD: Great question. So, calcium scoring has been around for several decades now, and there's a wealth of data linking this to population health studies that correlate with heart disease risk. So, it's very sensitive in the sense that if you have a calcium score of zero, I can tell you with great confidence that your risk for cardiovascular disease is low. It's a great screening test in reassuring patients about their underlying risk. It's most useful in patients who are not having symptoms, but are looking to better understand their risk.

Now, if you're having symptoms of heart disease, there may be better tests for you. So, the limitation of the calcium score is that it doesn't differentiate whether the plaque that's built up is causing limitation to blood flow. So, those blockages that typically reach to 70%, that's the threshold where you may start to experience symptoms of chest pain or shortness of breath. There may be additional testing that's required.

Now, in my practice, I tend to prefer a CT angiogram, which is actually similar. But it requires intravenous dye, and a little bit of premedication. And the advantage there is that a CT angiogram can actually show you the percentage of blockage within the vessel. Whereas the calcium score is telling you the building blocks are there, but it's not able to tell you the percentage of the block. So, that's the main differentiation. The key here is we need to understand who we're doing the test on. If it's a patient without symptoms, a calcium score is sufficient. If you're having symptoms, you may need something additional.

Host: And when we go beyond a CT scan, which is non-invasive as they come, I believe, any other risks or side effects with some of these other tests?

Abid Fakhri, MD: I assume when you say going beyond a CT scan, so the options would include a CT angiogram, which is with IV dying; stress testing, which typically involves either exercise and a treadmill, or it may require the injection of medication. Any of those can cause side effects, but the calcium score itself is actually safe, painless, with no side effects.

Host: Very good news. And how often should this kind of test be done for people who are first timers or those that have actual cardiac problems? I assume, like many things in life, it's going to vary, so much does it vary?

Abid Fakhri, MD: If you have a calcium score of zero, it may be reasonable to say a reassessment in five years can help reestablish whether or not that risk has changed from a very low risk, less than 1% over the next 10 years, to maybe something greater. So every five years, if you have a calcium score of zero.

Now, if you have a higher number, then it's less well-established that repeat testing adds value. At that point, once you've established that you have a score that's higher than zero, you already have gone down the pathway of talking to your doctor about preventative therapies, whether that's cholesterol management, blood pressure management, smoking cessation, and the focus should be more on those preventative steps rather than repeat testing if you've established yourself as somebody at risk.

On the flip side, those doctor visits also present an opportunity for you to reassess symptoms. And if you're having symptoms, again, those additional tests, whether that's a CT angiogram or a stress test may be the right step for you rather than repeating that calcium score. Bottom line, calcium score, if it's zero, you could repeat it after five years. But if it's anything more than zero, I wouldn't repeat it, I would focus on those preventative steps.

Host: That's excellent advice. And I just want to underscore that last bit about patients who have a high cardiac calcium score. Your first step, talk to your doctor. It's not about testing anymore. Now, it is go to a physician. Did I correctly state that?

Abid Fakhri, MD: Absolutely. These scans are a blueprint for you and your doctor to have shared decision-making about how to manage preventative health.

Host: Wonderful. What's the key message that you want listeners to take away from this conversation?

Abid Fakhri, MD: So, I think that calcium scoring provides a new era in Cardiology where we focus more on precision medicine. We can provide patients visualization of plaque within their arteries and help them better understand risks. It's simple, safe, non-invasive, and it's easily reproducible at most radiology facilities across the country. I think it helps patients to better understand their risk and engage with their doctors on more aggressive preventative care.

I'm also going to put a plug out there for making sure that you're doing those necessary basic things. Working with your doctor to quit smoking, eating a diet rich in fruits, vegetables, and whole grains, and then self-monitoring symptoms with a daily exercise routine. We can't express enough the benefit of the exercise itself, but it gives you a way of self-monitoring. So, the calcium score is one part of that equation, but it's simple, safe, and non-invasive.

Host: Excellent information, and thank you for all of that and for your time, Dr. Fakhri.

Abid Fakhri, MD: You're welcome.

Host: For more videos just like this one, please visit umms.org/podcast and check us out on YouTube. If you found this episode helpful, please share it on your social channels. I'm Evo Terra. And this has been Live Greater, a health and wellness podcast brought to you by University of Maryland Medical System. Thanks for listening.