Report from Washington II

16. July 2006 William Davis (0)
Today's discussions at the Society for Cardiovascular Computed Tomography (SCCT) focused on atherosclerotic "plaque characterization".

As CT scanners get better and better at imaging the various components of plaque, some fascinating issues emerge:

--CT heart scans provide insights into what exactly is contained in an individual's atherosclerotic plaque that are not often provided even during heart catheterization. In other words, CT heart scanning is, in many instances, superior to heart catheterization, since it provides images of the artery wall, not just the internal contents.

--Progression (i.e., increase) in heart scan score is a powerful predicter of heart attack risk. Dr. Matthew Budoff of UCLA argued persuasively that the annual rate of increase in score is probably the most accurate measure of risk available, superior to cholesterol and calculated measures like the Framingham risk score.

--Coronary calcium scoring remains the best method to gauge total plaque throughout the entire coronary tree. In a person free of symptoms, the risk of a cardiac "event" (heart attack, death, procedures) is low and additional imaging (like CT angiography) is generally unnecessary.


Dr. Budoff, among the true thought leaders in CT heart scanning, also recounted his perspective on the history of heart scans. He noted that the questions asked through the years have evolved:




1995-2000 Should we do coronary calcium scans?

2000-2002 Do high or low risk patients benefit from coronary calcium scoring?

2003-2004 What is the better scanner, EBT or MDCT?

2006 How often should we perform coronary calcium imaging?


I believe that Dr. Budoff summarizes wonderfully where the Track Your Plaque programs fits into the overall scheme of things: Serial (repeated)CT heart scans to gauge progression or reversal is the wave of the future. We shouldn't just be interested in identifying persons at risk for heart attack. We should also be interested in showing the person at risk exactly how to reduce or eliminate that risk.
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It's the score, stupid

It's the score, stupid

14. November 2009 William Davis (4)
Sal has had 3 heart scans. (He was not on the Track Your Plaque program.) His scores:

March, 2006: 439

April, 2007: 573

October, 2009: 799

Presented with the 39% increase from April, 2007 to October, 2009, Sal's doctor responded, "I don't understand. Your LDL cholesterol is fine."

This is the sort of drug-driven, cholesterol-minded thinking that characterizes 90% of primary care and cardiologists' practices: "Cholesterol is fine; therefore, you must be fine, too."

No. Absolutely not.

The data are clear: Heart scan scores that continue to increase at this rate predict high risk for cardiovascular events. Unfortunately, when my colleagues hear this, they respond by scheduling a heart catheterization to prevent heart attack--a practice that has never been shown to be effective and, in my view, constitutes malpractice (i.e., performing heart procedures in people with no symptoms and with either no stress test or a normal stress test).

It's the score, stupid! It's not the LDL cholesterol. Pay attention to the increasing heart scan score and you will know that the disease is progressing at an alarming rate. Accepting this fact will set you and your doctor on the track to ask "Why?"

That's when you start to uncover all the dozens of other reasons that plaque can grow that have nothing to do with LDL cholesterol or statin drugs.
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Comments (4) -

  • Dexter

    11/15/2009 5:43:29 PM |

    Even more evidence that CVD confusion reigns supreme among PCPs.

    http://www.theheart.org/article/1020935.do

  • Roger

    11/15/2009 5:52:16 PM |

    Dr. Davis,

    In June you kindly profiled my "near-miss" CT angiogram, where I had to take charge and make sure I was getting only a CT calcium score scan.

    The good news was that my score was a zero.  I can't really explain that; while I was a vegetarian for many years, I also ate too many refined carbs and until recently was carrying a few too many pounds. There is heart disease in my family.  I am 54 years old.

    Is it genes, luck, or inadvertantly prudent lifestyle?   How often should folks with low scores be re-tested?  I know you probably cover this at TYP but I'm sure the blog readers would also find it informative.  Thanks again for reporting my story.

    Roger

  • Dr. William Davis

    11/15/2009 11:31:13 PM |

    Hi, Roger--

    Genes enter into the equation in a big way. Lifestyle is important, but it is not everything.

    For people starting with a score of zero, I generally suggest waiting 3-5 years before thinking about another scan.

  • Jenny Light

    11/16/2009 5:00:14 PM |

    I'll second the motion about catherizations being malpractice!

    My mom died three years ago in a cath lab!  After having chest pains after a chemical stress test, she was hospitalized overnight and the next day had a catherization with two stents implanted.  

    Something went wrong during the procedure, and an artery was torn. She became unconscious, she stopped breathing, and they were unable to insert a breathing tube.  They did an emergency tracheotomy but it was too late.  No cardiac surgeon was in the facility at the time.

    The cardiologists explination to us was that "she had very small arteries".

    I would think it would be reasonable for a patient to request that a cardiac surgeon be "in the house" during this procedure.

    My dad about hit the roof when he saw the cause of death listed on her death certificate as "myocardial infraction". He requested that the coroner check the circumstances, after which he changed the cause to "cardio-pulmenary arrest due to long term heart disease".  Sorry, but it should have read: "Due to complications during catherization procedure".  

    Not a benign procedure folks!  Ask whether drugs can perhaps be used in lieu of this invasive (and very lucritive for the hospital) action.

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