The CT Calcium Score, Part II
Don't let fear of modern technology in the form of a pill keep you from safe, life-saving measures.
By Dr. Joseph Ferguson
GUEST COLUMNIST
Editor’s Note: These columns by local medical professionals offer insights and advice on a range of medical topics. The opinions or views expressed in these columns are not intended to treat or diagnose; nor are they meant to replace the treatment and care that you may be receiving from a licensed professional physician or mental health professional.
I wrote an article last year (“The CT Calcium Score: Could It Save Your Life?”) discussing my belief that the CT calcium score is a life-saving test, and that it is the most important of all screening tests. The article provoked a great deal of interest with my patients, and many of them wanted to know the specifics of how the results of the test can be used to save lives.
Briefly recapping, a blockage, or “plaque,” in an artery often becomes infused with calcium when it has been there for a long time. CT scanners are excellent at picking up on calcium. With the CT calcium score test, the CT scanner sees all the calcified plaque in the coronary arteries of the heart. It’s a fuzzy look inside those arteries because the non-calcified plaque is not seen, but it’s still a look inside the arteries and there is no substitute for actually taking a look. That’s why the CT calcium score is the most important of all screening tests. The test costs $180 and is not currently covered by any insurance company.
This follow-up article will help people understand the details of what it takes to save the lives of those with life-threatening coronary artery disease, and what it takes to make sure that people without significant coronary artery disease are able to keep their arteries clear for many decades to come.
A Case Study
We’ll call this patient Mr. Smith. Some of the details here have been changed to protect his anonymity. I tried to convince him to get the CT calcium score, and he said it would be difficult for him to come up with the $180 for the test. After his appointment with me, he contacted a trusted friend who said to him something along the lines of: “You are relatively young at 60 years old; you never smoked; people in your family don’t tend to have heart attacks; you are a runner; you maintain a healthy weight; you never have chest pain; your blood pressure, blood sugar, and cholesterol levels are all excellent. You do not need the CT calcium score test. You are free to spend the $180 elsewhere.”
At his next appointment, I persisted, and I told Mr. Smith that I still just wanted him to get the test. It came back with a dangerously high number and, within a few weeks, he had undergone coronary artery bypass surgery. There is a high likelihood that, if Mr. Smith had not gotten the CT calcium score test, there would have been a morning in the not-too-distant future when he just would not have woken up and everyone would have been blindsided.
Fewer people know about Jim Fixx these days because he has been departed from us for so long, but his 1977 bestseller, The Complete Book of Running, almost single-handedly inspired a running craze in this country. I was inspired by his book to become a runner, ran on my high school’s track and cross-country teams, and have been a runner ever since. Jim Fixx died of a heart attack in 1984, at the age of 52, while he was out on his daily run. On autopsy, his coronary arteries were found to have plaque that blocked as much as 95% of blood flow. Prior to his heart attack, he had experienced no warning signs of heart disease.
Are you starting to get an idea of the stakes we’re dealing with here? Are you starting to understand that even the most educated guesses in the world will never be the equal of actually taking a look? I don’t care if you have low risk of plaque in your coronary arteries: I still want to see whether there is evidence of plaque there. If you can afford it and you are at least 40 years old, will you please go ahead and talk with your doctor about getting the CT calcium score test?
It’s Not Just the Dramatic Cases
When a primary care doctor saves a life, it usually doesn’t happen in dramatic fashion like in the case of Mr. Smith. The story of a primary care doctor’s saving of a life is usually boring and mundane, involving lifestyle coaching and/or medication.
People often ask me why I want them to take medication to clear out their plaque when they should be able to get the same result with diet and exercise. My answer is that while diet and exercise are both essential, they are not enough, because getting blockages, plaque, to actually start to melt away is an extraordinarily difficult task. An average level of LDL (“bad cholesterol”) is about 110, and that includes all the people taking cholesterol-lowering medication. Many people walk around with LDL levels in the 200’s.
Studies going back as much as 20 years have shown that getting plaque to melt away becomes possible when LDL’s get lower than 70. Studies published in the last few years have shown that if you want to get plaque melting away at a pretty good clip, you should probably get your LDL down into the 30s. The vast majority of people will never get there without diet, exercise, and medication.
Medication for clearing out plaque is incredibly safe for a very simple reason: if there are side effects, they almost always go away rapidly. I have been prescribing medication to clear out plaque for three decades, and I have never seen a side effect that didn’t disappear quickly when the dose was decreased or the medication was stopped.
So trying the medication is almost risk-free.
This point, that trying certain medications is almost completely risk-free, is an important one on which I will linger for a bit.
First let’s consider medications that are not safe. Probably the most dangerous commonly used medication is ibuprofen. There are people with severe chronic pain who don’t have the money to see doctors or who simply don’t want to see doctors. They know that some doctors prescribe 800 mg ibuprofen pills to be taken three times per day, so they take four 200 mg over-the-counter ibuprofen tablets three times a day.
The problem with taking ibuprofen for a long time at those kinds of doses is that the ibuprofen frequently causes ulcers in the stomach or small intestine, and many ulcers are painless. The ulcers can bore into arteries (which are under high pressure) causing catastrophic bleeds that appear to come out of nowhere because there previously had never been pain or any other kind of symptom associated with the ulcer.
So the worst-case scenario with ibuprofen is that you just don’t wake up one morning. Find any ICU nurse and ask them how many patients they’ve seen fighting for their lives because of medications like ibuprofen.
With medication that clears out plaque, it’s an entirely different world. As mentioned previously, in the 30 years since I graduated from medical school, there have been precisely zero occasions where a medication I prescribed for clearing out plaque caused a side effect that didn’t vanish soon after the dose was decreased or the medication was stopped. Truly, the worst-case scenario with taking medication to clear out plaque is that you have to stop the medication.
People buy into all kinds of modern technology, but they refuse modern technology when it comes in the form of a pill. You’re going to drive a car on a highway, but you’re going to refuse a medication to clear out your plaque and keep you from an imminent heart attack when the worst-case scenario with taking the medication is that you have to stop the medication?
I saw a patient for the first time who had just undergone her third round of coronary artery stents. I mentioned using medication to clear out her plaque. She told me she didn’t believe in medication.
I was blunt: “You obviously believe in invasive procedures like getting stents, which means you clearly believe in modern medical technology. What is it about technology in the form of invasive procedures that is less scary to you than technology in the form of a pill? It looks to me like your plan is just to keep getting stents until you finally have a fatal heart attack, and that fatal heart attack is likely not very far off at this point. It doesn’t have to be like that.”
If your doctor wants to start you on a medication, ask what’s the worst-case scenario. If the medication is like ibuprofen where the worst-case scenario is death, maybe you should consider your options. But if the worst-case scenario is that you have to stop the medication, then maybe you should give it a try.
In my 30 years of doing this work, I know that I have saved countless lives through the routine acts of giving lifestyle coaching and prescribing medication. But there are also those I have lost to fatal heart attacks and strokes because, even though those patients were fine with flying on airplanes and riding on elevators, they had fears of modern technology when it came in the form of a pill.
And maybe we can go deeper here. Even those who have had only minimal experience with ChatGPT see that with artificial intelligence we are lurching headlong into the future. Some of the top human minds developing artificial intelligence are now stating that the technology that would have taken 50 years of human intelligence to develop will be made a reality with the assistance of artificial intelligence in the next ten years. The near future is going to be so different that none of us alive today will even be able to recognize it. People will not just live decades longer than they would have otherwise lived, they will have decades more of vigorous, fulfilling life. So let’s go ahead and take care of ourselves right now so we can reap the benefits of all that in the near future.
If you are a patient of mine, will you please let me find out about your level of coronary artery plaque with a CT Calcium score? If your level of plaque is concerning, will you please let me try to clear it out with lifestyle coaching and medication? If your level of plaque is not yet concerning, will you please allow me to use lifestyle coaching and medication so I can do my best to make sure your arteries are pristine for the many decades that you have left?
Joseph Ferguson, MD, is a graduate of The John’s Hopkins School of Medicine. He founded Fredericksburg Primary Care 20 years ago and he has operated that clinic ever since.
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Everyone should get the CT Calcium Score test. It's too bad insurances don't see fit to cover it. I had it done 5 years ago when Medical Imaging was advertising a BOGO for Father's Day! My husband and I both went. My score was 341 and his was much higher. But my score put me in the 99% for my demographics. I was 55, obese, never smoked and had decent numbers because I had been taking medication for years for both high blood pressure and high cholesterol. The nurse urged me to follow up with a cardiologist as soon as possible. So I made an appointment at Oracle Heart and Vascular. I underwent several in office tests and eventually a heart catherization which found a 67% blockage in my LAD. So, I follow up regularly with my cardiologist, my statin's were increased and I'm good with that. I go to every screening or test my PCP or any other doctor recommends because knowledge about what's going on in your is very important. Today I'm out of the obese range, I walk, I eat healthier and I'll be doing another CT Calcium Score this fall. My husband did all his follow ups and even though his numbers were high, he had no blockages. One bonus about this non-invasive screening is it can potentially pick up on possible lung cancer, so it's almost like a 2 in 1 test.
The danger from a bleeding ulcer of the stomach is very real. I lost my younger brother last month to a bleeding ulcer. Surgeons tried three times to stop the bleeding but could not. Ibuprofen was not the cause as far as we know but rather pain pills or so said the doctors. Thank you Doctor Ferguson for this most helpful article. Until my brother died I had never heard of a bleeding stomach ulcer.