I just looked up this topic in UpToDate, the online evidence-based reference library.

Bottom line on their recommendation:

quote:

●We suggest measurement of CAC for cardiovascular risk assessment in selected asymptomatic adults at intermediate risk (10 to 20, percent 10-year risk) by the Framingham risk score and modified Framingham/ATP risk scores (table 2A-B) when the result is reasonably expected to lead to change in management based upon reclassification to a lower or higher risk group. (See 'Use of CAC scoring' above and "Screening for coronary heart disease".)
●We recommend against CAC measurement in patients at low (<10 percent, 10-year risk) or high (>20 percent, 10-year) coronary heart disease risk as established by the Framingham risk score and modified Framingham/ATP risk scores (table 2A-B). (See 'Use of CAC scoring' above.)

So things haven’t changed: useful for a subset of patients in whom their risk classification could be changed by a very high or very low calcium score.

Thanks a bunch sjtill for the very through analysis and perspective.

I will wait until I go to a cardiologist before doing anything.

Dr. Goodheart,

I'm curious as to how up to date that UpToDate is. I haven't looked myself.

I also wonder if the source is biased as well.

It seems to me that a definitive test would be the standard of care, no? Granted, it's not a heart cath, but it's the next best thing.

I still maintain that speaking to your doc/cardiology first, instead of going for the test based on a rad tech's recommendation, or based on some ad put out by the company trying to make money, is the way to go. What are the tech's qualifications to make the recommendation? What do you know about the testing company? Quality control? Up-to-date machinery? Maybe your cardiologist knows just a little bit more, and will refer you to the appropriate high quality facility for the test, should it be necessary.

Thank you Dr. S for chiming in with his expertise.

As to why not just have it done to have peace of mind, I want to use another example to illustrate - a patient with sore throat. Do I test every single sore throat patient for Strep throat? It's quick, cheap, and easy. Why not? Peace of mind. Well, no, not everyone. Here, I will be doing an analogy to the CV risk assessment by asking if the patient has the following symptoms that suggest a viral etiology (instead of Strep) - coughing, congestion, runny nose, hoarseness, mouth/throat ulcers, low or no fever. If they do, then the picture strongly suggests a viral etiology (not Strep) like a cold, for example, and it is recommended by the Infectious Disease Society of America (IDSA) that Strep test should not be done (Strong recommendation, high-quality evidence).

So, to summarize, low risk for Strep throat = do NOT test.

And, btw, testing costs money. Somewhere, somehow, someone, one way or another, is forking out the money. Unnecessary testing is one of many reasons health care is so costly.

And, age alone is not the reason to do the heart scan. I'm 59, and my 10-year risk is 6.2%. Will I go and get the test done? Hell, no. I already have peace of mind.

Thanks, Q.

Bottom line for preventive medicine testing is:
Is there good evidence that doing the test results in better outcomes than just waiting until symptoms develop?
The coronary calcium score fails on that account.

And yes, UpToDate is in fact up to date. Any time that significant new evidence from studies, especially randomized, controlled trials enters the literature, the topic will be reviewed and updated if needed.

quote:

Originally posted by sjtill:
Thanks, Q.

Bottom line for preventive medicine testing is:
Is there good evidence that doing the test results in better outcomes than just waiting until symptoms develop?
The coronary calcium score fails on that account.

And yes, UpToDate is in fact up to date. Any time that significant new evidence from studies, especially randomized, controlled trials enters the literature, the topic will be reviewed and updated if needed.

So Doc, has your wife gotten you to start that book yet? LOL!

You asked one time for a follow-up. Doing great. Joined Planet Fitness and go three time a week. I normally spend 1.5 to 2 hours there. Start out with three different cardio machines, then strength training (alternate upper body and lower body by day).

March 19th was one year. I've had follow up and reports from the "phone home" pacer/defb. All have been glowing. Now get on that book!! I'll buy an autographed copy. Best Regards!

quote:

Originally posted by 12131:
I still maintain that speaking to your doc/cardiology first, instead of going for the test based on a rad tech's recommendation, or based on some ad put out by the company trying to make money, is the way to go. What are the tech's qualifications to make the recommendation? What do you know about the testing company? Quality control? Up-to-date machinery? Maybe your cardiologist knows just a little bit more, and will refer you to the appropriate high quality facility for the test, should it be necessary.

To be fair the tech only informed me of the availability of the test rather that saying I need to have it. When I checked my hospital's website the info they showed was that people at certain ages with certain risk factors were recommended getting the test which was consistent with what sjtill kindly posted info about the test being appropriate for those of intermediate risk and they will not do the test unless you have a doctor that the results can be sent to. Last I checked doctors offices also have a goal of making money and also do a fair amount of advertising of their services and goods, at least out this way. If had not planned on already seeing a cardiologist, I would not have hesitated to have the test done otherwise even with having a better understanding now of what it does and it's limitations.

quote:

Originally posted by sjtill:
Why not just get it done? Lots and lots of errors, both false positives and false negatives, which leads to unnecessary anxiety and unnecessary testing.

Let me tell you about my wife's experience with this test and the way it played out. It's been about 10 years, so I may be off on a few details, but it doesn't really change the overall story.

She went to one of the local Women's Heart Health seminars where they watched some lectures, did bloodwork and got a calcium scan for a few hundred dollars. She was about 40 at the time and without symptoms. This was done at the cardiac care center at the local hospital.

1. Scan was negative for calcium- Great

2. About a week later, she got a call from her doctor saying that the radiologist that read the scan (a few days after the seminar) agreed that the arteries were fine, BUT noticed something abnormal on one lung. Well, can't just let that go.

3. CT scan of the lung in question- inconclusive. Can't leave it at that and risk malpractice

4. Contrast CT of lung which identified a benign vascular malformation. No need to do anything with that, BUT....

5. This CT was high enough to reveal a couple of small nodules on her thyroid. Need an ultrasound to check those out.

6. Ultrasound showed them to be quite small, 4mm so just watch for now with annual ultrasounds. "Just for peace of mind".

7. Not much change until about the 4th year at which point one of the nodules hit the magic 5mm threshold for biopsy.

6. Ultrasound guided needle biopsy inconclusive, on one of the two

7. Back a few weeks later for another one- This one showed some abnormal cells. Can't have that. Better have half your thyroid removed. You know. "Just for peace of mind"

8. Thyroid surgery and subsequent pathology found a 4mm nodule (smaller than ultrasound indicated) with some neoplastic cells. So, technically she did have a tiny spot of thyroid cancer, but it is unlikely it would have EVER caused her a problem.

Bottom line: 5-6 years of annual testing, hospitalization and surgery, about $15,000 in out of pocket expenses, plus what ever insurance paid and now a lifetime of thyroid hormone replacement.

For what? "Just for peace of mind"

^^^ A classic example of what is referred to as an incidentaloma, https://en.m.wikipedia.org/wik...ntal_imaging_finding

Funny, I had one last week & was going to post about it. My cardiologist highly recommended it. I had AFIB due to undiagnosed sleep apnea (now under control). I have a family history of heart disease from grandparents and back (All smokers). Scan was $100. All arteries measured zero except 2 that were 1.4. A huge weight off my shoulders. My only issue is being overweight & I'm working on it.

Unless I'm mistaken this is still a CT-only procedure, meaning you're also getting a dose of radiation potentially unnecessarily if you aren't really in need of the testing to begin with.

Granted not a big dose, but more than zero.

As part of my pre-deployment med last year they ordered a sonogram based on a suspicious blip in the EKG. It was cool to watch the monitor as the tech moved the receiver around. Watched my valves and flaps all doing their thing. The good news was that it was just a blip. Contrary to my wife's opinion, I do not have a stainless steel heart!

quote:

Originally posted by MNSIG:

For what? "Just for peace of mind"

But she's fine now, right?

sjtill, I am curious if you are familiar with FFRct, marketed by HeartFlow.

https://www.heartflow.com/hear...eMJVKaBoCsJwQAvD_BwE

quote:

Originally posted by Georgeair:
Granted not a big dose, but more than zero.

It's actually quite a big dose. If I remember correctly, somewhere along the lines of the equivalent of 100 plain chest x-rays.

CTs nuke you pretty good...if you're worried about that sort of thing.

quote:

Originally posted by Gustofer:

quote:

Originally posted by Georgeair:
Granted not a big dose, but more than zero.

It's actually quite a big dose. If I remember correctly, somewhere along the lines of the equivalent of 100 plain chest x-rays.

CTs nuke you pretty good...if you're worried about that sort of thing.

I had the opportunity to get one on a CT being installed/tested/calibrated a couple years ago and asked one of my radiologist clients/friends if I should be worried about the dose. Once determining I'd not had a CT ever and no x-ray in past 5 years or so, his advice was not to worry about it. His analogy was the exposure was probably about the same as making a couple flights from DFW to Denver and back and for a over-ideal-weight 50 year old dude it was a no brainer.

Shockingly, mine came back golden.

quote:

Originally posted by Gustofer:

quote:

Originally posted by MNSIG:

For what? "Just for peace of mind"

But she's fine now, right?

Yes, the cure rate for non-diseases is quite high.

quote:

sjtill, I am curious if you are familiar with FFRct, marketed by HeartFlow.

I’m familiar with fractional flow reserve as used in conventional coronary angiography to determine severity of stenosis. Looks like this applies that function to images from a coronary CT angiogram (not the same as calcium score CT), to make it more accurate. Potentially useful, but not as screening test as high dose of radiation involved.

By the way: the reason for doing screening tests is to find disease that needs to be treated to prevent a worse outcome than would occur if you wait for symptoms.
The minority of people have disease such as left main coronary disease that will benefit from “revascularization”, that is improving flow through the arteries by surgery or stenting.
A lot of the intervention (stenting) done in the past on asymptomatic patients has now been shown not to prolong life.
That’s been a really hard thing for cardiologists and surgeons to accept, because we thought it was “obvious” that opening up those arteries would decrease the risk of death, compared with medical treatment (aspiring, statins, ACE inhibitors, BP control).

Here’s the relevant recommendations from UpToDate on this issue:

quote:

SUMMARY AND RECOMMENDATIONS

●We recommend coronary artery revascularization for two groups of patients with stable angina (Grade 1A) (see 'Improvement in survival' above):
•Patients in whom maximal medical therapy has not satisfactorily improved anginal symptoms or who are intolerant of medical therapy. (See 'Relief of angina' above.)
•Patients with high-risk criteria and selected patients with intermediate-risk criteria on noninvasive testing, regardless of anginal severity. (See 'Improvement in survival' above and 'Severity of coronary artery disease' above.)
●For patients with stable angina that is not significantly interfering with the quality of life, and for whom revascularization is not indicated to prolong life, we suggest initial medical therapy rather than immediate revascularization (Grade 2B). In such patients, patient preference may be important. (See 'Patient preference' above and 'Indications for PCI' above.)
Similarly, after a period of medical therapy, percutaneous coronary intervention (PCI) may be a reasonable option for patients who prefer to avoid the possibility of urgent revascularization.
●Coronary artery bypass graft surgery is preferred to PCI for many patients in whom a survival benefit from revascularization has been demonstrated, such as those with left main coronary artery disease. (See 'CABG versus PCI' above.)

As a result of these recent studies, there is a turn toward bypass surgery in diabetics and patients with left main disease, rather than the less-invasive stenting.

Yes, the technology is changing, but we need a solid base of scientific evidence, and new technology must be rigorously shown to be superior to the old in improving survival or reducing symptoms before it should be adopted.

Beltfed: fantastic that you are doing so well and getting lots of good exercise!
I am now working with a trainer at a gym in San Diego, mostly strength training, 2 hours a week. I’ve had a significant improvement in my back pain, unexpected but seems very real.

About the book: these days my passion is centered around our one-year old granddaughter. We’ll have to see.

I got one last year at age 45 and it was pretty low but my cardiologist did tell me that age plays a big part in the scoring of it and typically a 45 year old is not old enough to have any plaque turning into calcium to be detected in any amount just yet unless I had massive amounts.

They seem to be more geared toward people 60 and up I think.