Why I'm glad I got a calcium score test
Three friends of mine were among the founders of a concierge health company in New York City called Atria.
While I'm not a member of the service, they were kind enough to put my wife Susan and me through an initial series of tests that they give to all new members – including a calcium score test (also known as a coronary calcium scan), which I had never heard of.
It's an easy, quick test that involves only a couple of minutes in a CT scan machine. According to the Mayo Clinic's website:
A coronary calcium scan is done to check for calcium in the arteries that supply the heart. It can help diagnose early coronary artery disease.
Coronary artery disease is a common heart condition. A buildup of calcium, fats and other substances in the heart arteries are often the cause. This buildup is called plaque. Plaque collects slowly over time, long before there are any symptoms of coronary artery disease.
A coronary calcium scan uses a series of X-rays to take pictures that can see if there's plaque that contains calcium.
The Houston Methodist Hospital website has more details:
The coronary artery calcium (CAC) score measures the amount of calcified plaque you have in those arteries, which is important because coronary plaque is the main underlying cause of – or precursor to – atherosclerotic cardiovascular disease (ASCVD) events such as heart attacks and strokes.
Your calcium score can range from zero to infinity and is proportional with your risk of having such an event up to 15 years. People with no coronary artery calcium – even those with risk factors like diabetes, obesity, or advanced age – have low absolute risk of ASCVD events, or the lowest among individuals with similar characteristics. In contrast, people with high CAC scores have an elevated risk of ASCVD, even if they've never had any symptoms of heart disease and appear to be the picture of health.
A calcium test may be the most accurate predictor, or biomarker, of ASCVD risk to date – at least of the safe, noninvasive, and relatively inexpensive variety. But not everyone needs one and not everyone who could benefit from one knows about it.
Keep in mind that Susan and I are both super healthy.
We eat well and exercise regularly (see my December 28 e-mail about this) and have no family history of heart disease (other than my maternal grandfather, who was an overweight smoker who had a stroke and, later, a heart attack)... so we had no worries when we met with the doctor a few minutes after the test to review the results.
Sure enough, Susan had a perfect score of zero, meaning there was no plaque or calcium whatsoever in her heart.
But then he put up the image of my heart on the screen, pointed to white blobs in my coronary arteries, and said there was a problem – my score was 365, which I later learned is in the bottom 7% for men my age.
I couldn't believe it!
I run ultramarathons, climb big mountains, and exercise like a maniac. On pretty much any metric – running speed/distance, push-ups, pull-ups, sit-ups, grip strength, body fat – I'm in the top 1% among men my age.
So how could so much plaque and calcium have built up in my heart?
The doctor explained that this typically happens among people who have high low-density lipoprotein ("LDL," or bad) cholesterol, which often happens among overweight people with poor diets and exercise habits, but can also simply be genetic.
Sure enough, we checked the results of from the blood tests I had taken as part of my recent physical and my LDL was 116.
That wasn't high enough to trigger any action by my primary care physician at the time, but apparently high enough for plaque and calcium to build up in my heart. (According to the table on my blood test results, optimal is under 100, near optimal is 100 to 129, borderline high is 130 to 159, and high risk is 160-plus. As the Cleveland Clinic website says: "An LDL level above 100 mg/dL raises your risk of cardiovascular disease.")
The first thing the doctor did was order three tests to make sure there weren't any dangerous blockages.
The first was a carotid ultrasound of my neck to make sure the arteries supplying blood to my brain didn't have any blockages.
Then, I had a "exercise stress echo," where I was hooked up to a machine with nine sensors and put on a treadmill for 18 minutes. Here's what I looked like before starting the test:
It started at a slow walking pace with no angle, but every three minutes the speed and angle increased such that, by the end, I was sprinting up a steep hill. I was gasping for breath, sweat was flying everywhere, and my heart rate was at 185 beats per minute ("bpm") – spiking to a peak of 193 bpm (the doctor was very impressed, as that would be a good number for someone 30 years younger!).
The goal was to put my heart under maximum stress and then check for any blockages. So at my peak exertion, I jumped off the treadmill onto the hospital bed next to it, lay on my side, and a sonogram technician immediately began scanning my heart (you can see the machine behind me in the picture above).
Lastly, I received a CT coronary angiogram, which involved going back and forth in the machine for about 20 minutes, while having a dye (contrast agent) injection. Here I am about to start:
Fortunately, the results from all three of these tests were excellent – my heart is super strong and there are no blockages – so the doctor said I didn't have to scale back any of my activities... even my 24-hour World's Toughest Mudder.
The doctor summarized it this way: "Your heart is perfect. But it's like the pipes in your house – they might be fine, but there's a little rust in them."
With all this out of the way, the doctor developed a treatment plan that focused on getting my LDL much lower, which should, over time, reduce the crud that has built up in my coronary arteries.
He put me on one baby aspirin per day and prescribed generic Crestor, which, along with Lipitor and other statins, are taken by 40 million Americans to reduce their cholesterol.
This, he said, would likely get my LDL down to a range of 60 to 70. But he said the new best standard of care is to get it down to a range of 30 to 40, so he also prescribed a new monoclonal antibody drug called Repatha, which I inject (like an EpiPen) once every two weeks. (There's an even newer drug like this called Leqvio that supposed to be even better, but it's more expensive so my insurer, Cigna, won't cover it until I try Repatha first).
I've now been on the program for a few months. I haven't yet taken a blood test, so I don't know how well it's working... but I'll keep you posted!
So... should you run out and get a calcium score test?
My quick answer is: Ask your doctor. According to the Harvard Medical School website:
While a calcium score can be informative, the scans don't make sense for everyone. Not all cholesterol plaques have become calcified in younger people, so the scans aren't usually recommended for people under 40. Anyone who already has known heart disease doesn't need a calcium scan. That's because the results likely wouldn't change a doctor's treatment recommendations, which would very likely include a statin.
However, if you're at risk for heart disease but don't have any symptoms, knowing your calcium score can help you decide whether to start taking a statin. Statins can help lower your risk of heart disease even if your LDL cholesterol is in the normal range.
Current guidelines suggest that people estimate their 10-year risk of cardiovascular disease with a calculator from the American College of Cardiology. Statins are recommended for people with a score of 7.5% or higher. However, the score doesn't capture other possible situations that may elevate your risk – which include a family history of premature heart disease (defined as coronary artery disease occurring in men younger than 55 or women younger than 65).
In light of these guidelines, I don't think any doctor would have recommended that Susan get a calcium score test – and few would have recommended it for me despite my grandfather's history and my slightly elevated LDL level – but I'm sure glad Atria tested me!
If you're interested in getting a calcium score test, it's widely available and should only cost $200 to $400 – just try Google. If you live in New York City, my friend had it done at Lenox Hill Radiology.
Best regards,
Whitney
P.S. I welcome your feedback – send me an e-mail by clicking here.