Wednesday, September 26, 2007

It's STILL About the Plaque, Stupid!

I like In fact, I use it to keep up on my Spanish. But, just as with Yahoo!, it leaves a lot to be desired in terms of heart health advice. Since I took the time to "go off" on Dr.Margolis at Yahoo! Health, it's only fair I treat the drivel being pushed by Dr. Fogoros at with the same disdain. Such a pity too because he ALMOST got it right.

The good doctor attempts to answer the provocative question, "EBT (Ultrafast CT) Scans - Godsend, or Scam?" in the Heart Disease section. He actually does a pretty good job explaining everything until he gets to the real meat of the issue; the efficacy of using heart scans to track heart disease. Unfortunately, like many other traditional practitioners, he remains blinded by the hopelessly outdated fixation on OBSTRUCTIVE heart disease.

For many years heart disease theory and practice was centered on treating heart disease like a "plumbing" problem. You simply test the coronary arteries for flow and if it's adequate everything is just fine. If not, you hope you catch it in time and call "roto-rooter." Everything was focused on finding and fixing obstruction to flow. But a not-so-funny phenomenon kept occurring. People would pass their stress test and then die of a heart attack the next day! What the hell?

It is now known that most heart attacks actually occur at sites with no symptomatic or even detectable flow obstruction. Unstable, previously undetectable "silent" plaques rupture exposing their lipid core to blood, a clot forms, and bang, you're dead! The bottom-line is that what you need to know is NOT the amount of obstruction you have but your total PLAQUE burden. A heart scan will tell you this, a stress test or even a catheterization often WILL NOT.

Dr. Fogoros completely misses the point when he laments that a heart scan does not have the power to accurately predict who has an obstruction at any given instant. That is what a stress test is for. It will tell you if you currently have obstructive heart disease and are in imminent danger of dying immediately. However, it will not tell you a thing about what will happen at any point in the future - like tomorrow! A heart scan is the most accurate predictor of your risk for future heart attack.

Here is the bottom-line. Get a freakin' scan heart scan. If your score is zero, throw a party. If it is non-zero find a doc who understands what your risk is, how to determine the root cause of whatever is causing the problem (hint: High LDL cholesterol is not the most common problem), and put together a program to treat your root causes. Get a yearly repeat scan to see if your plaque burden is growing or shrinking. If it has been arrested or starts reversing - again - throw a party. This means your heart attack risk is almost as low as a zero score. If it is growing, you need to be more aggressive in your current program or change it. The key here is that without a follow-up scan you have no idea of what to do next.

So stop worrying about obstructive heart disease (OK, so don't worry quite so much). Focus on plaque burden.

Plaque is Where It's At!



Anonymous said...

Nice review Heart Hawk! I too was pretty excited about some positive information about EBT heart scans...on page 1 of the article. Being a CT/EBT tech, I am always interested in seeing information on the differences in radiation dose compared to other scanners, accuracy, etc. As usual, the significant dose to breast tissue from conventional CT scanners is not mentioned(EBT virtually eliminates that risk) but that's a rant for another time.

As usual, positive heart scan results indicating heart disease lead to an inappropriate approach to dealing with the disease.

I continuously hear patients tell me "my doctor tells me it's normal for someone my age to have some heart disease". NO amount of calcified plaque is normal! This article addresses the other side of the coin. I did speak with a patient who was very irate with us. His doctor received his heart scan results and immediately suggested a cardiac cath. After the procedure, his doctor said "your heart scan results are wrong, you have no disease". This patient's volumetric heart scan score was 15!! Obviously enough to conclude that there was no error in scoring but also obviously NOT enough for invasive intervention at ANY age! (Of course his flow was normal!) His anger was directed at us! We'll never know what becomes of this patient but I'm sure he is not currently taking any steps to halt progression of his disease.

This is the analogy I like to present to some people I think may "get it". You wouldn't consider a "small amount" of cancer to be normal, why do you think this disease is any different?

Bix said...

Do heart scans raise the risk for breast cancer?

Anonymous said...

Hi bix,

I'm not sure I will be able to answer this to your satisfaction but here's what I can tell you. The radiation dose from an EBT heart scan is approximately equivalent to a normal 2 view chest xray. (40 mrem). In 2001, a study determined that a heart scan performed on a conventional CT scanner exposed you to at least 20 times that dose. I have heard it can be as high as 38 times the dose. Is this dangerous? Any amount can be dangerous but we are exposed to radiation continuously. My beef is that this information is not readily available so people can make informed and educated choices.

Bix said...

Holy cow! Thank you, anon.

DrRich said...

Dear Hawk,

It's me, DrRich. I just noticed your recent article disparaging my old article on noninvasive scanning (which was written in 2003, when the purpose of such scanning was explicitly to find obstructions). My thinking (as well as the thinking of medical imaging specialists) has evolved since then. I'm sorry you didn't notice my more recent articles on noninvasive scanning:

I agree that in many patients, it makes sense to do this test for the purpose of detecting coronary artery calcification, which is virtually diagnostic for coronary artery disease. Especially if it gets the patient and doctor off the dime about beginning a Manhattan Project of risk modification, such information can be very helpful.

However, as some of your commentators have pointed out, there is a real and growing concern about the radiation one receives with these CT scans and the subsequent increase in the long-term risk of cancer. We're just beginning to hear about this - more will be forthcoming.

In any case, I admire your mission, have no hard feelings about your castigation of my old article, and wish you the best.

Rich Fogoros, MD

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