Matters of the Heart

If you were at risk for a heart attack, would you want to know?

October 2008

It's a busy Tuesday night at Laudisio Italian restaurant in Boulder. A group of about 20 Front Range physicians has gathered in the restaurant's dimly lit private dining room and, over platefuls of penne pasta and salmon, they're watching Dr. William Blanchet give a detailed PowerPoint presentation. A Boulder-based internist, Blanchet has invited all of these doctors here tonight for one reason: By the time the cannoli are served for dessert, Blanchet hopes to convince these doctors that heart, lung, and colon scans can be good—and often lifesaving—for patients.

It's not always an easy sell. Computed tomography (CT or "Cat") scan technology first became available to Coloradans as a form of preventive medicine more than a decade ago. The high-tech X-rays make it possible for patients and their doctors to view detailed images of organs in search of abnormal polyps or coronary calcium buildup (an indicator of coronary heart disease), among other things. Because of advances in the technology in the last five years, scanning has become more commonplace.

But this has only added fuel to a fiery debate. The medical community simply disagrees on the efficacy of elective scanning. Some consider the method dangerous. Others see the scans as superfluous—a rich person's fad you might hear about on Oprah, but not a viable or necessary method for prevention. Still others think of scanning as a windfall for opportunistic doctors—a view perpetuated by the fact that scans are sometimes administered at tony medical boutiques—and often aren't covered by insurance plans.

Blanchet, who's 54, is well aware of these arguments. At first, he wasn't exactly a believer himself. "I initially believed my cardiology colleagues who told me that it was sketchy technology," says Blanchet. But his mind changed four years ago when he was invited to a similar pro-scan lecture put on by another doctor. "I went there to heckle," he admits, "but I stayed to pray." Not long after, he spent almost $1 million on an Electron Beam CT (EBCT) heart scan and a four-slice helical scan for virtual colonoscopy, and opened the Front Range Preventive Imaging clinic in Boulder. He's also the new medical director for Colorado Heart & Body Imaging in Denver.

His two-hour lecture sometimes borders on evangelistic: Blanchet lets loose with phrases like, "This study really kicks ass," or "Who here thinks I am a heretic?" But the information Blanchet has gathered from medical journals and peer-reviewed studies—particularly statistics on heart disease, the country's number one killer—gives viewers pause, no matter where they stand on the controversy. The presentation is so persuasive, in fact, that it begs a question for both doctors and their patients: If you were at risk for a heart attack, would you want to know?

The American Heart Association reports that 38 percent of all Americans die from heart disease. More staggering, perhaps, is that for more than half of these people (that's 150,000 people a year) their first warning symptom of heart disease is sudden death—no chest pain, no shortness of breath, no warning. This past summer, celebrated NBC newsman Tim Russert died from an unexpected heart attack while preparing for an episode of Meet the Press. In the days before his heart attack, he'd exercised, symptom-free, and only six weeks before his death he had passed an exercise stress test. These tests, commonly administered by internists or cardiologists, look for abnormalities that might suggest blockage in the coronary arteries.

Stress tests are just one of several tools in a doctor's repertoire for detecting heart disease. Physicians also rely on the Framingham risk assessment score (named after an in-depth heart study out of Framingham, Massachusetts). Under Framingham, a patient is labeled with low, intermediate, or high risk for coronary heart disease based on age, gender, cholesterol levels, family history, blood pressure, or a history of diabetes or smoking. "These risk projections are regarded by cardiologists as useful when selecting the most appropriate candidates for medications, such as cholesterol-lowering statins [like Lipitor or Zocor]," says Dr. Brian Lyle, a cardiologist with Rocky Mountain Cardiology.

According to Blanchet, however, these tests alone are insufficient. "Sixty-two percent of men who suffer heart attacks," he says, citing a 2003 study from the Journal of the American Medical Association, "would not be at risk according to Framingham." Furthermore, a 2004 study by the Journal of the American College of Cardiology found that 80 percent of people who are at risk for heart disease will pass a nuclear stress test, in which a doctor injects a dye into the bloodstream and then takes pictures of the heart to check blood flow. Nearly 86 percent of heart attacks occur in vessels deemed normal by exercise stress tests, just like the one Russert passed.

Why the disconnect? It has to do with what actually causes heart attacks, says Blanchet. Heart attacks happen most often when plaque—a mix of fat, cholesterol, and calcium that builds up along the heart's arterial wall—ruptures or bursts. Therefore, just having plaque alone puts someone at risk for a heart attack. It doesn't matter, necessarily, what percentage of the arteries are blocked (which is what stress tests measure). And it doesn't matter, necessarily, how many compounded risk factors you have based on your lifestyle (what Framingham measures).

Heart scans, also called coronary calcium scores, have the ability to pick up where the traditional tests fail by detecting early-onset plaque buildup—before it bursts with deadly results.