If you were at risk for a heart attack, would you want to know?
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.
Lisa Goldstein, a 50-year-old Boulder marathon runner and Dr. Blanchet's patient, could have been another statistic. She was healthy, ate well, didn't smoke, and ran—a lot. The only factor that put her at risk for heart attack was her family history. By Framingham's standards, she would be very low-risk. But she got a heart scan on a whim—she'd purchased a gift certificate at her child's school fund-raiser—and discovered that her calcium buildup was above the 97th percentile for her age and gender. Her cardiologist ordered a follow-up angiography (a test that involves threading a catheter to the heart and injecting dye to measure circulation), which showed a dangerously clogged artery. For this she received a stent—a device that pushes into and holds open a clogged artery. "There are certain people for whom I am certain I prevented their heart attack," says Dr. Blanchet. "Lisa Goldstein is one of those people." Moreover, her follow-up scan one year after her first scan revealed a reduction in her plaque burden and therefore very low risk for a heart attack. A heart scan is a five-minute, outpatient procedure. The donut-shaped scanner takes multiple X-rays from which a computer generates cross-sectional images, like slices, of the heart. The most important information gleaned from a scan is the calcium deposits, which show up as bright white spots. (Calcium is an ingredient in arterial plaque—the stuff that bursts and causes heart attacks—and a strong marker for heart disease.) Doctors look at the amount of calcium to calculate a score that helps assess risk and dictate treatment.
Heart scans average about $450, according to Consumer Reports (at Front Range Preventive Imaging they cost $395). A patient can use a doctor's referral to get the procedure, or, in the case of free-standing clinics, they can self-refer. Most insurance plans do not cover the procedure, regardless of referral; United Healthcare does not cover calcium scoring, and Cigna covers the CT scan, but not on an EBCT machine like the one Blanchet uses. This year Medicare announced it would cover heart scans on a case-by-case basis.
But if a patient can afford a heart scan on his or her own and is a good candidate, the scan has shown to be a valuable tool for preventive diagnoses.
Here's how: If your heart scan reveals a high calcium score and thus high risk for heart disease, you'll be sent to a cardiologist for follow-up tests and analysis. The cardiologist will help you make lifestyle changes—such as diet, exercise, stress management, and cholesterol-lowering medications—to help stabilize the plaque. He will also order tests—like a stress test, cardiac catheterization, or coronary CT angiogram—to pinpoint blocked arteries. This sometimes leads to procedures like the placement of stents to open the clogged arteries, which is what happened in Lisa Goldstein's case. If your heart scan reveals intermediate risk for heart disease, your doctor will likely rule out invasive angiograms or stents, and instead prescribe lifestyle changes, effective immediately. If your heart scan reveals zero risk for heart disease, your doctor will send you on your way with a clean bill of health—for now.
To the nonmedical ear, scanning sounds like a miracle of science for which everyone should sign up. But is heart scanning for everyone? No, says Dr. Brian Lyle of Rocky Mountain Cardiology. "I think that there is a role for calcium scoring in asymptomatic patients with intermediate risk, based on their lifestyle," he says, adding that everyone else should proceed with caution. The American Heart Association agrees. In 2007 it issued a statement (along with the American College of Cardiology Foundation) recommending that only patients with intermediate risk should consider getting heart scans.
For healthy, young, and low-risk patients, some experts say, the negatives of scanning can outweigh any benefits. The radiation exposure from one EBCT heart scan equals around eight X-rays. Heart scans on the newer multidetector CT machines have a radiation exposure equivalent of up to 200 chest X-rays. Critics contend this puts a patient at an increased risk for developing cancer, thereby trading one potential deadly disease for another.
Essentially, it's up to the patient to consider the risk-benefit equation. "The benefit of this test clearly exceeds the small amounts of radiation exposure," says Dr. Karyl VanBenthuysen, cardiologist with South Denver Cardiology and director of Cardiovascular CT. "You'll get more radiation exposure living one year here in Denver [at a high altitude] than you will from one heart scan."
On their own, these scans don't stop heart attacks. It takes a motivated patient and an educated doctor, explains Blanchet, to make the lifestyle changes that will prevent heart attacks. But a heart scan can sometimes be an encouraging factor. According to the Southern Medical Journal, only 13 percent to 50 percent of patients will take cholesterol-lowering drugs if they are prescribed to them. "Statins can be a hard thing to convince patients to take every day of their lives," says Blanchet. "But if I can show them the actual plaque buildup in their hearts, and they can see it for themselves, they are more likely to listen."
No studies have been done to show how many heart attacks are prevented by CT heart scans—which is another reason critics don't buy the hype. Anecdotally, Blanchet says that in 36 months there has been only one coronary event in his internal-medicine practice. "This technology has allowed me to revolutionize my practice," he says.
Still, docs armed with scans, medication, and know-how can't always prevent heart attacks. Tim Russert himself received an EBCT heart scan 10 years ago at a clinic in Washington, D.C. Dr. James Ehrlich, a Denver-based physician who first opened Colorado Heart & Body Imaging in 1997 and is one of the nation's most vocal proponents of heart scans, was medical director for that D.C. clinic. According to Ehrlich, Russert's 1998 calcium score (210) showed heart disease. And in a statement issued by Russert's internal-medicine doctor shortly after the heart attack, Russert had "done everything he was supposed to do to manage the disease," though his weight was still "a problem."
In the end, Russert's story serves as a wake-up call. Ehrlich says the Washington, D.C., clinic has been busy since the respected newsman's death, particularly with high-profile journalists and former NFL players.
Meanwhile, Dr. Blanchet will continue to give his PowerPoint presentations—he schedules two lectures a month—to try to change the medical community's perceptions about scans. If it were up to him, everyone over 50 years old would get a scan. "I know this is real," he says. "But until we circumnavigate the globe, they'll keep thinking the Earth is flat."