Coronary Artery Calcium Scan Embraced By New AHA/ACC Cholesterol Guidelines: Will Insurance Coverage Follow?

Thank you Dr. Pearson.

The Skeptical Cardiologist

The skeptical cardiologist has been utilizing coronary artery calcium (CAC) scans to help decide which patients are at high risk for heart attacks, and sudden cardiac death for the last decade. As I first described in 2014, (see here) those with higher than expected calcium scores warrant more aggressive treatment and those with lower scores less aggrressive treatment.

Although , as I have discussed previously, CAC is not the “mammography of the heart” it is incredibly helpful in sorting out personalized cardiovascular risk. We use standard risk factors like lipids, smoking, age, gender and diabetes to stratify individuals according to their 10 year risk of atherosclerotic cardiovascular disease (ASCVD) but many apparent low risk individuals (often due to inherited familial risk) drop dead from ASCVD and many apparent high risk individuals don’t need statin therapy.

Previously, major guidelines from organizations like the AHA and the ACC did not recommend…

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Cardiologists Should Mind Radiation Doses, ESC Says

Because radiation used in imaging tests is proven to cause cancer, they wrote, “cardiologists should make every effort to give ‘the right imaging exam, with the right dose, to the right patient.’

via Cardiologists Should Mind Radiation Doses, ESC Says.

We are seeing more applicant/patient initiated cardiac scans.  I recently became aware of a life insurance application where the underwriter requested a repeat cardiac CT scan.  The applicant’s cardiologist flatly rejected this course of action in an a asymptomatic patient with a correspondingly low CHD risk score.

Now you understand the cardiologist’s thinking.

Did I hear someone say “litigation risk”?

CACS Improves Risk Classification

JAMA — Abstract: Coronary Artery Calcium Score and Risk Classification for Coronary Heart Disease Prediction, April 28, 2010, Polonsky et al. 303 (16): 1610

Conclusion: In this multi-ethnic cohort, addition of CACS to a prediction model based on traditional risk factors significantly improved the classification of risk and placed more individuals in the most extreme risk categories.

Calcium Scoring May Miss CAD

Medical News: Calcium Scoring Misses 20% of CAD Cases – in Cardiovascular, Acute Coronary Syndrome from MedPage Today

Contrary to guidelines, the absence of coronary artery calcium doesn’t rule out coronary artery disease in symptomatic patients, researchers found in a new study.

In a multicenter clinical trial, 19% of patients with a coronary calcium score of 0 had stenosis of at least 50% in one or more coronary artery segments, according to Carlos E. Rochitte, MD, of the University of São Paulo, Brazil, and colleagues.

Likewise, 20% of vessels seen to be totally occluded on revascularization had no calcium on scans, they reported in the Feb. 16 issue of the Journal of the American College of Cardiology.

“The absence of coronary calcification should not be used as a gatekeeper and should not prevent a symptomatic patient from undergoing angiography,” the researchers wrote.

Oops.