Roger's near-miss CT angiogram experience

Heart Scan Blog reader, Roger, described his near-miss experience with CT coronary angiograms.

Hoping to obtain just a simple CT heart scan, he was bullied to get a CT coronary angiogram instead. Roger held strong and just asked for the test that we all should be having, a CT heart scan.

I posted yesterday that I was about to have my first CT heart scan...well, it was an interesting experience for reasons I coudn't possibly have anticipated. Dr. Davis has commented in the past on the confusion in the media about the difference between a CT calcium score scan, and a CT angiography, the latter requiring a far higher dose of radiation. I assumed this was a source of confusion only among patients and lay folks, but, lo and behold, I discovered today that doctors--or at least their helpers--can be just as confused.

Here's my story:

After checking in, I asked the receptionist to see if she had any information on whether my medical insurance was covering the scan. She called someone, and I heard her say over the phone, "He's here for a CT angiogram." At that point my ears perked up. I explained I wasn't here for a CT angiogram, only a regular CT scan. "Well, do you want to call your doctor and talk about this?" she asked. No, I said, I would like to ask one of their folks to verify exactly what test my doctor had ordered. As luck would have it, the technician was walking by at that point. "Is this a CT angiogram?" the receptionist asked. "No, it's just a CT calcium score scan" was the reply. But apparently the technician had been unclear herself, and had called my doctor just to verify. In other words, the "default" procedure they were accustomed to doing at this august Houston vascular clinic was a CT angiogram.

In fact, my appointment was even listed on their calendar as a "CT angiogram." For all I know, my insurance will be billed for the same. Later, during the procedure, the technician acted surprised I wasn't doing the "full test." I explained I had minimal risk factors (actually only one, an HDL of 34 a couple of years ago, which has since been raised to 50 partly as a result of taking advice from this site), but that my doctor was progressive (he is an MD for the Houston Astros) and thought it was a good idea since there is heart disease in my immediate family. My doctor did indeed prescribe only a CT calcium score scan, but it seems to have been an order that this clinic, at least, wasn't all that used to seeing.

So, I guess the message is: we have a lot of educating to do. Had I not been a faithful reader of these pages, I certainly wouldn't have known what kind of test I was about to get, or what questions to ask!

As for the heart scan itself, a piece of cake. If you can hold your breath, you can take this test. Just be sure it is the right one!

Why the "push" towards CT coronary angiograms and not "just" a CT heart scan? Well, I know it's shocking but it's . . . money!

CT coronary angiograms yield around $1800-$4000 per test. CT heart scans yield somewhere around $200. Though the scan center support staff might not care too much about the money themselves, their administrators likely make the cost distinctions clear to them.

Another reason: Most scan center staff, ironically, don't understand what a heart scan means, nor do they understand how it might serve to launch a program of prevention. They do understand that severe blockage by CT angiogram "needs" to be stented or bypassed. So they push patients towards things they understand.

Nobody makes money from CT heart scans, just as nobody makes money from a mammogram. Heart scans also don't lead to heroic, "lifesaving" procedures. They just lead to this sleepy, unexciting, inexpensive thing called prevention.

There's a fascinating and vigorous debate going on at the Heart.org website among Dr. Melissa Shirley-Walton, the recently publicized proponent of "a cath lab on every corner": Dr. William Blanchet, a physician in northern Colorado; and a Track Your Plaque Member who calls himself John Q. Public.

John Q. has been trying to educate the docs about the Track Your Plaque program. Unfortunately, Dr. Shirley-Walton essentially pooh-poohs his comments, preferring to lament her heavy work load. In her last post, when she discovered that John Q. was not a physician, she threatened to block his posts and delete all prior posts.

However, Dr. Blanchet has emerged as a champion of heart scanning, intensive lipid management, and lipoproteins, much similar to our program. In fact, many of Dr. Blanchet's comments were so similar to mine that John Q. asked me if it was really me! (It is definitely not.)

Here's a sampling of some of the discussion going on now:

Dr. Blanchett started out the discussion by saying:

Stent Insanity
I have no trouble agreeing with the argument that we have initiated the widespread use of DES without adequate study regarding outcomes. Shame on us.

That said, we are ingoring the DATA that shows that most heart attacks occur as a result of non-obstructing plaque and all the talk about which stent to use ignors the majority of individuals at risk. In addition, for a decade we have known that stenting does not improve net outcomes anyway.

What ever happened to effective primary prevention? We discarded EBT calcium imaging like moldy cabbage without even looking at the outcomes DATA. With direction provided by EBT calcium imaging and effective primary prevention, I have been able to reduce myocardial infarction by 90% in my very large Internal Medicine practice. Through effectively identifying patients at risk and measuring success or failure of treatment with serial EBT, I have made the argument as to which stent to use moot. No symptomatic angina and rare infracts equals little need for any stent.

Is anybody listening? Certainly not the cardiologists whose wealth and fortunes are based on nuclaer imaging, angiography and stenting.

Dr. Shirley-Walton, skeptical of Dr. Blanchet's claim of >90% reduction of heart attacks using a prevention program starting with a heart scan:

To rely soley upon a calcium score will deprive you of a lot of information that could be otherwise helpful in the management of your patients.

Without seeming sarcastic, I must refute : "of 6,000 patients I've seen 4 heart attacks in 3 years". Although I certainly hope your statistics are accurate, I will suggest the following:

You've not seen all of the heart attacks since up to 30% of all heart attacks are clinically silent. So unless you are echo'ing or nuclear testing all of these patients in close followup, you aren't certain of your stats.

Secondly, in order to attribute this success to your therapy, you would have to have nearly 100% compliance. In the general population, compliance is often less than 50% with any regimen in any given year of treatment. If you can tell us how you've achieved this level of compliance, we could all take a lesson.

Dr. Blanchett, commenting on his use of heart scanning as a primary care physician:

CAC [coronary artery calcium] is an inexpensive and low radiation exam to identify who is at increased risk for heart attacks.

A study of 222 non-diabetic patients admitted with their first MI found 75% of them did not qualify for cholesterol modifying therapy prior to their initial MI (JACC 2003:41 1475-9). In another study of 87,000 men with heart attacks, 62% had 0 or 1 major risk factors (Khot, et al. JAMA. 2003). Almost all individuals with 0 or 1 risk factor are Framingham "Low risk" and therefore will not qualify for cholesterol lowering therapies. (JAMA. 2001;285:2486-2497)

Risk factors alone are not sufficient. In my practice, of the last 4 patients who have died from heart attacks, none qualified for preventive therapies by NCEP guidelines.

Studies have shown that CAC by EBT provides an independent and incremental predictor of heart attack risk. (1. Kondos et al, Circulation 2003;107:2571-2176, 2. Am Heart J 141. 378-382, 2001, 3. St Francis Heart Study Journal of the American College of Cardiology July, 2005) The old saw that CAC simply reflects risk factors and age is just wrong.

Although CT angiography shows great promise to reduce unnecessary conventional angiography and is helpful in emergency room chest pain evaluation, I do not see CT angiography as a screening study in asymptomatic individuals. 10 times more radiation than EBT calcium imaging plus the risk of IV dye exposure makes CT angiography inconsistent with the principles of a screening test. Taken in the context of a primary care physician's evaluation of heart attack risk, EBT calcium imaging has great value.

Coronary calcium changes management by: 1. Identifying those at risk who do not show up with standard risk stratification (St Francis Heart Study: Journal of the American College of Cardiology July, 2005). 2. Motivating patients to be compliant with therapies (Atherosclerosis 2006; 185:394-399). 3. By measuring serial calcium, we can see who is and who is not responding to our initial treatment so that we can further refine our therapeutic goals (Atherosclerosis, 2004;24:1272).

When used in the primary care preventive setting, CAC imaging is indeed of great incremental value. In my practice, in improves my outcomes so greatly that it compels Melissa Walton-Shirley to question my veracity.

Dr. Melissa Walton-Shirley:

Ahhhhhh.......the aroma of profit making, I thought I smelled it. [Accusing Dr. Blanchett of referring patients for heart scans for personal profit.]

I will tell you that I was a little hurt when I was called "a typical cardiologist with a butcher block mentality" after my primary pci piece for med-gen Med was reviewed by the track your placque [sic] folks.

Though, it's clear that they misunderstood and thought I was cathing for dollars, instead my intention was to "push" for primary PCI for AMI, it left me seething until the blessing of a busy schedule and a forgetful post menopausal brain took its toll.
None the less, an honest open discussion is always welcome here but I would appreciate it if everyone would just divulge their affiliations up front so that the context of their opinions could be better understood.

I also insist that the compliance described by you William B. is rather astounding and a bit unbelieveable, however if it's accurate, you are to be congratulated.

Dr. Blanchett, in response to Dr. Shirley-Walton's statement that she relies on stress testing:

I think that the threshold of comfort you get from stress test stratification is different than what I consider acceptable. It is hard for me to tell a bereaved spouse that the departed did everything I suggested and still died from a MI. Coronary calcium imaging provides me the tool that I need.

Are you aware that there are a number of studies that show a dramatic increase in risk of MI in individuals with an annualized increase in calcified plaque burden of >14%? I consider this to be a valuable measure of inadequacy of medical management. A stress test does not become positive until we have catastrophically failed in medical management. Consequently, even in the patient with “high risk” stratification, one can justify a calcium score to establish a baseline to measure adequacy of primary prevention. Calcium scores by EBT cost about 1/5th the cost of a nuclear stress test and subject the patient to 1/10th the radiation of nuclear imaging and provides more precise information.

Regarding John Q, I do not think that non-medical prospective should be excluded from this blog. I think we as physicians benefit from hearing how the non-physician public views medicine. I have become much better at what I do by listening to my patients and learning from them.

Dr. Blanchett continues:

Yes, I have seen a dramatic reduction in coronary events. Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.

The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk facto is low risk and most are do not qualify for preventive treatment. EBT calcium imaging could have identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.

Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Ateriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card

Melissa, I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test.
Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority of patients with less than 70% vessel obstruction will pass thier stress test.

William, regarding your question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologists stress lab.

How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.

So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.

Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.

John Q. Public jumps into the fray with:

Fascinating, isn't it, that there appear to be two doctors, William Blanchet in this forum and Dr. William Davis, FACC, of cureality.com that both claim to have dramatically reduced risk of heart attack among their patients and/or actual calcium plaque score regression and BOTH are ardent proponents of CT Calcium Scoring?

Despite Dr. Blanchet's persuasive arguments backed up with numerous scientific citations and John Q.'s support, I sense they had no effect whatsoever on Shirley-Walton's way of thinking.

Such are the deeply-entrenched habits of the cardiology community. It will be many years and impassioned pleas to see things in a different light before the wave of change seizes hold.

Mark K. Sprengel
6/28/2009 11:35:08 AM |

I had a friend that recently went for a heart scan. He said his score was zero. Is that possible?

Anonymous
6/28/2009 4:31:52 PM |

I hope the USA can see its way to some sort of national standards for State run medicare. As recent events show, if you have the will, the money will be found.

I live in Ontario, Canada and only had to ask my primary care physician in order to get a CT angiogram (did not know about the Calcium score at the time) It's cost is covered under our social medicine program OHIP.

A new study shows 30% drop in mortality from CD

http://www.theheart.org/article/980589.do

Anna
6/28/2009 5:30:18 PM |

Sure it is. My score was 0. That's despite doing quite a bit in direct opposition to the AHA recommended dietary advice:

-no wheat/gluten at all (whole or refined)
-very few, if any grains (whole or refined)
-very low sugar and starch consumption (low carb)
-pastured red meat several times a week (bison, beef, or pork) with normal ferritin level
-high saturated fat consumption (grassfed butter, coconut oil, home-render lard)
-whole fat dairy (incl raw whole milk and raw milk aged cheese)
-no attempt to artificially increase fiber, though there's probably a fair amount of fiber in the ample fresh non-starchy veggies I consume
-2 to 3 "backyard" eggs cooked in ample butter nearly daily for breakfast

fred88
6/28/2009 7:04:06 PM |

i am 72 years old my calcium score is zero.2 yrs ago i was diagnosed with angina.i took the linus pauling protocol and cured my heart disease.on march 20th 2009 i had a calcium score scan and astounded my cardiologist as my arteries were completely cleared.vitamin c and amino acid is cheap and available. no money in it for doctors.discredited by medical profession.

Jim the Guacamole Diet guy
6/29/2009 5:54:45 AM |

"Why the "push" towards CT coronary angiograms and not "just" a CT heart scan? Well, I know it's shocking but it's . . . money!"

No, surely not.

billye
6/29/2009 11:12:29 AM |

Rogers experience brought back an unpleasant near miss CT Angiogram memory of an episode that I had while being in the hospital 5 years ago. I was brought in with congestive heart failure-EF 20/25, Now Don't think you are soon to lose a faithful reader, my EF is now 45/50, due to Aranesp injections, that I am doing exceptionally well on. My anemia is now under fabulous control.
But, I digress, one day while in the hospital a beautiful young lady with long flowing hair wearing a white coat and stethoscope came in to see me and identified her self as the cardiologist assistant. She quickly started to promote me to have an angiogram. I refused. The hospital cardiologist came to see me and I told him not to send me any more sales reps. (he must have learned this technique from big Pharma with all their beautiful drug sales reps). I never did have that apparently unnecessary needless invasive procedure done. Guess what?, I lived to tell the story.

Jim, Guacamole Diet
6/29/2009 1:03:19 PM |

One morning last year, I drank way too much strong tea. A few hours later, I had chest pains and tachycardia. I had forgotten about the tea, which with hindsight was the obvious cause, and I went to an emergency room.

By the time I got there, the pain had gone, and I should never have stepped into the ER waiting room.

As soon as they got their hands on me, they wouldn't let me go, claiming that insurance wouldn't pay if I left against doctors' orders. They quickly ran up any thousands of dollars of expensive tests, all of which came back fine.

They were very unhappy that I refused a coronary artery stent.

My ejection fraction was 65.

Anna
6/29/2009 6:09:24 PM |

Anonymous in Canada,

"A new study shows 30% drop in mortality from CD"

Yes, modern medicine "saves" more people all the time.

But is the *incidence" of CD dropping? or is medicine just getting better at treatment.  I want to avoid CD, not just be saved from it.

I used to be a strong believer that the US needed a universal medical care system similar to Canada and the UK.  Now that I have had a closer look at the UK's system over the last 14 years (in-laws are there) and have experienced the profound lack of primary prevention under a US HMO system (healthcare rationing), I'm not-so-sure.

Sure, we are a rich nation and we should be able to afford decent healthcare for everyone.  The current system is for haves and have-nots with the in-betweens really getting pinched.  And furthermore, the haves don't get nearly the quality of care that they pay through the nose for anyway (though many don't realize it).

But I can't see how turning over the decisions to government is going to be any better than it has been to turn over decisions to HMP insurance companies and accountants.  In fact, it could get worse.  Especially since government has turned into the handmaiden for special interests.  As much as I think it should happen, I have a hard time getting behind the proposals.  Be careful what you wish for, you might get it.

Anonymous
6/30/2009 12:51:29 AM |

ok fred88, you almost got me excited....until I saw the oral EDTA chelation.... I'm calling BS by association

Kent
6/30/2009 1:54:06 AM |

Fred,

I've heard a mixture of reports on the Pauling protocol with varied success. Can you give a little more detail as to how much vitaming C, L-Lysine, etc. you took per day at what intervals, and the time duration you believe it took for the protocol to do it's job?

Thanks,
Kent

TedHutchinson
6/30/2009 8:39:34 AM |

Pauling Protocol in PDF format
take note of this section
The half-life of vitamin C in the bloodstream is 30 minutes.
Linus Pauling advised taking vitamin C throughout the day in divided doses. The Hickey/Roberts Dynamic Flow theory predicts that taking vitamin C every four hours will produce the highest sustained blood concentrations. Take more before bedtime.
I use a time release formulation

TedHutchinson
6/30/2009 8:46:51 AM |

Heart Disease, Ascorbate, Lysine and Linus Pauling by Jeffrey Dach MD A useful summary here

buy jeans
11/3/2010 8:25:24 PM |

CT coronary angiograms yield around $1800-$4000 per test. CT heart scans yield somewhere around $200. Though the scan center support staff might not care too much about the money themselves, their administrators likely make the cost distinctions clear to them.

Anonymous
11/20/2007 1:32:00 AM |

I give thanks that the health of my heart does not rely upon the Melissa Shirley-Waltons of the world.

Anonymous
11/20/2007 3:37:00 AM |

Where exactly is this debate going on? I was unable to find a forum at that site, even though the site index. I did a search for the doctors' names, and came up blank.
Thanks,
S

Dr. Davis
11/20/2007 3:45:00 AM |

Just go to heart.org and the Forum is on the left navigation bar. You will have to sign in, presumably as a media representative.

Anonymous
11/20/2007 1:24:00 PM |

Looks like this "John Q Public" has emerged from the shadows over at the HeartCipher blog.

http://www.heartcipher.com/archives/42

Anonymous
11/20/2007 1:27:00 PM |

The link to the forum in question is:

http://www.theheart.org/viewForum.do

The thread title is:

"DES showdown: Serruys vs Virmani"

Paul Kelly - 95.1 WAYV
11/21/2007 5:23:00 PM |

Hi Dr. Davis (and everyone!) -

In talking with my family physician today about CT Heart Scans, she said she doesn't like them because of the level of radiation. She said she just read an article that said even one CT can increase your chances significantly for leukemia, cancer, etc. She's a believer that a comprehensive stress test can tell you what you need to know - i.e. if you have plaque, it's going to affect the results of your stress test and is therefore detectable that way. Is the level of radiation really something to be scared of?

Paul

Rich
11/21/2007 10:20:00 PM |

Dr. Davis recently wrote a blog piece titled "Are Cardiologists the Enemy?" that seems particularly relevant here.

-Rich

Anonymous
11/23/2007 3:48:00 PM |

Since it seemed like I had read John Q Public's writing style recently, I clicked on this blog's side links, and found JQP was most likely HeartCipher. I read through some of HeartCipher's recent posts and found the link to the forum, at theheart.org -- not heart.org as originally linked.

Dr. Davis, perhaps the link could be corrected in the blog post?

Many thanks to the anon commenter for the DIRECT link to the thread (too bad I didn't reread through the comments before sleuthing LOL)! Once I receive my confirmation letter from theheart.org I'll be able to read it.

S

Dr. Davis
11/23/2007 4:05:00 PM |

Yes, my mistake, now corrected. Thanks.

Roger's near-miss CT angiogram experience

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The Heart.org online debate

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Treat the patient, not the test

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