I just enjoyed a wonderful conversation with Ivor Cummins, an engineer from Ireland who, with the assistance of my friend, businessman David Bobbit, also from Ireland, have been advocating for the power of CT heart scans and coronary calcium scoring to uncover and identify cardiovascular risk through their organization, Irish Heart Disease Awareness, or IHDA. Ivor has been especially vocal about the numerous misinterpretations of the cholesterol and statin drug conversation that comes from conventional healthcare and doctors and pointing out, for instance, that much cardiovascular risk is determined by inflammatory markers, insulin resistance, and lipoprotein distortions, not cholesterol values. He does a very good job of articulating these concepts in a series of YouTube videos such as this.
For those of you unfamiliar with coronary calcium scoring, it involves scanning people’s hearts with a rapid CT device (speed of image acquisition is crucial, since the heart is a moving object) to precisely measure the amount of calcium in the walls of the three coronary arteries. Because calcium occupies 20% of total atherosclerotic plaque volume, measuring calcium provides a gauge of the volume of atherosclerotic plaque in the coronary arteries: the more calcium, the more atherosclerotic plaque you have. If you have one cubic millimeter of calcium, for instance, you have five cubic millimeters of total atherosclerotic plaque volume. Calcium therefore represents a virtual dipstick for the burden of atherosclerotic plaque you have in your heart’s arteries. The more calcium you have, the more atherosclerosis you have, the greater your risk for heart attack and similar events. This relationship has proven reliable and powerful in dozens of clinical studies.
Some people, unfamiliar with heart scans, have argued that calcium doesn’t matter because it represents “hard” plaque, as opposed to “soft” plaque of the sort prone to rupture and cause heart attack. But that is not true: calcium is a gauge of total plaque that includes all hard, soft, fibrous, and other elements. This helps explain why coronary calcium scores obtained via CT heart scans are the most reliable and accurate predictors of cardiovascular risk, far superior to cholesterol values or risk calculations such as the Framingham Risk Score. (If the coronary calcium score were only an index of stable calcified plaque, it would not be such a powerful predictor—but it is.) A coronary calcium score is not a risk factor for coronary disease; it IS coronary disease. Having a coronary calcium score therefore tells you with excellent (though not entirely infallible) accuracy whether or not you have the disease and how much of it you have. LDL cholesterol, total cholesterol, and risk calculators do NOT tell you any of this—they are no better than crude guesses that prove to be fatal mistakes time and time again: people with low-risk have heart attacks, people with high-risk live long healthy lives free of heart disease.
During our conversation, we talked a lot about the notion of regression of coronary calcium scores as tracked by CT heart scans. Ivor was interested in clearing up some of the confusion that comes from the statin world in which the apologists for the statin drug industry have argued that calcium is protective or a stabilizing factor in coronary atherosclerosis. Is this true?
No, this is nonsense. It originated with the observation that, if you do nothing, coronary calcium scores increase by 25% per year on average, a horrifying rate that takes you closer and closer to heart attack, developing anginal chest pains, or sudden cardiac death. If you take aspirin, follow a low-fat diet, and take a statin drug like Lipitor, your coronary calcium score increases 25% per year—what doctors call “optimal medical therapy” does not slow the progression of coronary calcium scores. “Optimal medical therapy” would be more properly labeled “laughably ineffective medical therapy.” Several studies have also shown that statins actually accelerate the accumulation of calcium. The implications of this statin-related effect are not understood, but apologists for the statin drug industry postulate that statins therefore stabilize plaque by causing calcium deposition. This is sheer speculation with no evidence to support. But this led to people to suggest that the regression many of us enjoy by reducing our coronary calcium scores—a frequent occurrence in the Undoctored program—may be destabilizing and lead to cardiovascular events.
But people who stop the progression of their coronary calcium scores or achieve a reduction, i.e., regression, have virtually zero risk of cardiovascular events, even if their score remains high. In other words, stabilization of the score or reduction means that plaque is no longer actively growing and is no longer prone to rupture. Heart attacks are virtually unknown. (I say “virtually” because there are rare instances of such things as coronary spasm, heart attacks caused by amphetamines or cocaine use, or other exceptional situations.) Tracking coronary calcium scores can therefore be a hugely empowering way to manage cardiovascular risk that does not require a statin drug. (In Undoctored, of course, we assess NMR lipoproteins, blood sugar/insulin measures like HbA1c and fasting insulin, 25-hydroxy vitamin D, thyroid measures, RBC magnesium and a handful of other measures to more precisely chart causes for coronary atherosclerosis and then correct them, efforts that go way beyond the limited benefits of statins.)
The biggest danger of getting a heart scan for a coronary calcium score? The upsell process that this test triggers. Behind closed doors, cardiologists and hospital administrators call heart scans “loss leaders,” i.e., charge less than the test costs to perform, e.g., $99 or $149, then hope that each person has a score high enough to be used as a crowbar to get you into the hospital or clinic for more testing. It is the rule, for instance, to be advised to have a nuclear stress test (around $4800, not to mention considerable radiation exposure, about 30-fold more than the CT heart scan), CT coronary angiogram (an angiogram of the coronary arteries performed on the same device as the basic heart scan but involving far more radiation and costing around $3000-4000), heart catherization, even “prophylactic” stent implantation even though this has been shown to yield no benefit and no reduction in future cardiovascular events. This is the alchemy of modern cardiovascular care: Convert the $99 loss leader CT heart scan into $90,000 or more of heart testing. This sort of upsell process is exceptionally common, something I have witnessed many times, no different than the car salesman trying to tack on all sorts of added costs to the car you’re looking to buy. But the consequences of upselling medical procedures is far more risky.
CT heart scanning to obtain a coronary calcium score is a wonderful technology that can identify risk, then empower you in crafting a cardiovascular risk reduction program, providing a powerful and quantitative tracking tool to assess the results of your preventive efforts. Just don’t fall victim to the predatory and exploitative ways of cardiologists and hospitals. There is a time and place for additional testing. If you are uncertain what to do when a cardiologist advises you that you are a “walking time bomb” or that you might be at risk for sudden cardiac death and need additional testing despite walking, jogging, biking, etc. without symptoms, post your experience and questions in our Undoctored Inner Circle discussion forum, or join our weekly Virtual Meetups and discuss your situation for feedback. Heart scans are wonderful—until the doctor uses it against you.