Feb. 3, 2000

High-tech heart scan gives early warning By John Morgan

A Doctor in Your House.com programs

King of Hearts: Coronary Artery Disease with Larry King and Charles Fleischer

Holding your breath for 20-30 seconds may save your life.

That's how long it takes to complete a coronary artery scan using electron beam computed tomography (EBCT). This special scan - also known as the ultra-fast CT scan - is so fast that image clarity and resolution are unaffected by the motion of the beating heart. By identifying calcium build-up in the heart, EBCT offers cardiologists a relatively low cost, completely non-invasive method for determining a patient's coronary heart disease risk.

Without even having to remove your clothes, you lie on a table and two EKG monitors are attached to your wrists with Velcro straps. You hold your breath, and just that fast you're done.

A few minutes later you and a board-certified cardiologist are reviewing 30 cross-sectional scans of your heart. If calcium is present, it shows up on the screen as bright white specks. The computer measures the size and density of each speck, assigning a numerical value. Your total score, derived by adding up the numbers from all deposits, indicates your risk for heart disease.

"Essentially, EBCT identifies calcium build-up or a plumbing problem in your heart," explains Dr. Matthew J. Budoff, director of electron beam tomography at Harbor-UCLA Medical Center.

Studies show that EBCT is extremely reliable at identifying the presence of calcium in coronary arteries, and that the presence of calcium is highly predictive of atherosclerosis or plaque. We know that as plaque increases, the risk for blockages and heart attacks also increases. And since the detection of calcified plaque represents about 20% of the total plaque volume, EBCT is an excellent screening test for early coronary disease.

Approximately 13% of patients tested have a zero score - no plaque whatsoever or only a 1-2% chance of having heart disease.

• A score of 1-10 indicates minimal plaque burden
• A score of 11-100 indicates mild plaque burden
• A score of 101-400 indicates moderate plaque burden
• A score of over 400 indicates extensive plaque burden

Scores are then evaluated based on one's age and sex. For example, a score of 50 in a 60 year-old is not as serious as the same score in a 40 year-old because the presence of calcium tends to increase with age. This determination is then factored into the patient's overall medical history before treatment recommendations are made - such as aspirin therapy, dietary changes, smoking cessation, weight loss, exercise, and cholesterol-lowering drugs.

While scores over 400 correlate with coronary artery obstruction, additional diagnostics like thallium stress tests or angiography are recommended to determine conclusively if there are actual blockages or obstructions.

ABC's 20/20 recently reported that studies show soft or vulnerable plaques are more likely to rupture and cause heart attacks than the hardened plaques that show up on most tests. But the only way to determine which are vulnerable plaques is an intravascular ultrasound that is extremely expensive and highly invasive. "You can't give these ultrasounds to everybody, and they're not without risk," explains Dr. William J. French, director of cardiology at Harbor-UCLA Medical Center.

French believes there may be characteristics of the soft plaques that EBCT will be able to identify inexpensively and non-invasively. Further, when EBCT identifies calcified plaque, cardiologists know there is also a significant amount of soft plaque. Prescribing cholesterol control drugs known as statins can help reduce and even reverse plaque build-up.

Change versus status quo

EBCT represents a major change in fighting coronary heart disease. Previously treatment of heart disease was only possible after symptoms manifested themselves. By then patients were in the end stage of the disease. With EBCT, people can be diagnosed in the earliest stages of heart disease when it can be most effectively and inexpensively treated.

While EBCT has been available to the general public since 1992, the test is only recently gaining favor among cardiologists. The American Heart Association (AHA) and the American College of Cardiology (ACC) are currently authoring a new position paper regarding EBCT, but sources indicate that the report will be neutral in its recommendation. This reflects a divergence of opinion among heart specialists regarding the test's usefulness.

"I think the test is over-hyped," says Dr. David Cannom, president of the California Chapter of the ACC and director of cardiology at the Hospital of the Good Samaritan in Los Angeles. "An experienced cardiologist knows how to identify risk factors without needing a $400 (EBCT) exam."

But ACC president-elect, Dr. Michael R. Nagel, fellow of the American College of Cardiology, believes the test is a very useful tool. "I recommend it. Patients are much more adherent to therapy when they've actually seen the plaque growing in their arteries."

Seeing is believing

Recent studies support Nagel's point of view. Traditionally only 40% of patients comply with cholesterol-lowering therapy mandated by their physician. But those who actually see the evidence of calcium in their heart via the EBCT are 90% compliant with their doctor's recommendations. "The experience is very profound," says Budoff.

Evidence also suggests that a significant number of people who present no apparent risk factors as a result of conventional diagnostic methods may actually be at risk. While Cannom calls this group "a few exceptions," data indicates that 30% of first-time heart attacks occur in people who exhibit no warning signs. "A heart attack is a hell of a way to find out you have heart disease," says Bruce Friedman, whose company Heart Check America markets the test in several locations across the country.

"We've seen people with cholesterol of 160 and no risk factors with massive calcium build-up," adds Budoff. "We've also seen people with high cholesterol with no calcium. Those two types of patients get better therapy precisely because of this test."

Another advantage of the test is it allows cardiologists to track the progression and efficacy of their prescribed therapy. Just getting the cholesterol to go down does not necessarily mean you're treating the heart disease effectively.

Budoff cites several examples of patients who lowered their cholesterol from the upper 200's to below 150 but continued to build significant calcium. "We knew we needed to look further because just using statins was not working," says Budoff. "Without EBCT thes guys think they're out of danger and could end up in serious trouble."

Cost versus benefit

The debate now seems to be centering less on the test's efficacy and more on the cost-benefit merits. Jay Garacochea, a Heart Check America patient got the test without his doctor knowing it. "When I showed him my score he immediately put me on a cholesterol-lowering drug. I asked him why he didn't tell me to get the test, and he said it was because it wasn't covered by insurance."

Medicare and nearly all private health insurance does not cover EBCT screening.

With healthcare dollars shrinking, doctors are increasingly becoming guardians of patient's (and insurers) pocketbooks. It's not something anyone likes to talk about openly. "I don't have the sense this test is being covered," says Laura Diamond, a spokesperson for the American Association of Health Plans (AAHP) that represents over 1000 HMOs, PPOs and network-based plans which cover nearly 140 million Americans.

Take HealthNet as an example. "As a policy, HealthNet considers the procedure experimental but delegates the coverage decision to its medical groups," explained HealthNet spokesperson Lisa Haines. This essentially translates to a non-recommendation from one of the nation's largest health insurers, in spite of the fact that hundreds of thousands of Americans have been tested in the past eight years, hardly an "experimental" sample.

"The test is an incredible tool. The problem is really that it works too well," explains Dr. Hossein Alimadadian, an ACC Board Member and former director of cardiology at Western Medical Center in Santa Ana, Calif. "There are nearly 100 million people with high cholesterol. Some already have significant heart disease and don't know it."

Of course, the prospect of funding the screening and subsequent treatment for 100 million people will overload an insurer's calculator in a hurry.

"I don't think insurers should pay for everyone to get screened," says Friedman. "But I also don't think the test should be slandered. Unless you have known risk factors that indicate to the contrary, we do not recommend this test for people under 35, over 75 or for previous heart attack patients."

People over 75 are not good candidates because at this age nearly everyone has calcified plaque and many are not good risks for invasive procedures. Previous heart attack patients already have specifically known coronary heart disease and should be under a cardiologists care.

Ironically, the cost of the test could be significantly lowered if the healthcare system uniformly embraced the procedure. "I'd love to lower the cost," says Friedman, who estimates the screening price could eventually be reduced to $250 if direct-to-consumer marketing costs could be eliminated. "The reality is because insurance doesn't pay for the test, doctors are hesitant to recommend it to patients, so we have to advertise to generate our own referrals." Nearly 25% of the fee goes to advertising.

Some doctors are offended by this direct-to-consumer marketing. But as one Heart Check America patient said, "They (doctors) are offended. I'm alive."

For more information about EBCT, contact Heart Check America at 1-800-NEW TEST or http://www.heartcheckamerica.com/.

ⓒ Copyright 2000 USA TODAY, a division of Gannett Co. Inc.