Calcium Scoring Tests - Anecdotes

The plural of anecdote is data.
- R. Wolfinger

A number of studies have addressed the usefulness of Calcium Scoring Tests. Researchers evaluate risk ratios, cost-benefit analyses, and even the risk of cancers caused by one or two Calcium Scoring Tests over a lifetime (a reasonable guesstimate is 0.1% more cancers than occur now - an unmeasurable effect - and comparable to the cancer risk from having regular mammograms).

In some ways, to evaluate the usefulness of Calcium Scoring Tests it's more valuable to look at individual results, evaluated rather than just analyzed by statistics, to see whether Calcium Scoring Tests have benefited individuals. That is, a good study would be to interview 100 people 50 years of age or older who have had Calcium Scoring Tests, and see to what extent the results of the test have changed their medical treatment and/or their lifestyles.

I don't have access to 100 such people to interview. However, a number of people I know about have had calcium scoring tests. Below are the results. I've changed ages slightly (a year or two higher or lower), etc. to make sure people can't be identified.

The net result for the eight anecdotal cases below:
For only one of the cases was the CACS (Coronary Artery Calcium Score) measurement essentially a waste of time and money (Anecdote 5 - the patient actually was me!). In the other six cases, the CACS measurement was - or should have been - an important factor in treatment decisions: medication changes, lifestyle changes, and/or additional testing.

Anecdote 1.
A 48-year-old African-American man ("Barry") is a smoker, but is reasonably thin and otherwise physically fit. His CACS was measured the result was CACS=0 (zero). This case was in the news, with much discussion about his increased risk of cancer from the test, the lack of usefulness of the test for a man his age, etc. In my opinion, since he was a smoker and African-American - both considered risk factors for heart disease, having a Calcium Scoring Test at his age was a very reasonable decision, especially in view of the importance and stress of his job. As you may have guessed, Barry is President Barack Obama.

Anecdote2.
Tim Russert, the anchor of the NBC program Meet the Press and the Washington, D.C. bureau chief for NBC. His CACS was measured at age 48 and was found to be 210. According to his physician, his heart condition was "well controlled by medication [presumably statins] and exercise." The physician said this shortly after Russert died of a massive heart attack nine years later. See that portion of the blog below for details. Hint: his heart attack was predictable; it's somewhat surprising he hadn't had one earlier.

Anecdote 3.
A 60-year-old man ("Adam") had his CACS measured, and a value of 250 was found. Adam's physician decided that additional testing was in order. After additional tests, Adam had a bypass operation and is now in good health. There were no symptoms, other than moderate high blood pressure, before the CACS test was done.

Anecdote 4.
A 64-year-old woman ("Jane") was newly diagnosed with Type 1 diabetes. [Note: it is extremely rare for someone this old to develop Type 1 diabetes - Type 1 diabetes is generally called "juvenile-onset diabetes" for a good reason. However, antibody tests confirmed the Type 1 diagnosis.] Jane's's physicians immediately said that her diabetes was a risk factor equivalent to having already had a heart attack. [Note: this is medical dogma, but really isn't true for a newly-diagnosed diabetic; the damage from diabetes builds up over a relatively long time.]

Jane's physicians said she needed to take statins. Jane could not tolerate statins: muscle weakness and pain, bleeding around insulin injection sites, and erratic blood sugars. Jane had a calcium scoring test, and the result was CACS=11. Jane's physicians decided to have her take a Cardiolite test as well, and no problems were found. Jane currently does not take statins. [Note: Jane is well aware that a low CACS does not guarantee she will never have a heart condition, but a low CACS does mean that she can consider the risks versus benefits of statin therapy in low-risk patients. The long-term risks of statins are a subject for another day.]

Anecdote 5.
A 64-year-old man ("Bill") with no symptoms, normal blood pressure, and no significant risk factors had his CACS measured, and the result was CACS=25. This is the sort of "worried well" case for which the usefulness of the CACS can be questioned. On the other hand, the only downsides to the test were its cost of $200 and - possibly - a 0.01% risk of cancer as a result of the radiation from the test (one chance in 10,000 as a result of the test compared with the population risk of 1 chance in 5) .

Anecdote 6.
A 67-year-old woman ("Betsy") whose mother died of a heart attack in the mother's early 60s (the mother was a smoker). Betsy has Type 2 diabetes, and high cholesterol. Betsy has been strongly urged by her physicians to take statins. Betsy finds statins difficult to tolerate because of a variety of side effects. Betsy had her CACS measured with the result CACS=0 (zero). Betsy currently does not take statins.

Anecdote 7.
A 64-year-old man ("John") whose father had a non-fatal heart attack when the father was in his mid 50s. John's brother had a mild heart attack when the brother was 59. John is a former smoker, but for the last 30 years has been very physically active (running, golf, etc.). John has previously been treated an for irregular heartbeat (I don't know the details). John had his CACS measured, with the result CACS=500. John's cardiologist has not ordered additional testing, but has prescribed statins. Whether the cardiologist is correct, or if more extensive testing should be done (e.g., Cardiolite) remains to be seen. We hope the cardiologist is right.

Anecdote 8.
A 71-year old man ("Mark") whose father died of a massive heart attack when the father was in his mid 40s (the father was a smoker). Mark is probably the most physically fit person I know. Mark's blood pressure is low. Mark's CACS was measured, with the result CACS=450, and with the calcified plaque concentration in the left anterior descending artery (the "widowmaker artery"). Mark's cardiologist ordered additional testing, and no other anomalies were found. Although there was a lot of calcification, the blood flow was unobstructed. Mark has improved his already-healthy diet to minimize consumption of red meat and other fats, with a strong emphasis on fish and vegetables. Mark continues to run regularly, and to engage in other physical activity that would tire an ordinary 30-year-old. Mark sees his cardiologist regularly.

A reasonable hypothesis is that if Mark had the same lifestyle as his father, he would have had a heart attack a long time ago. There is clearly a genetic predisposition for plaque deposit in dangerous areas.

More to come.