A Case Study: How a Little-known Test Called a Coronary Artery Calcium (CAC) Score Saves Lives
The personal story of a patient who sought to gain a better picture of his cardiovascular health – and saved life as a result
This is a true story about one of my patients who took the advice and got a series of heart tests purely for preventive measures, which, in the end, paid off. If we’re willing to take control, go outside the conventional healthcare space, and jump into the driver’s seat, we have far more power over our health span and lifespan than many believe. This is called decentralized medicine, and it’s becoming more popular.
“I Want A Health Check-up”
One of my patients, I’ll call him JD for anonymity, approached me about health optimization as he was approaching his fifties. His story conveys the power of the above message far better than statistics or citing studies ever could. With his permission, I share it here in the hope that it serves as a reminder that each of us is our best advocate for our health, and regardless of age or fitness level, the time to take action is now.
JD wouldn’t stand out as one who might be at high cardiovascular risk. He’s in his forties, an airline pilot has normal body mass, no unusual family history, keeps a reasonably healthy diet, and participates in martial arts about four times weekly. So, after a thorough history and physical, I suggested getting some labs, an ECG, a cardiac stress test, an echocardiogram, and a CAC scan. I’ll explain each of these tests and their importance.
Blood labs can show what’s under the hood. A metabolic panel shows how the electrolytes, the liver and kidneys, and much more, are distributed. I check a plethora of labs that are often not included in a typical wellness check, including fasting insulin, APO B, lipoprotein a, hs-CRP, homocysteine, and uric acid, as well as the regular battery of tests one might get at a wellness check.
All these labs are centered around the biggest killer in today’s society: cardiac death.
This comprehensive battery of tests included:
Blood labs offer insights into the body’s internal state and metabolic profile.
An electrocardiogram (ECG) traces the heart’s electrical activity.
A Cardiac stress test gauges the heart’s response to physical stress.
An Echocardiogram is an ultrasound imaging of the heart.
Coronary Artery Calcium (CAC) scan — a CT scan that quantifies calcium buildup in coronary arteries, indicating potential plaque.
Blood Tests — were normal except for a slightly elevated LDL, lipoprotein a, and fasting insulin. The fasting insulin and glucose reveal how well one handles glucose and the associated inflammation.
Cardiac Stress test — measures the electrocardiogram (ECG) under stress called Metabolic Equivalent Table (MET). For example, when you usually walk, this is about 4 METs; when you run, it is about 8 METs. This puts everyday stress on the heart, and we can see changes or not when measured with an ECG. A treadmill stress test can indicate a heart blockage if there are changes. I helped develop an instructional video on cardiac stress tests, which can be found here.
Echocardiogram — this test is an ultrasound of the heart and carotid arteries. It shows how well the heart beats, blood moves through the valves, and much more.
CAC Scan – this is a Coronary Artery Calcium scan. A CT scanner takes a picture of the heart and the coronary arteries. It shows the amount of calcium buildup that can indicate a plaque in the coronary arteries. Note that non-calcified plaques will not be shown.
Back to JD, he was able to obtain all of these tests. It’s essential to highlight that he felt completely normal and exercised at very high-intensities several times per week. His blood tests were regular; his lipid tests were Apo B and Lipoprotein, and his LDL were slightly elevated. ECG was also normal. The exercise stress test showed a minor change in the area that the circumflex coronary artery covers but was otherwise unremarkable. Finally, the CAC scan showed a significant calcium buildup in the circumflex artery and was measured with a CAC score of about 800.
When I spoke to JD about his tests, I emphasized that the CAC score and the cardiac ECG stress test results suggest that he should see a cardiologist and get a heart angiogram, which is the gold standard for seeing blockages in the heart. He was reluctant to do this at first because he felt fine. At my request, he scheduled a consultation with a cardiologist some months later. The cardiologist agreed he should have a heart angiogram and possible stenting.
During the angiogram, a 99% blockage was discovered in a branch of the circumflex artery, and the decision was made to place a stent. JD recovered well and was taken to the recovery room. He explained that the nurses approached him and asked, “Don’t you already feel better?” He thought it a strange question. After all, he didn’t feel any better because he had no pain in his chest to start with. However, this would play out a bit later.
He was sent home, and his initial feelings were that he was unsure if it was a good decision that he received a stent. After we discussed the angiogram and his situation, I felt he made the right decision and possibly averted a major cardiac event in the long term. Indeed, he was not dealing with a 90% blockage in his left anterior descending artery (LAD), a major coronary artery long known as the “widow-maker.” But his stress test showed the same thing found on the CAC, and angiogram tests were enough evidence that he needed the stent.
It’s hard to say whether or not JD was a time bomb; in all likelihood, he had a lot left on the clock. But thanks to his initiative, he was able to change the course of his story.
Based on the information he’d gathered from these preventative tests – apolipoprotein B and lipoprotein a – neither included in typical lipid panels. A coronary artery calcium (CAC) scan raised further red flags; JD saw a cardiologist, who ordered an angiogram confirming the grim reality: severe circumflex stenosis.
After some months, JD was allowed to resume martial arts and start flying again. It wasn’t until he started working out hard again that he realized that he had indeed made the right decision. He could tell that when he reached his max heart rate while wrestling on the mat, he could give a little more. In the past, he recalled being “gassed” earlier and had slight chest discomfort. In addition, his maximum heart rate had decreased by about ten beats for the same effort. This suggests that his heart did not have to compensate for the blocked artery.
But no one suspected anything because of his young age and healthy lifestyle. Were it not for his proactive steps, his atherosclerosis – for which he has now undergone stenting surgery and is currently on a treatment regimen – may not have been discovered until it was too late. Likewise, it’s possible that he would have formed new blood vessels around the circumflex lesion, but this would have taken much time.
A Common (But Avoidable) Problem
Similar cases are familiar; unfortunately, far too many end in tragedy. Such cases are all the more painful when we realize they are largely preventable with early monitoring and intervention. Even JD is fortunate simply because he lives to tell his tale, that we met at the right time, and through a simple battery of tests that all cost less than 500 dollars cash, his condition was caught before it potentially ended his life.
Get in the Driver’s Seat
The single most important message I can communicate is that we must actively improve and preserve our health. I have often repeated that avoiding cardiovascular death – and health decline more generally – depends on acting early. Particularly in light of the limitations in current practices for screening and intervention, early action requires that we take responsibility for making decisions regarding our health, even if it means paying cash out of pocket for those tests.
JD heard these messages loud and clear, and he was thankful. I can only offer knowledge to help create a roadmap, but even the best map is only helpful if someone gets behind the wheel to start down the road.