What Your Coronary Artery Calcium Score Means
What Your Coronary Artery Calcium Score Means
After graduating from a Caribbean medical school, finishing my internal medicine residency, and my cardiology fellowship I will be starting my day in the life as a non-invasive cardiologist shortly. Follow along for medical education content covering cholesterol management, echocardiography, invasive cardiology procedures, and much more.
In this video I review the basics of cholesterol management, atherosclerosis, and how it relates to coronary artery calcium scores. Coronary artery calcium scores (CACS) help cardiologists better risk stratify their patients. It can help doctors make more informed decisions with their patients on cholesterol lowering therapy like statin medications and evaluate a patient’s risk of future ASCVD (atherosclerotic cardiovascular disease), or their future risk of heart attack or stroke. I review the pathophysiology of atherosclerosis, the basics of our ASCVD risk calculator, images of a few coronary artery calcium scores (CACS), explain in detail how that information can change our medical management, who does and does not benefit from this imaging study, and how much the test costs (typically ~$100 out of pocket.
*This video is purely for educational purposes and is not meant to replace medical care. So if you have follow up questions about this video drop them in the comments but I cannot provide personalized medical advise.
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Content
0 -> My name is Dr. Katz. I'm a non-invasive
cardiologist and today I'm going to be
3.6 -> talking about coronary artery calcium scores in
order to better understand what that is we're
8.04 -> going to first delve into the pathophysiology of
atherosclerosis or the narrowing of the arteries
12.36 -> of the body as well as the thought process
behind clinicians management of cholesterol
16.62 -> lowering medications as well as coronary artery
calcium scores at the most basic level a coronary
21.18 -> artery calcium score is a CT scan of the chest
that specifically looks at the arteries of the
26.82 -> heart and specifically the degree of calcification
the basics of the test involves going into a CT
31.68 -> scanner or computerized tomography scanner we gate
that image or We sync it up with the patient's EKG
38.22 -> so when we take multiple slices of images of the
heart we can sync them up to make that moving
44.28 -> image look 2D or two-dimensional a computerized
system counts up how much calcium based on the
50.82 -> pixel count a patient's arteries have and gives
us a total score as well as individual scores for
55.92 -> each coronary artery or the arteries that supply
the heart itself but why is that important it's a
60.72 -> surrogate marker of atherosclerosis and future
risk of heart attack stroke death the process
66.36 -> of atherosclerosis involves the gradual deposition
of cholesterol fat and calcium within the coronary
73.56 -> arteries and the rest of your arteries of your
body this is a chronic inflammatory condition
77.4 -> that everyone has let's take a look at this
animation to better understand here we're
81.54 -> showing a cross section of the coronary arteries
in the muscular layer of the artery itself and the
86.52 -> underlying endothelial layer so here in this
endothelial layer inflammation occurs which
91.68 -> causes your immune system to respond and try
to heal it that causes a fatty streak to occur
97.56 -> and eventually it causes this deposition of white
blood cells red blood cells and lipid Rich LDL and
103.98 -> it causes a lipid core to form that lipid-rich
core over time becomes more and more calcified
110.34 -> and that's what we're looking at in a coronary
artery calcium score this is a very important
115.08 -> part to understand because just because you don't
see calcification on your skin and doesn't mean
121.02 -> you don't have atherosclerosis it's simply that
we cannot visualize this lipid-rich plaque that
126.6 -> is yet to calcify these are pictures of the raw
scanning images that we actually see on the left
132.06 -> a coronary calcium score of zero on the right a
score of 29. here we see much more significant
138.12 -> coronary calcium scores on the left 250 and
on the right 1200. everyone has some degree
144.24 -> of atherosclerosis and we know that patients who
have higher cholesterol levels are prone to higher
149.22 -> degrees of atherosclerosis which puts them at
a greater risk of heart attack stroke or death
154.02 -> those clinical conditions that are repercussions
of atherosclerosis we kind of group together
159.18 -> and call them atherosclerotic cardiovascular
disease or ASCVD now the reason that I bring
164.34 -> up atherosclerotic cardiovascular disease as
well as cholesterol levels is that you have to
168.78 -> understand why we're going to be performing this
study in the first place it's not for everyone
173.4 -> and just like any test you have to understand
what you're going to do with the results and
177.54 -> what it means for your patients or you a corner
our artery calcium score is going to better risk
182.1 -> stratify our patients to better decrease those
risks it's all about the card you're dealt and
186.96 -> how you play them the genetics that you're born
with and the predisposition that you may have to
191.1 -> developing these issues and some modifiable risk
factors like your cholesterol level just because
195.96 -> you have high cholesterol levels doesn't mean you
will have a heart attack and just because you have
199.86 -> low cholesterol levels doesn't mean you won't
but we know that if we could clone one person
203.88 -> and give one of them high cholesterol levels
that individual is going to have a higher risk
208.08 -> of future heart attack stroke death I think of
coronary calcification kind of as the end result
213.3 -> of atherosclerosis the presence of calcium in
your coronary arteries means that you already
217.86 -> have some atherosclerosis that has developed
over many decades and has hardened into calcium
223.32 -> so let's take a look at how doctors manage
cholesterol levels the first thing that every
227.94 -> society guideline says is lifestyle modifications
obviously healthy diet low in red meat high in
233.34 -> green leafy vegetables low in trans fats low in
fried foods and low in processed foods as well as
239.16 -> diets that help prevent event the development of
diabetes those are generally heart healthy there's
243.18 -> no magic cure or magic nutritional supplement or
Diet that's going to prevent heart disease but
248.64 -> we've noticed certain Trends and certain foods
that can decrease your risk of increasing your
253.68 -> cholesterol levels and developing atherosclerosis
things like a Mediterranean diet or a vegan diet
258.66 -> now I know that if my doctor said you have to go
on a vegan diet I would either just lie to them
263.82 -> or find another doctor so it's not that you have
to go to those extremes but it's that everyday
268.62 -> Improvement in trying to do better than you were
yesterday because just like atherosclerosis your
274.38 -> diet can impact you over many many decades over
the years a very unhealthy diet for one weekend
280.2 -> ain't going to kill you but doing that same
unhealthy diet for 10 20 30 years is going
285.06 -> to put you at a higher risk of heart attack death
stroke so the first thing every doctor is going to
288.6 -> recommend is a healthy diet healthy lifestyle not
smoking exercising regularly and generally just
295.26 -> being healthy but if it was that easy doctors
would be happily out of a job back in the day
299.7 -> we used to have absolute cutoffs of where we would
want your cholesterol levels to be nowadays we try
304.68 -> to look at who the patient is in totality and
calculate their ASCVD 10-year risk calculator
309.78 -> what that means is what's their 10-year risk of
things like heart attack stroke death now if we
314.64 -> look at the ASCVD risk calculator you can look
it up online yourself and it takes into account
318.66 -> a lot of risk factors things like your current
age your systolic and diastolic blood pressure
322.8 -> your total cholesterol levels and HDL levels
if you're a current smoker or former if you're
327.72 -> being treated for hypertension and if you have
a history of diabetes as well as your sex being
331.98 -> male or female as well as your race being white or
African-American now those are the only two races
337.62 -> that this calculator has and it would take me a
whole other video to go into the details of why
341.82 -> I think that's a little iffy when we're looking
at a diverse patient population and trying to use
346.44 -> statistics that are made for certain populations
that were studied and extrapolating but that is
351 -> the Crux of this video and that is the importance
of coronary artery calcium score because these are
355.62 -> the only risks that this calculator takes into
account and that's where our coronary calcium
361.02 -> score can really come in handy so if this risk
calculator has you at a moderate or intermediate
366.6 -> risk a coronary artery calcium score can push
your risk lower or potentially higher generally
372.78 -> patients who do not qualify for a coronary artery
calcium score are ones that really should already
377.94 -> be on a Statin or other lipid lowering medications
those are things like patients who have already
382.62 -> had heart attacks or Strokes patients who
have a greater than 20 percent 10-year risk
387.72 -> of atherosclerotic cardiovascular disease or
patients who have familial inherited disorders
392.4 -> of lipid metabolism so now what you probably are
watching this video for what does your actual
397.74 -> coronary artery calcium score mean the best score
is zero and the reason for that is that if you
403.92 -> have a coronary calcium score of zero you likely
do not require medications to further lower your
410.94 -> cholesterol levels so again a coronary calcium
score of zero great you still can have underlying
416.4 -> atherosclerosis that is yet to harden and calcify
but it means that at least right now you haven't
422.28 -> had it for many years and hasn't gotten to that
point let's talk about patients who have a calcium
426.54 -> score of one to ten any calcium score that is not
zero I consider abnormal but you again have to
433.32 -> look at that in the clinical context if someone
is 75 years old I anticipate that their calcium
438 -> score will likely not be zero but if you're a
40 year old who's relatively young and has a
443.04 -> calcium score of somewhere between 1 and 10 that
means that you do already have some evidence of
449.04 -> coronary artery disease of atherosclerosis that's
hardened to calcium it means that you have minimal
454.2 -> coronary artery disease but it's there and it's
already progressing so those patients can always
458.82 -> consider cholesterol lowering medications after
a conversation with their physician and they
463.32 -> really have to focus on lowering their overall
cardiovascular disease risk by modifying the
468.12 -> things that are in our control again healthy diet
exercise not smoking now patients often will see
473.64 -> attached to their coronary artery calcium score
a report that shows a percentile what their score
479.52 -> is compared to other people that have been studied
in their age group now again a patient who has a
485.16 -> calcium score of let's say eight who's 41 years
old might be an 85th or 90th percentile compared
491.82 -> to other individuals that are their age again that
doesn't mean that you're gonna have a heart attack
496.74 -> in fact one to ten typically means minimal
coronary disease and you're unlikely to have
501.9 -> a heart attack you still can but patients often
get concerned when they see that percentile score
506.7 -> it simply means again that any calcification is
abnormal and compared to other people their age
512.76 -> they have a higher coronary calcium score than
if their percentile is 90 then 90 percent of
518.16 -> other individuals their age if you have a calcium
score of 11 to 100 that means you have some mild
523.62 -> coronary disease it means that that calcification
is there it's not just going on in the background
528.48 -> but it is actively progressing and I bet you
know what I'm going to say you need to have a
532.38 -> conversation with your physician and talk about
risk factors and consider cholesterol lowering
536.88 -> medications let's say you're at 101 to 400
that's moderate coronary artery disease and those
543.06 -> patients should certainly consider cholesterol
lowering medications along with healthy lifestyle
547.32 -> and diet modifications on the other side of things
a score greater than 400 is severely abnormal and
553.14 -> some of these patients even if you're asymptomatic
without limiting chest pain shortness of breath
558.3 -> your doctor after a further conversation with you
might still order another test like a stress test
564 -> to see if those large areas of calcification are
actually flow limiting or decreasing the amount
569.52 -> of blood that gets through that artery that
information we can't see on a pure coronary
574.14 -> artery calcium score we're just looking at the
calcium so we are unable to see what's the blood
579.66 -> flow in the arteries of the heart look like a
coronary calcium score of greater than 400 is
584.4 -> quite abnormal but it doesn't go right up to 400
you can have up to thousands I've seen patients
589.98 -> with coronary calcium scores of 1500 and way
higher earlier I mentioned that not everyone
594.84 -> should be getting this test and the reason for
that is that it was studied in specific patient
598.98 -> population you always have to know what am I
going to do with this test when I get the results
603.36 -> a coronary artery calcium score was studied
in patients 40 to 75 years old the reason for
609 -> that is when people are younger than 40 they very
rarely have development of coronary calcification
614.7 -> and a score of zero should be interpreted with
caution because it doesn't mean that they can't
619.5 -> develop atherosclerosis it's just that maybe they
haven't been old enough and it hasn't been there
624.06 -> long enough for it to develop so it's really
not recommended in patients younger than 40 but
629.16 -> it certainly can be ordered after a conversation
with your physician especially in those patients
633.36 -> who have premature coronary disease or other high
risk factors and overall coronary artery calcium
638.28 -> score helps us modify our treatment plan in that
same train of thought patients who are already on
643.56 -> a Statin medication where it's not going to be
changing our management it is not recommended
647.64 -> that you get a coronary calcium score so who does
benefit from a coronary artery calcium score now
653.04 -> in this video I've spoken at length about people's
risk of having heart attack stroke death because
658.02 -> atherosclerosis increases your chance at that
and that is what we're looking for in a coronary
662.88 -> artery calcium score but how do doctors actually
quantify a patient's risk of heart attack stroke
668.04 -> or death we use something called an ASCVD risk
calculator it calculates a patient's risk of
672.6 -> atherosclerotic cardiovascular disease it takes
into account a number of factors like a patient's
678.36 -> age diabetes if they're a smoker their total
cholesterol their HDL levels their systolic blood
684.3 -> pressure if they're being treated for hypertension
as well as their race only two that are Quantified
688.68 -> here on this calculator is unfortunately white
African-American or other and I'll get into that
693.78 -> in a minute but after you put in all of those
factors it spits out a percentage of what your
699.06 -> 10-year risk of ASCVD is or your 10-year risk
of atherosclerotic cardiovascular disease that's
705.42 -> where we're able to see are you relatively low
risk intermediate risk or high risk patients who
710.82 -> have a risk of greater than 20 percent should
be on a Statin medication patients who are
715.2 -> low risk are less than five percent and those
patients it is not recommended that they're on
719.76 -> this risk calculator just like coronary artery
calcium score was really studied in patients 40
725.52 -> to 75 years of age and there are other caveats
that I mentioned earlier in this video that also
730.02 -> apply to this risk calculator it doesn't
really work well for patients less than 40
733.38 -> years of age or patients greater than 75 years
of age and that's where that conversation with
737.94 -> your physician really comes in now take a look
at the central illustration from an American
741.24 -> College of Cardiology review article on coronary
artery calcium scores it gives you a good example
746.34 -> on the top row a patient's 10-year ASCVD risk
that's their risk calculator that we use and
752.34 -> it shows you those four levels that we talked
about less than five percent low risk greater
756.9 -> than 20 high risk those ones are the easier ones
statins not recommended for less than five percent
761.58 -> greater than 20 you should be on one and similarly
neither of those populations have use for coronary
767.82 -> calcium score because it really is not going to
be changing our management again can still have
772.08 -> it done if you talk to your physician but based
on these guidelines it's really not recommended
776.28 -> like many tests that we use in cardiovascular
disease it's the p people that are in the middle
780.72 -> that most benefit from a coronary calcium score
so let's take a look at that second call five to
785.34 -> seven and a half percent if we're just talking
to our patients alone with just that piece of
789.6 -> information we can convince ourselves one way
or the other do we want to be on it if a patient
794.64 -> tells me they want to do everything they can to
decrease their risk of ASCVD then we can start a
799.14 -> Statin and we don't need to do a coronary calcium
score conversely if a patient says you know doc
803.46 -> I'm fine taking medications but I don't want
to if I don't need to that's an ideal patient
807.54 -> to then get a coronary calcium score to either
increase their risk profile and reclassify them
814.38 -> as higher risk or lower their risk and say you
know what even though this risk calculator said
820.02 -> you're in that intermediate range based on your
calcium score you're actually lower risk because
824.7 -> no risk calculator is perfect similarly in that
third category that is greater than seven and a
829.68 -> half to twenty percent we really should recommend
a Statin those patients those patients we can also
834.48 -> get a coronary calcium score and if they have a
calcium score of the zero you've heard it already
838.62 -> they do not need to be on the Statin conversely
if it's anything else they really should be so
843.9 -> ultimately what I try to help people understand
with coronary calcium scores is that it's going
848.82 -> to help us reclassify patients as higher risk or
lower risk based on more physiologic information
855.18 -> doctors aren't perfect and we look at all the
data that we can this gives us more information
859.98 -> to better treat the person in front of us one
last point that I'll make about the ASCVD risk
864.66 -> calculator and about patients who might think
about getting a coronary calcium score these
868.92 -> are patients who have risk factors that aren't
taken into account in the ASCVD risk calculator
873.48 -> that might prompt me and my patient to pursue a
coronary calcium score these include patients with
878.64 -> familial hypercholesterolemia chronic inflammatory
conditions like CKD or chronic kidney disease
884.22 -> rheumatoid arthritis SLE or lupus premature family
history of atherosclerotic cardiovascular disease
890.46 -> that's first degree relatives parents or siblings
who have had heart attacks or Strokes people with
895.56 -> metabolic syndrome women who have had pregnancy
related cardiovascular complications like
900.48 -> preeclampsia lipid biomarkers these are blood
tests that kind of like a coronary or calcium
905.88 -> score might help push a patient into a higher or
lower risk category although I still think the
910.14 -> coronary calcium score is superior to these but
it's still more useful information these include
914.76 -> elevated High sensitivity CRP or C-reactive
protein elevated lipoprotein a levels elevated
920.64 -> APO B levels or evidence of peripheral vascular
disease like an abnormal ankle brachial index
926.22 -> as well as individuals of South Asian descent
we know these individuals have a higher risk
930.24 -> of atherosclerotic cardiovascular disease and
those individuals risk can be underestimated
934.8 -> in the Contemporary ASCVD risk calculator one
more thing I want to talk about in this video
938.88 -> is the cost of the test at the time of filming
this video in July of 2022 for some reason it
944.16 -> is not covered by Insurance patients have to
pay for it out of pocket it typically costs
948.9 -> typically a hundred dollars don't quote me on
it because Healthcare in the United States is
953.82 -> weird but you should know that this test is not
going to be covered by insurance and it's going to
958.56 -> be an out-of-pocket expense so if you or a loved
one is getting coronary calcium score and you're a
963.06 -> little bit confused send in this video hopefully
it'll help them understand it before their next
967.38 -> appointment with their physician now I know that
was a lot of information but I like to provide the
971.52 -> full train of thought of what doctors are thinking
when we're ordering tests specifically a coronary
976.08 -> calcium score and the repercussions of what
we're going to do with that information if you
979.86 -> found this video helpful I'm happy to answer any
questions or concerns in the comments I cannot and
984.84 -> will not comment on your specific conditions but I
can answer general questions about cardiovascular
990 -> health and if you want to see a new video about a
different topic concerning cardiovascular disease
994.38 -> drop it down in the comments and I'll add it
on to the to-do list and follow, like, share
Source: https://www.youtube.com/watch?v=ckvRgUDILPQ