Coronary Calcium Scoring: Hidden Dangers for High-Risk and Symptomatic Patients
Coronary Calcium Scoring: Hidden Dangers for High-Risk and Symptomatic Patients
In this video, we delve into the limitations of coronary calcium scoring as a diagnostic tool for patients at high risk of coronary artery disease (CAD) and those exhibiting symptoms. While coronary calcium scoring has gained popularity as a non-invasive method to assess heart disease risk, it may not always provide accurate results for specific patient populations.
We begin by describing how the risk of heart disease is calculated and explore the causes of chest pain in coronary artery disease. Then, we take a deep dive into the limitations of this method, highlighting the potential inaccuracies and inconsistencies in its results, particularly for high-risk CAD patients and those experiencing symptoms.
Key discussion points in the video include:
Briefly explain coronary calcium scoring: Understanding how it works and its role in evaluating heart disease risk.
The limitations of coronary calcium scoring: Exploring its shortcomings in detecting soft plaques, the possibility of false negatives, and the lack of specificity in determining actual disease severity.
High-risk CAD patients: Examining why coronary calcium scoring may not be recommended for individuals with a strong family history of CAD, existing risk factors, or those already diagnosed with the disease.
Symptomatic patients: Discussing the pitfalls of relying on coronary calcium scoring for individuals exhibiting symptoms of CAD, such as chest pain, shortness of breath, or extreme fatigue.
Finally, we present a real-life case that shows why coronary calcium score should not be ordered in high-risk and symptomatic individuals such as those having chest pain. This comprehensive video aims to educate and inform viewers about the limitations of coronary calcium scoring in specific patient populations, empowering them to make better decisions for their heart health. Don’t forget to like, comment, and subscribe for more insightful content on heart health.
Content
0.66 -> Hello everyone, and welcome to this video
on coronary calcium scoring limitations.
5.58 -> Over the past 10-15 years, the coronary
calcium score has become a widely used
11.4 -> test to assess someone's risk of a future heart
attack. However, it is extremely important to
19.14 -> understand this test's limitations, which, if
ignored, could lead to serious consequences.
26.16 -> In this short presentation, I'll highlight two
key factors to consider when it comes to calcium
31.8 -> scoring and to emphasize the importance of these
limitations, I'll wrap up with one of my cases
37.86 -> from a few months ago. So, let's start. In this
presentation, I will talk about two groups in
44.82 -> whom we don’t recommend calcium scoring. First,
patients who have already been classified as
51.66 -> “high-risk” for heart attack and second, patients
who present with symptoms, such as chest pain.
60 -> But, in order to understand the reasoning behind
these recommendations, it is crucial that we first
66.54 -> learn how risk is calculated and how patients are
categorized as 'high-risk' in the first place.
74.64 -> And to explain why calcium scoring is
not recommended for symptomatic patients,
80.16 -> like someone who presents with chest pain, we
first have to know what the cause of symptoms are.
89.58 -> Before answering those questions, let’s have
a one-slide refresher about calcium score. Ca
96.42 -> score is a non-invasive CT scan that measures the
amount of calcified plaque in coronary arteries.
105.72 -> It gives us an idea of a patient's future risk
of heart disease. It is important to understand
113.88 -> that calcium scoring does not directly detect
plaques— it only detects the calcium inside them.
123.42 -> This means that a large plaque without any
calcium can go undetected by this test.
130.02 -> By the way, plaques are fatty deposits in the
arterial wall that accumulate over years and
136.2 -> are the main drivers of the heart attacks
and strokes. For example, here, we have a
142.26 -> cross-section of a coronary artery with a large
plaque blocking over 50% of the lumen. This is
149.4 -> a very concerning and significant finding that
raises the risk of future heart attack enormously.
156.42 -> Now, the general idea is that calcium usually
deposits within these plaques over time,
163.08 -> making them detectable, basically putting them on
the radar. But in some cases, like a young patient
172.26 -> with familial hypercholesterolemia, large plaques
may be present without calcium deposits. In these
181.14 -> situations, CT calcium scoring can easily
miss these plaques. So, CT calcium scoring
188.4 -> detects plaques only and only if they contain
calcium deposits; otherwise, it misses them.
197.88 -> The other point in this slide is that the
primary goal of this test is to assess the
203.58 -> future RISK of heart disease— Ca scoring is
all about RISK assessment and NOT diagnosis.
213.96 -> After this brief overview, let's
get back to the two questions and
218.22 -> see how someone is categorized
as high risk for a heart attack.
225.12 -> To calculate someone's risk of future heart
disease, we consider various factors such as age,
231.84 -> gender, cholesterol levels, blood pressure,
smoking status, and history of diabetes or
237.9 -> heart disease. We enter these factors into a risk
calculator, which then estimates the likelihood of
246.66 -> that person having a heart attack or stroke within
the next 10 years. To access this calculator,
254.34 -> search for 'ASCVD risk estimator plus.'
But before using this risk estimator,
262.68 -> it's essential to remember that this calculator
should only be used for ‘PRIMARY PREVENTION.'
272.4 -> This simply means that if you have had a
heart attack, stent, or bypass surgery in
280.2 -> the past or if you are known to have coronary
artery disease based on previous imaging,
286.5 -> then you are HIGH-RISK, and further risk
calculation or calcium scoring is unnecessary.
296.16 -> And this is a close-up of the calculator. We
can see various required fields like age, sex,
303.06 -> blood pressure, cholesterol level, diabetes,
smoking status and so on. Assuming you have
309.42 -> had no prior heart disease, this calculator
provides a 10-year heart attack risk estimate.
318.78 -> Now, if your risk is over 20%, you're considered
high-risk, which means you need intensive medical
326.88 -> therapy, smoking cessation, and significant
lifestyle changes to reduce your risk.
333.42 -> In this case, a calcium score won’t
help. Even if your score is zero,
338.58 -> you still need therapy—you can't ignore
diabetes or hypertension and continue to
343.44 -> smoke just because of a low calcium score.
On the other hand, If your score is high,
349.14 -> it also doesn't change anything; you still
need therapy and risk-factor management.
356.76 -> If you are in the intermediate category, a calcium
score can be useful in nudging you towards either
364.74 -> the low or high-risk group. This helps determine
the intensity of your therapy. For example,
371.64 -> if your cholesterol is mildly elevated and
you're in the intermediate category, a calcium
378.78 -> score of zero can be reassuring. It gives you
time to make lifestyle changes and reassess
385.38 -> the situation without medications if you prefer.
But if your score is high, it pushes you towards
394.38 -> the high-risk category, emphasizing the need for
intensive medical therapy and lifestyle changes.
401.46 -> Even for those in the low-risk group, a calcium
score can be helpful. We should know that
408.54 -> some important risk factors, like a strong
family history of heart disease, high Lp(a),
415.92 -> or the presence of inflammatory diseases like
rheumatoid arthritis, that are known to increase
421.98 -> the risk of a heart attack are not yet included in
risk calculators. Imagine you're a 50-year-old man
430.8 -> with a strong family history of heart disease, but
you don't smoke, and you don’t have hypertension,
436.2 -> diabetes, or a very high cholesterol. In this
case, you might be classified as 'low-risk.’
444.6 -> Now, if you do a calcium score and it
comes back as significantly elevated,
450.42 -> you are not low-risk anymore. Hopefully,
we can now understand why we don’t need
456.36 -> a calcium score test in people with
high-risk of coronary artery disease.
463.26 -> To answer the second question, let's see what
causes cardiac symptoms, such as chest pain.
471.78 -> Let's take a look at this simple diagram
of the coronary arteries. There are three
477.18 -> main arteries surrounding the heart.
Their main job is to deliver oxygen
482.4 -> and nutrients through the blood to the heart
muscle, so the heart can continue to pump.
488.64 -> Now, if there's a severe blockage in any
of these arteries or their main branches,
494.7 -> the blood supply to the heart muscle can be
compromised, which is called ischemia. This lack
503.16 -> of blood supply or ischemia causes symptoms like
chest pain or shortness of breath with minimal
510.84 -> exertion. If the blockage becomes complete,
or 100%, that's when a heart attack occurs.
519.42 -> Have a look at these cartoons showing a
cross-section and longitudinal section
524.94 -> of normal coronary arteries. As you
can see, they have a wide opening,
530.34 -> or lumen, free of fatty deposits
or plaques in their walls. However,
534.96 -> over time, these fatty deposits can
start to accumulate and grow larger,
541.26 -> leading to a partial blockage of blood flow. The
more risk factors and unhealthier the lifestyle,
548.76 -> the sooner these plaques appear and potentially
causes blockages at younger ages. In more severe
556.08 -> cases, the blockage becomes significant, leaving
only a tiny passage for blood to flow through.
565.44 -> In this image, you can see the coronary arteries
with different types of blockages. For example,
570.96 -> here, there's a large plaque or fatty deposit
that has grown and is reaching the opposite wall,
577.86 -> nearly blocking the artery. And here, we have
fatty deposits on both sides of the wall coming
583.5 -> together and obstructing blood flow. With
these blockages, you might not feel chest
589.62 -> pain or shortness of breath while at rest because
your heart isn't demanding much oxygen. But when
597.06 -> you start doing physical activity, your heart
needs more oxygen. As there is a severe blockage,
603.72 -> these increased requirements cannot
be met, which leads to ischemia or
609.12 -> "inadequate blood supply", causing
chest pain or shortness of breath.
615.96 -> Now that we've discussed the causes of chest
pain and symptoms let's explore why ordering
621.72 -> a calcium score for symptomatic
patients isn't the best approach.
627.84 -> When someone experiences symptoms like chest
pain or severe shortness of breath with minimal
634.2 -> exertion, we need to investigate the possibility
of 'severe blockages' that could lead to ischemia.
641.64 -> In other words, we need to determine how narrow
the arterial lumen is. The thing is that a calcium
650.64 -> score test isn't designed to do that. It only
detects the presence or absence of calcium.
659.64 -> This test doesn't provide any information on
the presence or the severity of the blockage.
667.26 -> If there's no calcium, it can't distinguish
between any of these images, regardless of the
674.16 -> severity of the blockage. For instance, in this
image, where the blockage is mild, if there are
679.68 -> calcium deposits, your score would be elevated.
But in this other image, where the blockage is
686.34 -> quite severe, if there's no calcium, your score
would be zero, and a serious blockage could go
693 -> undetected. This can be especially problematic in
high-risk young people, as more time is needed for
702.24 -> their plaques to calcify, and they mostly have
non-calcified plaques, which cannot be detected
708.96 -> by calcium score. I hope this helps clarify why
we shouldn't rely on or order calcium scores for
716.34 -> patients with symptoms, as it's easy to miss these
types of blockages that are the real culprits.
726.84 -> Now let's take what we have learnt and apply
it to a real-life case from a few months ago.
732.66 -> Picture this: A 37-year-old man visits his primary
care doctor complaining of recent shortness of
739.02 -> breath and throat pain during exertion. These
symptoms have been limiting his activities,
745.56 -> especially for the past 3 weeks. He has been
feeling anxious and avoiding getting checked out,
752.1 -> fearing he might have a serious condition. His
medical history was notable for hypertension, high
760.02 -> cholesterol, and mildly elevated sugar levels,
a condition we call prediabetes. Despite this,
766.8 -> he hasn't been prescribed any medications in the
past, thinking "he was too young to be on meds".
773.76 -> He is a non-smoker and has no family history of
heart attacks, and leads a sedentary lifestyle.
782.1 -> His lab results reveal a cholesterol
level of 7.5 mmol/L or 290 mg/dL,
790.98 -> LDL 5.5 mmol/L or 212 mg/dL and an HbA1c of
6.7%, signalling the onset of diabetes. It
805.48 -> is important to note that his cholesterol has
been consistently high for the past 5-10 years.
813.78 -> His blood pressure measured 145/104 mmHg,
his BMI was 28, and his ECG appeared normal.
826.02 -> Sadly, a CT calcium score was ordered for this
man, and it came back as zero. Based on this
834.24 -> result, he was reassured that his risk of coronary
disease with a calcium score of zero was minimal.
840.96 -> But looking back, we can see that calcium
score was entirely unsuitable for this patient.
847.98 -> First, he had symptoms, and second, he was already
at high risk for developing coronary artery
855.42 -> disease due to several untreated risk factors.
One notable factor is his consistently high LDL
864.96 -> level of 5.5 mmol/L (212 mg/dl), which could even
suggest possible Familial Hypercholesterolemia,
874.86 -> putting him at substantial risk. He didn't need
another test to assess his "risk"; instead,
882.9 -> he needed a test that could replicate his symptoms
for a proper assessment, like stress test.
891.96 -> As his symptoms continued, he was
referred for further evaluation.
896.4 -> He had a stress echocardiogram and could
only exercise on treadmill for 4 minutes,
904.44 -> achieving 5 METs before complaining of
shortness of breath and throat pain.
912.6 -> 5 METs is equivalent to the energy you spend
raking leaves in the backyard. This is a very
919.62 -> low level of fitness for a 37-year-old man.
However, even at this level of exercise,
925.5 -> he had symptoms and changes consistent
with significant ischemia on ECG.
934.32 -> This is his echocardiogram after stress
test, which shows an abnormal motion in
939.6 -> this part of the heart muscle or
myocardium. All these changes are
944.76 -> suggestive of an underlying severe blockage
in one of the main arteries and ischemia.
954.42 -> He also had a CT coronary angiogram. If you need
to learn more about the difference between a CT
960.24 -> Coronary Angiogram (CTCA) and a CT calcium score,
check out this video. As we can see, the RCA and
969.66 -> LCx arteries look wide open with no blockages,
but the LAD artery is nearly blocked, what we
978.42 -> call "subtotal occlusion". By looking at this
image, you can appreciate why his calcium score
984.9 -> was zero. It's because there's no calcium in these
plaques that have almost occluded the artery.
992.4 -> There's only a tiny passage left, which allows
a minimal amount of blood to flow through.
998.76 -> This amount of blood supply may be enough
at rest, but the blockage becomes apparent
1004.28 -> as soon as the demand for oxygen increases, with
exercise. No more blood can be supplied to this
1012.02 -> part of the heart muscle, which leads
to ischemia and the resulting symptoms.
1019.46 -> He underwent a coronary angiogram at the
Hospital, which once again revealed the
1024.62 -> severe near occlusion of the LAD artery. The
blockage was successfully opened with a stent.
1036.349 -> These are two still images of his invasive
angiogram, before and after stenting. The
1042.229 -> blockage was so severe that the artery
was hardly visible. After the angioplasty,
1047.689 -> you can appreciate the large size of the artery,
which supplies a significant area of the heart.
1054.709 -> He was just days away from a complete occlusion
and a massive heart attack. Ironically, during
1061.309 -> those days, he was undergoing the wrong test,
which gave him misleading and reassuring results.
1070.729 -> The main learning points to remember from
this presentation. Calcium scoring is a
1076.489 -> risk assessment tool and not a diagnostic test.
1081.709 -> Calcium score should only be ordered in
asymptomatic and low-intermediate risk patients.
1090.529 -> And last but not least, Calcium score should
never be used to assess patients who have cardiac
1096.349 -> symptoms, such as chest pain. And that wraps up
our discussion on the importance of choosing the
1102.289 -> right test for the right patient. Don't
hesitate to comment or ask questions,
1106.249 -> and thank you for watching. If you found this
video helpful, be sure to like it, subscribe
1113.029 -> to the channel and stay tuned for more videos
on heart health. Take care, and stay healthy!
Source: https://www.youtube.com/watch?v=OfTCrZSVA6U