I fell in love with calcium scoring nearly a decade ago. In our office, it's become nearly as common a recommendation at a new patient visit as an echocardiogram. Today's presentation on the topic left me feeling all warm and fuzzy.

We finally got a real glimpse of the future of calcium scoring during a session at the American College of Cardiology 2014 Scientific Sessions . It seems it's been the right thing to do, but there are lingering questions. I found the comments provided by the panel that consisted of Drs Kim Williams, David May, and Harvey Hecht as compelling as the data. I hope more front-line providers, family practitioners, internists, and others will embrace it as well.

First, we learned from a Houston Methodist Hospital study that testing of asymptomatic individuals really has worth. Nearly 1000 patients deemed low risk by the Framingham calculator and a plain treadmill exam were tracked for seven years. Coronary calcium proved a far better predictor of risk. May then said, "Calcium scores are better predictors than routine exercise evaluation," and Hecht even more emphatically stated, "If you've thought about doing a stress test on someone with no symptoms, do a calcium score first. There is no such thing as a false-positive calcium score. It is 100% accurate for coronary atherosclerosis."

From Los Angeles BioMed at Harbour UCLA Medical Center came a fantastic 20-year study of nearly 5600 subjects. Mortality data was presented on no-, low-, moderate-, and high-calcium scores of those otherwise considered to be at low risk for heart disease. With an average follow-up period of 10 years, even patients with low calcium scores (1–99) were 50% more likely to die than patients with a calcium score of zero. Moderate scores (100–399) were associated with an 80% greater likelihood of dying, and high scores (above 400) were associated with a three-times-greater risk of dying as compared with patients with zero calcium. These patients had zero to one risk factor, including diabetes, hypertension, current smoking, family history, or diabetes. Ten percent of these "low-risk" patients had a severe burden of coronary artery calcium >400.

Again, the panel drove several points home. May said, "The significance of that observation period cannot be overstated. Should they have been tested with stress testing? Coronary artery calcium gives us a real measure of individuals they should be focusing on."

Hecht replied, "You can have zero or one risk factor and still have significant atherosclerosis. . . . and you are just as dead if you have five or zero risk factors. The key is to start therapy based on the amount of plaque you have." (My take was that we still don't know all of the risk factors, we don't recognize the patient has a risk factor, and obviously risk factors aren't equally weighted for everyone. Wonder how many of these zero-risk-factor patients would truly have passed a 75-g glucose challenge?).

Data from researchers at Johns Hopkins presented information from MESA . Of the 1850 patients studied, a zero calcium score in "middle age" or older is a sign of healthy vascular aging and a good predictor of longevity. Younger participants and those without multiple traditional risk factors were more likely to maintain a score of zero during a second scan 10 years later. A healthy lifestyle was the best predictor of risk in those individuals.

Finally, a research team from Mount Sinai St Luke's-Roosevelt Hospital Center in New York found some correlation between coronary calcium scores and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), which produces a 3-D image of the heart. A negative calcium score generally indicated a normal perfusion status, but scores of >400 were usually associated with ischemia.

I particularly appreciated this data because I too believe these tests are complementary. Here's a typical conversation in my office, and by all indications, after today's presentations, one I'll keep having throughout the years:

"I'd like you to have a calcium score. It's easy because it requires no IV and no dye. There is no need to get undressed unless you have metal in your clothing. Hold your breath for 15 seconds and they will take a photograph of your heart arteries. You are born with pink, glistening, supple arteries, but the ravages of time take their toll and cause inflammation that attracts calcium. Smoking, diabetes, hypertension, heredity, and illnesses like arthritis, psoriasis, or gout cause us difficulties. A ruptured appendix or diverticulitis likely adds to our calcium burden as well. We are born with a score of zero, and as we go through life, most of us gain calcium counts.

"Folks with a score of less than 100 have less risk of cardiac events than folks over 100, and the risk increases as the score increases. I have patients who range from zero to 9400."

I further clarify: "Calcium scoring isn't everything, and it isn't for everyone. It's not for people who have had a bypass surgery or a stent, and it's not for most people who've already had a heart attack. It's not for the typical young person. It's $99 out of pocket except during February; the hospital runs a special for $50. Radiation exposure is minimal, and it might save you from having to take statins for the rest of your life. It's difficult to have a heart attack with a calcium score of zero, but don't ever ignore symptoms. I've treated three smoking patients below the age of 20 with acute coronary syndrome. Their arteries were normal on cath, and I'll bet their calcium scores would have been too. I have one patient with a stent whose score is 67, but it was all in a single vessel. My patient with the highest calcium score didn't require CABG or PCI, so the results require a good history and physical for complete interpretation. Please bring your results with you the next time you come into the office. Your insurance company won't pay for it because our guidelines haven't acknowledged that it will save lots of money for unnecessary caths and stress testing . . . yet!"

I'm waiting for a calcium score now on a nice gentleman with the typical "nonspecific patchiness of tracer uptake" with "minimal reversibility in a single view" on his nuclear. Sometimes folks walk in the door with their studies already ordered by their family doctors. Pouring over the chart is like reading tea leaves, but having a calcium score is about as close to having a coronary crystal ball as anything (except this one really works). At 60, if he has a calcium score of zero, he won't get a prescription for a statin. He won't leave with a bottle of nitro, but he'll get the Mediterranean diet and a prescription for exercise and a recommendation to avoid sodium. I'll direct him to return about five years later for an office visit. If he has any calcium points, I'll prescribe aspirin, a statin, a stress exam, and depending on the outcome, a nitro prescription.

Medicine is every bit as much an art as it is a science. Lots of us have been practicing the art of calcium scoring for several years. Today we are practicing the science of medicine, and we'll keep doing it because now we are finally justified!


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