By Judy O’Gorman Alvarez
Heart disease is the leading cause of death for both men and women in the United States, according to the U.S. Office of Disease Prevention and Health Promotion, causing 1 in 4 deaths a year. And a little-known non-invasive scan could help identify calcium buildup on the walls of arteries and potentially save lives.
Anthony DeNoia, M.D., of Atlantic Highlands Internal Medicine, knows the importance of heart health and tells patients the key to preventing cardiovascular disease is to manage risk factors such as high blood pressure, elevated cholesterol levels, diabetes, smoking, obesity, and sedentary living.
In addition to standard blood tests, physicians typically order cardiac testing with an EKG as part of a yearly physical. However when there are risk factors for heart disease, they frequently order stress testing which measures how the heart responds to exercise as well as an echocardiogram, an ultrasound of the heart.
What is important to note, according to DeNoia, is that a nuclear stress EKG will only show if there is a blockage of greater than 60 percent in one of the coronary arteries. “A negative test does not pick up lesser degrees of blockage and in fact does not tell you if you have coronary artery disease,” he said. “That is why a negative test can give a false sense of security.”
DeNoia said that sometimes we hear the story of how someone died suddenly when he just got a clean bill of health. He explained: “The reason is that most people who die of a massive heart attack or sudden death do not die because of a high-grade blockage but rather from rupture of plaque that ruptures from the coronary arterial wall, suddenly occluding 100 percent of the vessel. This plaque is not picked up even on nuclear stress testing.”
However, there is a test that can pick up this plaque: a CT calcium score. A CT scan of the coronary arteries will detect the amount of plaque which shows up as calcium on the scan. It is this plaque that can rupture and cause a major heart attack. DeNoia said if the calcium score is high, it prompts him to treat his patients’ risk factors more aggressively – that is further lowering of their cholesterol and blood pressure readings to reduce the risk of progression of the coronary artery disease that was detected on the scan. In addition, if calcium levels are significantly elevated, he will refer his patients to a cardiologist for a cardiac catheterization.
A coronary catheterization – or angiogram – involves a liquid dye injected into the arteries of the heart through a long, thin tube that’s fed through an artery. The dye makes the arteries visible on X-ray, revealing blockages.
DeNoia has been very vigilant about his own heart health for many years. He had a strong family history of heart disease on both sides of his family. Consequently he exercised, followed a heart healthy diet, did not smoke, and controlled his blood pressure and cholesterol levels to guidelines with medication as advocated by his cardiologist. He had multiple nuclear stress tests over the years and all were negative. He thought his cardiac risk was under control. “However,” he said, “genetics won out.”
In April 2015, one evening as he was going to bed, he developed chest pain for the first time. He immediately took several aspirins and within 30 minutes of the chest pain he was in the ER at Riverview Medical Center. Standard cardiac testing revealed no evidence of a heart attack, but DeNoia insisted on having an emergency cardiac cath. It showed that he had high-grade blockages of all three major coronary arteries and would require bypass surgery which was done at Jersey Shore University Medical Center.
Now fully recovered and walking 3 miles nearly every day, DeNoia has a message to share. His cardiologist told him he was an unusual case in the sense that he had controlled his risk factors and nuclear stress testing was negative. “The cause was my genetics, but if I had not been controlling my risk factors I would have been dead years ago,” he said.
His stress testing was negative because of a phenomenon called balanced ischemia – where all three major coronary arteries were equally blocked giving a false negative result on his stress test.
As a result, DeNoia feels that a nuclear stress test alone is not sufficient to give a patient all the information he needs. “A negative test does not tell you that you do not have coronary artery disease, and in some rare cases can miss significant coronary artery disease – as was the case with me,” he said. “If it can happen to me, it can happen to anyone.”
Since then DeNoia said he changes the way he evaluates and treats his patients. For those who are at high risk for coronary disease, he frequently orders a CT calcium score to see if they have increased calcium scores representing plaque and coronary artery disease. When identified, he then aggressively treats their risk factors to goal – such as LDL cholesterol levels to 70.
In fact, he has estimated in the past year this test has detected close to 20 of his patients that ultimately were referred for cardiac cath that showed high-risk lesions that were not picked up on nuclear stress testing. These patients were saved from having a cardiac event. He realized that if he himself had had this test, his heart disease would have been detected much earlier and certainly before his emergency cath.
Even though the test is frequently denied by insurance companies, DeNoia said it only costs $195 out of pocket at Riverview Medical Center. “Think of it as dinner at a nice restaurant,” he said. “The information this test gives you is well worth it.”
Making people aware of this test is part of DeNoia’s mission to encourage people who are at high risk for heart disease. The other part of his mission is to convince his patients of the need to aggressively control their modifiable risk factors. Age, gender, and family history cannot be modified, but other risk factors can be. “Remember, you are in charge of your health,” DeNoia said. “And these strategies just may save your heart – and your life!”
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