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Calculating cardiac calcium scores

On the X-ray image they printed out for me, trouble is a pink triangular speck, labeled LAD.

The pink spot represents a calcium buildup - hardened plaque. And the LAD tag means the plaque lies in my "left anterior descending" coronary artery - the one cardiologists call "the widow maker."

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A blockage in the LAD tends to kill you.

No one has said definitively that's what killed NBC newsman Tim Russert last week at the age of 58. But it wouldn't be a bad bet.

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Russert died after a heart attack in his Washington office. Three attempts to shock his heart back to life failed.

For those of us in his age group, Russert's death came as a vivid reminder of our own mortality. Dr. Stephen Pollock is 58 and chief of cardiology at St. Joseph Medical Center in Towson.

"His death upsets me," Pollock said.

"My father died at 58 of a heart attack," he added. "I've been scared of this forever."

But more importantly, Pollock believes thousands of lives could be saved every year if everyone 40 and older would get a quick and simple test called a calcium score and, if needed, seek treatment.

American Heart Association guidelines say calcium scores aren't needed for people in low-risk categories or for those whose history and behavior indicate they're at high risk.

But "for the people who have one or two risk factors, who are asymptomatic or having chest discomfort, coronary calcium scoring can be beneficial," said Dr. Shannon J. Winakur, a cardiologist with Midatlantic Cardiovascular Associates and an AHA spokeswoman.

Risk factors include hypertension, diabetes, high cholesterol, a smoking habit, family history of heart disease and advancing age.

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"Calcium scoring is helpful to see if somebody has coronary disease," she said. "It's not as helpful to determine ... where critical blockages are or which plaque is going to cause a problem. It's a good screening test. We go from there to try to reduce the risk of having a heart attack."

It would not have helped Russert, according to his doctors. He already knew he had coronary artery disease. He was taking medicine for it, exercising and watching what he ate.

But "that's not the point," Pollock said. Early diagnoses with calcium scoring could help thousands.

Pollock had the test five years ago. It changed everything for him.

With his poor family history, he was already on alert for signs of heart disease. "I took a stress test every year, and every year it was normal," he said. He reckoned he was doing fine and saw no need to push his cholesterol levels down with drugs that can have significant side effects.

But when the calcium test became available, he took it. His score was "really high," he said. A subsequent nuclear stress test revealed two blocked coronary arteries. Two stents opened those arteries, and he started taking aspirin and cholesterol-lowering drugs. "So far, so good," he said.

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Russert, too, had passed a stress test not long before he died. That's not uncommon. "Normal" results don't mean you don't have coronary artery disease, Pollock said. "It just means it's not critical."

You could still have a 50 percent blockage. And if a piece of that plaque breaks off and plugs up a coronary artery, heart muscle dies.

"This happens 850 times a day in this country - cardiac death - frequently with people who had no warning. They didn't know they had coronary artery disease, which is eminently treatable if you get on cardiac drugs," Pollock said.

He finds it exasperating that more people don't get that diagnosis earlier. "Everyone in this country knows if you're over 50 you should get a colonoscopy," he said. Women know they need regular mammograms, and men routinely get PSA tests, as part of their regular checkups, to catch the early signs of prostate cancer.

"But nobody gets a test for the No.1 [killer] disease in this country," he said. Worse, insurance companies that pay for colonoscopies, mammograms and PSA tests won't cover calcium scoring.

Pollock felt so passionate about the topic that 18 months ago, he and St. Joseph established the Heart Aware program, offering calcium score tests to men ages 45 to 75 and women 55 to 75. At $90, the price of the test does not cover the hospital's cost to administer the test, said cardiology services manager Jean Seiler. Almost 1,000 people have had the test.

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Heart Aware patients can calculate their own risk factors online at stjosephheartaware.com, get tested and receive counseling afterward from a nurse. Seiler said 42 percent of test-takers have scored high enough to warrant a follow-up with a physician.

Other area hospitals also offer the test at fees ranging from $75 to $250. Among them are Anne Arundel Medical Center, Greater Baltimore Medical Center, Johns Hopkins Hospital and University of Maryland Medical Center .

I have no family history of coronary artery disease, and my cholesterol numbers aren't too bad. I passed a nuclear stress test a few years back. My cardiologist told me I had the heart of a 35-year-old. At least that's how I remember it.

But I'm 60, and I've had plenty of time to lay down a lot of crud in my arteries. My doctor thought it was a good idea, and for $90, I was game.

I showed up at St. Joseph's radiology lab for the hourlong session and paid the $90. I was led into a large room with a big doughnut-shaped CT (computed tomography) machine and climbed onto the table that rolled me through the doughnut hole.

CT scans are X-rays. This one produced detailed images of 64 slices through my chest. It's a significant dose of radiation - likened to almost a year's worth of natural "background" radiation at sea level. But cardiac death is a serious risk, too. You strike a balance.

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Inside the doughnut, I was instructed to breathe in and out three times then hold my breath. The machine hummed and whirled around me. We did that three times, I think, and the staff slid me out.

Afterward, Seiler, a registered nurse, explained my results. The scan had detected calcified plaque in my LAD, she said, but the rest of my coronary arteries showed none.

The calcium score on my LAD was 23, which Seiler said placed me in the 35th percentile for men my age. In other words, 65 percent of men age 56 to 60 had more calcium and plaque in their heart arteries than I do.

Seiler said my score put me in the "mild plaque burden" category, with a "moderate" risk of cardiovascular disease.

The papers she gave me said men in that range should follow a "healthy" diet; stop smoking; follow an exercise program with a doctor's approval; take aspirin; and, if their cholesterol numbers are high, take cholesterol-lowering drugs called statins.

Well, I do most of that. My internist agreed, after considering my cholesterol levels and other factors, there was no need to start me on statins.

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Pollock disagrees. The calcium score only indicates how much calcium and hardened plaque is present and where. It doesn't reveal noncalcified "soft" plaque or say what percentage of the affected artery is blocked, as a more costly and invasive CT angiogram might.

"I would push your cholesterol down [with drugs]. With your current regimen, you're laying stuff down [in your arteries]. There's some disease there," he told me.

I'm thinking about all that. I'm also thinking about Russert, who did all that his doctors asked and still died an early death. Medicine can't save us all.

But it can save many, Pollock says. "There are thousands of people ... every year that drop dead as their first symptom."

"We have treatments that we can show prevent heart attacks and prevent progression of the disease before we have to do heart surgery," he said. "We need to be making this diagnosis, not in 55-year-olds, but in 40-year-olds, so we don't have dead fathers on Father's Day."

Pollock is equally passionate about the need to station automated external defibrillator machines almost everywhere. If used within three minutes of a heart stoppage, an AED can restore normal heartbeats and save a life.

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They're designed so that anyone can use them, without training, just by following recorded instructions from the machine.

"They're 75 percent effective in preventing death," Pollock said. By comparison, CPR works only 10 percent of the time.

Pollock said he has one at home. "How many restaurants have them? How many businesses have them? How many law firms? They only cost $1,000, and you can buy them on amazon.com. ... They should be everywhere."

There was one in NBC's Washington offices. Russert was shocked three times, starting almost immediately after his attack, his doctor said. That couldn't save his life, either.

frank.roylance@baltsun.com

Calcium Scores

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Zero: No identifiable atherosclerotic plaque; very low cardiovascular disease (CVD) risk.

Action: Healthy diet (low in saturated fat and cholesterol); stop smoking; maintain recommended weight; exercise program with physician approval.

One-10: Minimal plaque burden; low CVD risk.

Action: All of the above, plus tight control of diabetes and hypertension; consider use of statins if cholesterol is high.

11-100: Mild plaque burden, moderate CVD risk.

Action: All of the above, plus estrogen for post-menopausal women; aspirin use; use of statins in cases of high cholesterol.

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101-400: Moderate plaque burden; high CVD risk.

Action: All of the above, plus use of statins in cases of high or borderline cholesterol; consider use of folic acid and fish oils.

401 and higher: Extensive plaque burden; very high CVD risk.

Action: All of the above, plus exercise test to rule out obstructive disease; consider angiogram for symptomatic patients or those in high-risk occupations.



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