Calcium Index Test

[John_Mace]

I had a Calcium Index test done about a week ago, and I just got the results. I did a little googling, and I think I understand it, but I was wondering if any of you guys had any experience and would like to weigh in. I do have an appointment with my cardiologist to go over this in about 2 weeks, so I’m not asking for advice in lieu of a doctor’s advice, but I thought it also might help if anyone would suggest some questions I might ask at my next visit.

My CI Score was 200, which I understand indicates “moderate” build-up. But that range is 100 - 400, so it would seem that I am in the low-mid range of the “moderate” reading. Also, I’m wondering how age impacts the reading-- I might be very concerned at such a reading if I was in my 20s, but I’m in my early 60s, so that might affect how it’s interpreted.

The test also detected a 6mm “well circumscribed pulmonary nodule” in my right, upper lung lobe. That seems to be just outside the “probably not an issue” range (which I think is 4mm), and might have a small, but still significant chance of being malignant. I’m wondering what tests might be recommended for further analysis. Biopsy???

Any input will be appreciated, and once again I do have an appointment with my cardiologist soon, so I’m not asking for advice here instead of seeing a doctor.

[Bill_Door]

I can’t give you a lot of information, but my wife who is in her mid-sixties had one done and her number was 4.

[John_Mace]

@Bill_Door

I can’t give you a lot of information, but my wife who is in her mid-sixties had one done and her number was 4.

That’s good news for her! I think anything under 100 is considered “good”.

[beowulff]

These tests are notoriously inaccurate if you are relatively young.

I had one at age 50, and it came back zero.

That didn’t stop me from having emergency bypass surgery to fix an almost complete occlusion of my LAD, though.

[DSeid]

It sees calcified plaques. It does not see the plaques that have not calcified and are the ones most vulnerable to rupture and thereby causing occlusion.

It is not a replacement for other risk stratification but it can be a supplement to them, possibly moving someone up a level to more aggressive care if they were not quite there.

But therein lies the dings against it.

Low risk individuals getting the test are sometimes having overly aggressive responses to something that is really only a modest adjunct to stratification. And individuals who already qualify for statins based on other risk stratification aren’t going to have treatment changed as the result.

Said Dr. Greenland, “From my point of view, the biggest challenge facing any new risk marker today—and CAC is a good example—is that if you have a recommendation based on a traditional risk factor score that says that pretty much anybody with a risk score above 7.5% should be treated with a statin, then why exactly do you need any additional risk marker?”

He said some clinicians may continue to use CAC, as he has in the past, as a “tie-breaker.”

John what’s your Framingham Risk Score? (You can calculate it yourself here.) Are you already on a statin?

Bottom line as I understand it is that if you are not already on a statin and your Framingham puts you right near the edge of 7.5% risk then a high calcium index might get a doc to put you on one and a low one to say no need. But if you are otherwise over 7.5% just go on the statin in any case.

[Wesley_Clark]

@DSeid

It sees calcified plaques. It does not see the plaques that have not calcified and are the ones most vulnerable to rupture and thereby causing occlusion.

How long does calcification of a plaque take?

So if I went and had one done in my late 30s, it would give me a false sense of security?

My Framingham risk scale is 2%, but it doesn’t seem to account for a whole lot of variables.

[DSeid]

Not a cardiologist or even an internist or FP but the overarching idea is that the Framingham is the best evidence-based risk stratification tool we’ve got. Details here. It may even likely be that items like family history of premature heart disease, hs-CRP, cardiorespiratory fitness, and others, could be additive in predicting future risk, but the large RCTs using them in a screening capacity have not been done, so due to insufficient evidence the ability to quantify risk according to them does not exist. Like the coronary artery calcium score (CAC) they are placed as items that can be considered when treatment decisions are still uncertain by Framingham alone.

Yes a good score at any age, if used as the primary means of assessing risk, could be giving you a false sense of security, and not having calcified plaques at 30 does not mean that plaques are not forming.

In terms of time course thisis the best information I can find to try to answer that.

… In brief, intimal thickening is observed early in the disease process. The early atherosclerotic lesion is composed of smooth muscle cells and is affected by increased macrophage and lipid influx. If this process continues, a necrotic core is formed and the lesion progresses to a fibrous cap atheroma. The necrotic core contains lipids and apoptotic macrophages. A stable fibrous cap may prevent rupture of the lesion. If the fibrous cap loses matrix proteins and smooth muscle cells, a thin cap atheroma can result. Intraplaque hemorrhage is also seen frequently in this entity, leading to further enlargement of the lipid core. The risk of plaque rupture is increased as the fibrous cap thins and the lipid core enlarges.14 The fibrocalcific plaque is considered to be more stable, although the processes involved in calcification are not fully understood …

… calcium deposition is felt to be a late event in the formation of atherosclerotic plaque. The relevance of noncalcified plaque is emphasized by prospective IVUS studies that show coronary fibroatheroma without significant calcification confers an elevated risk for myocardial infarction.18 Noncalcified plaque is more common than calcified plaque in asymptomatic individuals aged <45 years. …

[allotrope]

I’m curious as to why the calcium test would be ordered when a doppler scan of the carotid artery is generally considered an adequate substitute indicator of cardiovascular status.

[Qadgop_the_Mercotan]

@allotrope

a doppler scan of the carotid artery is generally considered an adequate substitute indicator of cardiovascular status.

Is it? Do you have a cite for that? I am not aware of using carotid duplex ultrasounds to screen for coronary disease, and my review of recommended screening protocols doesn’t doesn’t turn up anything. The US Preventive services task force advises against carotid ultrasound being used for screening of asymptomatic patients.

Certainly the presence of carotid lesions is an indicator that the patient may also have coronary lesions, but I know a lot of individuals have clean carotids yet have significant coronary lesions. So a normal carotid u/s wouldn’t (in my mind) be all that reassuring.

But perhaps I’m missing some correlation.

[allotrope]

@Qadgop_the_Mercotan

Is it? Do you have a cite for that? I am not aware of using carotid duplex ultrasounds to screen for coronary disease, and my review of recommended screening protocols doesn’t doesn’t turn up anything. The US Preventive services task force advises against carotid ultrasound being used for screening of asymptomatic patients.

Certainly the presence of carotid lesions is an indicator that the patient may also have coronary lesions, but I know a lot of individuals have clean carotids yet have significant coronary lesions. So a normal carotid u/s wouldn’t (in my mind) be all that reassuring.

But perhaps I’m missing some correlation.

I can’t find the article I originally read about this. I thought I had clipped it but no luck.

The best I can find doing a quick google is this brief description from WebMD.

     **Plaque Scan (Carotid Intima-Media Thickness Testing, or CIMT)**

          This test is similar to a carotid [ultrasound](https://www.webmd.com/a-to-z-guides/what-is-an-ultrasound). That test uses sound waves to detect blockages in the [carotid artery](https://www.webmd.com/heart/picture-of-the-carotid-artery), the main artery that supplies blood to the [brain](https://www.webmd.com/brain/picture-of-the-brain). A plaque scan uses complex software to measure the thickness of the lining of the carotid artery.
   "An increase in the thickness of the lining indicates the  patient is at higher cardiovascular risk, even if no … plaque is  present," says Mark F. Sasse, MD. He's an associate professor of  cardiovascular medicine at the University of Alabama at Birmingham  School of Medicine.

I know that doesn’t support my statement however.

[John_Mace]

@DSeid

It sees calcified plaques. It does not see the plaques that have not calcified and are the ones most vulnerable to rupture and thereby causing occlusion.

It is not a replacement for other risk stratification but it can be a supplement to them, possibly moving someone up a level to more aggressive care if they were not quite there.

But therein lies the dings against it.

Low risk individuals getting the test are sometimes having overly aggressive responses to something that is really only a modest adjunct to stratification. And individuals who already qualify for statins based on other risk stratification aren’t going to have treatment changed as the result.

John what’s your Framingham Risk Score? (You can calculate it yourself here.) Are you already on a statin?

Bottom line as I understand it is that if you are not already on a statin and your Framingham puts you right near the edge of 7.5% risk then a high calcium index might get a doc to put you on one and a low one to say no need. But if you are otherwise over 7.5% just go on the statin in any case.

Thanks for the advice. I’m not at home this weekend, so I don’t have access to my medical records. But when I get back home, I’ll take that test and see what my Framingham Risk Score is. I seem to remember that my cholesterol levels were squarely in the “normal” range, but I could be wrong. In any case, I don’t know what the precise value is.

[Qadgop_the_Mercotan]

@allotrope

I can’t find the article I originally read about this. I thought I had clipped it but no luck.

The best I can find doing a quick google is this brief description from WebMD.

I know that doesn’t support my statement however.

So it’s basically a research tool at this point, and whether using CIMT for risk stratification will transform into better outcome for patients is unknown. Therefore, routine use of CIMT is not recommended as a screening tool by medical authorities at this time.

[Wesley_Clark]

Goofing around with the Framingham calculator, it seems like age and smoking are the biggest factors. Thats not a hard and fast rule, it just seems to be what I"m seeing when I mess around with it.

Which I guess isn’t surprising, I remember a few years ago when a study came out showing 4 lifestyle factors played a big role in whether a 75 year old would survive another 10 years.

The factors were alcohol consumption, exercise levels, fruit consumption and smoking status. However when you do the calculations, smoking is a big a factor as the other 3 combined. So if you eat right, exercise, don’t drink too much but smoke your odds are about the same as someone who doesn’t eat right, doesn’t exercise, drinks too much but doesn’t smoke.

The combined effect on survival of four main behavioural risk factors for...

The four ­simple rules that add 10 YEARS to your life expectancy, acco

[allotrope]

@Qadgop_the_Mercotan

So it’s basically a research tool at this point, and whether using CIMT for risk stratification will transform into better outcome for patients is unknown. Therefore, routine use of CIMT is not recommended as a screening tool by medical authorities at this time.

IDK, I get the impression from the article that it’s being viewed very favorably as an alternative to a calcium score.

Although CIMT has been primarily used as a research tool in epidemiological and clinical trials, it is becoming more widely available and has the potential to play a significant role in clinical medicine. CIMT is relatively straightforward, safe and inexpensive. No radiation is involved, and no contrast is needed.
CIMT measurements are used to screen for atherosclerosis, assess the risk for future cardiovascular events, and analyze the effect of drug therapy.

CIMT has a few favorable characteristics as a screening tool for cardiovascular disease. It is noninvasive, safe and correlates with clinical outcome.
Another method commonly used to quantify atherosclerosis is coronary artery calcium score (19). The main disadvantage of this method compared to CIMT is the radiation exposure involved.
Appropriate reasons for using CIMT include patients at intermediate risk for coronary heart disease, and those with metabolic syndrome, diabetes, or a positive family history of premature heart disease (20).

I’d also point out that this is the method my cardiologist used for my last complete check up which also included a stress test and echocardiogram. So at least some specialists seem to be moving toward this test.

[Qadgop_the_Mercotan]

@allotrope

IDK, I get the impression from the article that it’s being viewed very favorably as an alternative to a calcium score.
I’d also point out that this is the method my cardiologist used for my last complete check up which also included a stress test and echocardiogram. So at least some specialists seem to be moving toward this test.

It’s still rather an odd duck of a test, as your own sources point out, since it’s presently recommended for intermediate risk patients, but NOT for low risk or high risk ones. Not many screening tests are recommended for that sort of group.

We’ve got a LOT of new technology that tells us lots of things and looks at old problems in new ways, but we’re still far, far from certain just how much of it will actually help preserve health and life vs how much harm it can do with false positives and false negatives. Which is really the basic quandary facing every screening test.

[John_Mace]

@beowulff

These tests are notoriously inaccurate if you are relatively young.

I guess I could qualify as “relatively young” for certain definitions of “relatively”.

Actually, I’m always a bit surprised when my cardiologist tells me (as he often does) that I’m “young”. I assume he means “relative to his typical patient”.

[DSeid]

@allotrope

… at least some specialists seem to be moving toward this test.

For certain values of “some.”

Seriously there are always docs who jump on whatever the newest toy is and over-order. A stress test as part of a routine is also funky. Explicitly recommended against by the American College of Cardiology.

American College of Cardiology

When initially evaluating patients who are not having cardiac symptoms, don’t perform stress cardiac imaging or advanced non-invasive imaging unless there are markers the patient is at high risk.

Don’t perform stress cardiac imaging or advanced non-invasive imaging as part of routine follow-ups in patients without symptoms of cardiovascular disease.

“Some” is long long way from “generally.”

Anyway, the reason why a calcium test (CAC) would be ordered rather than the carotid artery thickness is simply that the latter is not generally considered an adequate substitute indicator of cardiovascular status and does not have very much evidence behind it yet as a predictor of risk for cardiovascular events. Maybe it will in the future. Maybe not. The CAC’s value in that regard, such as it is, is well established.

I’m still though left at not understanding why so many of these CACs are done. If the test is high the patient should be advised to improve their lifestyle, not smoke, exercise regularly, and eat right, and the doctor should do their best to treat any blood pressure elevation and maybe prescribe a statin? And those whose tests are not high should not bother with those things? Seems to me like the only one of the list that is not something everyone should be doing in any case already is the statin and hell, cheaper and more effective likely to just cast an even wider net with a lower Framingham score.

QtM, any insight? Is it just that people psychologically respond more to “a test result”?

[John_Mace]

I’m fairly certain that in my case it was to determine if I need to be on a statin or not. As you surmised, above, I am not currently taking one. Plus the test is pretty cheap. My insurance didn’t cover it at the facility I went to, but it was only $150.

[Qadgop_the_Mercotan]

@DSeid

QtM, any insight?

I attribute it to the doctor’s desire to ‘do something’ and ‘please the patient’, the patient’s desire to perceive that ‘something is being done’, and if the insurance does cover the test, that’s a further incentive.

Having been in private practice x 16 years, then in the public practice (my ‘captive’ prison population) for almost as long now, patients tend to get unhappy when you tell them they don’t need what they want, and as a result I won’t give it to them. I try to explain it logically but even so, many go away unhappy, complain, and some even file lawsuits. In the private sector, the squeaky wheels get the grease, and these issues are minimized.

Or so I perceive it, from my rather exceptional perspective.