This was a documentary about heart disease and how a test called the cornoary artery calcium scan (CAC scan) can give you a rough impression of how much plaque you have in your coronary arteries. It was very pro-CAC but also very anti-stent and claimed stents are overprescribed because they are a money maker for hospitals.
Having said that, I have no idea how much was true or how much wasn’t since the bias was obvious.
It also didn’t make sense how much they harped on both how cheap a CAC scan is, sub $100 (I think some places do them for $49) but then they talk about how the fact that health insurance doesn’t cover them is a massive barrier. In the days of $6000 health insurance deductibles, in what world is a scan that costs $100 every few years going to bankrupt anyone? Can’t people pay out of pocket to get a rough idea of how much plaque they have in their heart? I would pay $50 to get a good idea of how my heart is doing irrelevant of whether insurance covered it or not.
I did find a study showing people with low scores had a much lower rate of death than people with high scores
Does getting a stent prevent you from getting coronary bypass surgery at a later date?
Are 80-95% of stents useless? I’ve read they don’t do much to prevent heart attacks or death.
I thought coronary bypass surgery was also overprescribed heavily. However I"m having trouble finding the study right now.
One datapoint:
A few years ago I went to the doctor because I was having chest pain upon exertion. I was not in what they considered a high-risk category for CAD (relatively young (49), not overweight, athletic). The doctor sent me for a Calcium Score.
The test came back ZERO.
So, the doctor started to look elsewhere, but wasn’t able to give me a reasonable diagnosis, so I went to a cardiologist, who recommend an Angiogram. This test showed a 90-90% blockage in my LDA (AKA the Widowmaker), and they took me in for immediate bypass surgery.
Even before the surgery, I had looked up the statistics for the Calcium Score test, and found that it was very, very bad at detecting CAD in younger patients.
That is interesting that you got a 0 in the CAD but an angiogram showed a 90% blockage in the LDA.
How does atherosclerosis that doesn’t show up on a CAC scan work? Is it possible the people doing the scan missed it, or did the blockages not have calcium?
I think “younger” is relative - it depends on when the subject started to get CAD.
The reason the scan missed it is because “young” plaque deposits haven’t had time to calcify. I don’t know how long that takes, but it’s probably a decade or more.
The other issue with this test is the huge number of “irrelevant positives” it returns for some people. It’s not uncommon to get scores in the hundreds - and still not have any symptoms. What are you going to do with that information?
Not a cardiologist but do know how to accessthe guidelines created by panels of expert cardiologists.
The place they view for it to be of some potential use is if risk stratification by traditional methods results in an “intermediate risk” … if traditional risk stratification results are clearly “low” or “high” it is clearly not advised. If a risk-based treatment decision is uncertain after formal risk estimation then CAC is a “IIb” recommendation: that is a “Procedure/treatment MAY BE CONSIDERED” level,; the next one down is “not helpful” and the next up “IT IS REASONABLE to perform”.
So performing a CAC may be considered (but is not necessarily considered reasonable to perform) if it is unclear by more tradition formal risk assessment scoring whether someone should be on statins (or whatever) or not, as it might modify the risk assessment in one direction or the other. In that context a CAC ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity would move the individual up to the higher level and below those would move one down to the lower one. Likewise family history, high sensitivty CRP, and ankle-branchial index, can be optionally considered.
Note: these are as applicable to using the test to screen populations; not as a diagnostic tool. beowulff’s circumstance was not screening; it was using the test as part diagnosis for chest pain and then the degree of suspicion should have been based on the complete clinical picture, not only formal risk assessment but when did the pain occur and what was it like, etc…
Maybe one of the adult docs will be able to comment more about stents than I can. But maybe you should get this moved to IMHO?
FWIW this about at least stents vs coronary artery bypass grafts (CABG). Note: neither compared with the option of no procedure done at all.
Meta-analysis published in 2014.
Stents compared to “standard medical care” and no procedure is discussed in this 2012 NYT article, at least for stable coronary artery disease.
The actual article. Note drug eluting stents made a small fraction of all stents used.
But in this 2014 meta-analysis of those with stable CAD and documented, objective findings of myocardial ischemia, drug-eluting stents were more common. And stents added initially to medical therapy (MT) resulted in
This paragraph in the latter cite is potentially pertinent to the limited value of the calcium artery scan (CAC) score.
Let me try to parse that out. It is especially pertinent to beowulff’s circumstance and comment.
Old established lesions, those that cause high CAC scores, cause myocardial ischemia, but tend to not be the ones that rupture and cause new MIs. Stenting those narrow areas apparently does little good. It’s the newer lesions, which have not yet calcified, and which are more likely to not be so narrowed, that are more likely to rupture and cause MI and death.
It seems to me that the current guideline giving at most a weak optional nod to CAC to help further stratify intermediate risk individuals is reasonable.
FWIW.
I’d still be interested in what one of our adult-side docs’ take on this stuff is.
Sorry to multi-post but this editorial may be of interest to our op.
I am sure that each case should be an individualized decision but it sure does seem like often stents are done when optimized medical therapy alone would work better, and often instead of that more effective and less risky approach, and that when a procedure is needed CABG is more often the better choice.
