Every year, about 720,000 Americans have a first heart attack. One in five will die, many without reaching the hospital. We want to change this status quo starting in you own community.

According to the American Heart Association, every year about 720,000 Americans have a first heart attack and 335,000 happen in people who already had a heart attack. How many of the 720,000 first heart attacks can be prevented every year? A lot of them. But first, we need to identify them and then treat them medically to prevent plaque rupture, stop plaque progression and induce plaque regression.

My journey to heart attack (and stroke too) prevention started in 2001 when I realized that the future of cardiovascular disease management was not putting more stents and performing more heart bypass surgeries. A nationwide physician survey called L-TAP study, revealed that only 18% of CHD patients were treated to an LDLc of less than 100 mg/dL; 82% were either not being treated with statin or not treated adequately. My journey to prevention began after that.

I decided to find a way to incorporate aggressive prevention as part of every patient visit. This lead to the creation and development of a numerically goal-oriented clinical management system which included CV risk assessment for every patient and setting treatment goals based on the magnitude of risk. The higher the risk, the lower the LDLc treatment goal. We published our first LDL-c treatment performance data in 2006 and the second in 2016. In 2006, 85% of high risk patients (CHD and CHD risk equivalent patients) were treated to an LDLc level of less than 100 mg/dL and 32% had an LDLc level below 70 mg/dL. In 2017, 89% had reached LDLc level of less than 100 mg/dL and 52% were below 70 mg/dL. CV events declined progressively every year to the point that they had become very uncommon and unexpected. The duration of treatment is directly proportional to the magnitude of event reduction so it is important to identify these 720,000 Americans earlier.

The most common method is to calculate the 10–year Framinghan risk score. It is very inaccurate resulting in under-treatment, over-treatment and even no treatment due to non-compliance by either the patients and the care providers. High Framingham risk scores of over 20% means that a patient is at high risk for CV events but the approach does not answer two fundamental questions: firstly, does the patient have plaques or not, and secondly, how much plaques are present. Some well-informed patients may ask after they are told that they are at high risk with a score of 25% before they start taking statin: Question 1: Do I have plaques? (Framinghan does not know.) Question 2: If I have plaques, how much do I have? (Framingham does not know.) Question 3: If I don’t have plaques, am I still at high risk? (No. You are not at high risk.)

This approach starts to look more and more like cardiac palmistry in the 21st century medicine. It is like reading the patient’s palm to determine the likelihood of having a heart attack, stroke and sudden vascular death based on one’s age, sex, blood pressure, HDLc, smoking, etc. It is not based on whether or not coronary plaques, the cause of heart attack, are present or not.

In the last 10 years, coronary calcium scoring has become more accessible at $49 to $99 for the test and most patients are willing to pay out-of-pocket if they understand what the test is for. Calcium scoring is like mammography for the heart but needs to be done only once in most cases. It is not an annual test and requires no special preparation, no fasting, no IV line, no injection, no exercise, very low radiation exposure and usually completed in less than 30 seconds. The result is diagnostic for the presence of calcified plaques – an accurate reflection of total plaque burden. The score can range from 0 to over 4,000. The need for and the intensity of medical therapy are determined accordingly. 

Some patients may ask what about doing a nuclear stress test instead. The hospital charges for a nuclear stress test is around $30,000! A normal nuclear stress test does not mean that the patient is not at high risk. A patient can have a calcium score of over 2,000 and still have a normal stress test. It only means that there are no coronary plaques causing severe obstruction of 70% or greater.

About 68% of plaques that cause heart attacks obstruct the artery by 50% or less. Stress testing plays no role in the risk assessment of asymptomatic patients. 

There are many practical importance of knowing the coronary calcium score in the primary prevention patients. 

1. The patient is more likely to get appropriate medical therapy. A 50 year old man and a 60 year old woman had calcium scores of 850 and 450 respectively. They were started on statin therapy and their on-treatment LDLc level were both less than 70 mg/dL. They will not be on statin if they did not have their calcium score.

2. A patient needed to be on statin therapy but had refused for years. The calcium score was 500. Patient started taking statin.

3. A patient had been on several different statins but continue to experience on and off muscle aches. Calcium score was 0. Statin was discontinued and myalgia resolved after several weeks.

4. A patient already on low dose statin but not at goal. Refused to take a higher dose statin in combination with ezetimibe. Calcium score was 1,864. Patient agreed to take statin-ezetimibe combination therapy. On-treatment LDLc dropped to 45 mg/dL.

I remember that for decades, the American Heart Association and the American College of Cardiology were actively waging a war to end heart disease. I believe, we won that war. Why are so many Americans still having heart attacks needlessly every year? Did we stop fighting just before the battle was won?

In 2015, the ACC president Dr. Kim Williams said: “It is time to turn off the faucet instead of just mopping the floor.”

Coronary calcium scoring provides the new tool that we need to resume our fight and stop heart attacks before they happen.

An added bonus: The same medical treatment that prevents heart attacks also prevents most strokes.

Improved patient outcomes while lowering healthcare cost - who does not support it.

The total economic burden of CV disease is estimated at around $500 billion annually. It kills more Americans than the three 3 leading causes of death combined. Compared to the mean cost of all cardiologists nationwide, aggressive CV prevention helps us save Medicare about $9,000 per beneficiary with diagnosis of CHD and about $6,500 per beneficiary with diagnosis of diabetes.

Who should consider getting their calcium score?

Get your calcium score if you are male over 45 or female over 50 and have at least one of these heart attack risk factors:

1. You smoke.

2. Have high cholesterol or taking statin.

3. Have high blood pressure or taking blood pressure medications.

4. Have diabetes or taking diabetic medications.

5. A family history of heart disease or stroke.

6. Have experienced chest pains and have none of the above risk factors.

7. If statin therapy was previously recommended and you don’t want to take it unless you really need to or if you are already taking statin but you are considering stopping it because you are having some side effects or you are not really sure you need to take statin. (If your score is ZERO, you may not need to take statin.)

All the three previous and current US presidents had a coronary calcium scan for their calcium score. Get your calcium score - your gift to yourself. Or to someone you care. Watch the award-winning Netflix documentary - The Widowmaker.

SaveYourHeartCampaign.org was developed by Dr. R. deGoma to help primary care physicians eliminate more preventable premature cardiovascular deaths, heart attacks and strokes in the community.

Why not everyone supports ending heart disease as we know it - because not everyone benefits for it. The total economic burden of heart attack and stroke is estimated at $500 billion annually. There is a lot at stake both in human lives and $$$$$.

My approach to heart attack and stroke prevention uses the accumulated scientific knowledge from all the placebo-controlled clinical trials and my own vast experience in aggressive prevention since 2001 and the patient data we collected over a period of 15 years of treating high risk patients. We build an almost impenetrable barrier of supra-optimal medical therapy and high patient compliance that prevents the occurrence of first heart attack and stroke and for those who already had suffered cardiovascular events, stops the cycle of recurring events.

Who benefits? Patents who are expected to have a heart attack and don’t, their families, their employers, their communities, Medicare and the country.

Who does not benefit? They are on the right side of the barrier - all that are not paid when heart attack and stroke are prevented: the hospitals, some specialists, medical device manufacturers, insurance companies, etc.

The money spend on treating heart attack and stroke serves as the fuel that support the disease care economy and GDP. But that money could be better spent by the patients themselves in ways that is even better for the economy.

© Rolando L. deGoma MD  2019     www.deGomaMD.com     Capital Cardiology Associates     Princeton Physicians' Organization