A victory for SHAPE, CT heart scans, and doing what is RIGHT

The efforts of Texas House of Representatives Rep. Rene Oliveira and the SHAPE Guidelines committee have paid off: The Texas legislature passed a bill that requires health insurers to cover CT heart scans.

(NOTE: Don't make the same mistake that the media often makes and confuse CT heart scans with CT coronary angiography: two different tests, two different results, two different levels of radiation exposure. The difference is discussed here.)

Track Your Plaque previously reported the release of the SHAPE Guidelines, an ambitious effort to open CT heart scanning to people who would benefit from a simple screening test for coronary disease. Rep. Rene Oliveira initially introduced the bill in 2006, after having a heart scan uncovered extensive coronary plaque that resulted in coronary bypass surgery.

The bill requires that health-benefit providers cover the cost of CT heart scans (and carotid ultrasound) in men between the ages of 45-76, women 55-76, as well as anyone with diabetes or at "intermediate-risk" or higher for coronary disease by Framingham risk score.

The usual panel of cardiology knuckleheads stepped to the media podium, expressing their incredulity that something as "unvalidated" as heart scans could gain the backing of legislative mandate. Heartwire carried this comment:

"Contacted by heartwire, Dr Amit Khera (University of Texas Southwestern Medical Center, Dallas) confirmed there are still no comprehensive, adequately powered studies showing that these screening tests lead to better outcomes. In a phone interview, Khera said he has major concerns about how physicians will use these tests, particularly primary-care physicians. "I gave a talk last week to primary-care doctors, and there were probably 250 people in the room, and when I asked how many people had ordered a calcium scan, just one person raised a hand. . . . Most people don't even know what to do with the Framingham risk score, so they're going to follow an algorithm that they don't know how to follow to order a test result that they don't know what to do with."

It's the same criticisms hurled at heart scans over the years despite literally thousands of studies validating their application.

Studies have conclusively shown that:

--Coronary calcium scores generated by a CT heart scan outperform any other risk measure for coronary disease, including LDL cholesterol, c-reactive protein, total cholesterol, HDL cholesterol, blood pressure.
--Coronary calcium scores yield a graded, trackable index of coronary risk. Scores that increase correlate with increased risk of cardiovascular events; scores that remain unchanged correlate with much reduced risk.
--A coronary calcium score of zero--no detectable calcium--correlates with extremely low 5-year risk for cardiovascular events.
--Coronary calcium scores correlate with other measures of coronary disease. Heart scans correlate with coronary angiography, quantitative coronary angiography, carotid ultrasound (intimal-medial thickness and plaque severity), ankle-brachial index, and stress tests, including radionuclide (nuclear) perfusion imaging.

The reluctance of my colleagues to embrace heart scans stems from two issues, for the most part:

1) No study has yet been performed showing that knowing what the score is vs. not knowing what the score is changes prognosis. That's true. But it is also true of the great majority of practices in medicine. While many wrongs don't make a right, the miserable and widespread failure of other coronary risk measures, like LDL cholesterol or c-reactive protein, to readily and reliably detect hidden coronary disease creates a gaping void for improved efforts at early detection. If your LDL cholesterol is 140 mg/dl, do you or don't you have coronary disease? If your doctor's response is "Just take a statin drug anyway" you've been done a great disservice. (If and when this sort of study gets done, its huge cost--outcome studies have to be large and last many years--it will likely be a statin study. It is unlikely it will include such Track Your Plaque strategies that help reduce heart scan scores, like vitamin D and correction of small LDL particles.)

2) Fears over overuse of hospital procedures triggered by heart scans. This is a legitimate concern--if the information provided by a heart scan is misused. Heart scans should never--NEVER--lead directly to heart catheterization, stents, bypass surgery. Heart scans do not change the indications for performing revascularization (angioplasty, stents, bypass). Just because 20% of my cardiology colleagues are more concerned with profit rather than patient welfare does not invalidate the value of the test. Just because the mechanic at the local garage gouged you by replacing a carburetor for $800 when all you need was a new spark plug does not mean that we should outlaw all auto mechanics. Abuse is the fault of the abuser, not of the tool used to exercise the abuse.

All in all, while I am not a fan of legislating behavior in healthcare, the blatant and extreme ignorance of this simple tool for uncovering hidden heart disease makes the Texas action a huge success for heart disease prevention. I hope that this success will raise awareness, not just in Texas, but in other states and cities in which similar systemic neglect is the rule.

Remember: CT heart scans are tools for prevention, not to uncover "need" for procedures. They serve as a starting point to decide whether or not an intensive program of prevention is in order, and I don't mean statin vs. no statin.

Though not a multi-million dollar statin drug study, I have NEVER seen a heart attack or "need" for procedure in any person who has stopped progression or reduced their heart scan score. A small cohort from my practice was reported:

Effect of a Combined Therapeutic Approach of Intensive Lipid Management, Omega-3 Fatty Acid Supplementation, and Increased Serum 25 (OH) Vitamin D on Coronary Calcium Scores in Asymptomatic Adults.

Davis W, Rockway S, Kwasny M.

The impact of intensive lipid management, omega-3 fatty acid, and vitamin D3 supplementation on atherosclerotic plaque was assessed through serial computed tomography coronary calcium scoring (CCS). Low-density lipoprotein cholesterol reduction with statin therapy has not been shown to reduce or slow progression of serial CCS in several recent studies, casting doubt on the usefulness of this approach for tracking atherosclerotic progression. In an open-label study, 45 male and female subjects with CCS of >/= 50 without symptoms of heart disease were treated with statin therapy, niacin, and omega-3 fatty acid supplementation to achieve low-density lipoprotein cholesterol and triglycerides /=60 mg/dL; and vitamin D3 supplementation to achieve serum levels of >/=50 ng/mL 25(OH) vitamin D, in addition to diet advice. Lipid profiles of subjects were significantly changed as follows: total cholesterol -24%, low-density lipoprotein -41%; triglycerides -42%, high-density lipoprotein +19%, and mean serum 25(OH) vitamin D levels +83%. After a mean of 18 months, 20 subjects experienced decrease in CCS with mean change of -14.5% (range 0% to -64%); 22 subjects experienced no change or slow annual rate of CCS increase of +12% (range 1%-29%). Only 3 subjects experienced annual CCS progression exceeding 29% (44%-71%). Despite wide variation in response, substantial reduction of CCS was achieved in 44% of subjects and slowed plaque growth in 49% of the subjects applying a broad treatment program.

Comments (7) -

  • billye

    6/24/2009 4:51:58 PM |

    Dr. Davis,

    I know how frustrated you and a few other doctors are relative to the contrariness of some of your colleges.  They hide behind the necessity for long term CYA clinical trials that never seem to take place.  I know that the road to good health and fiscal solvency of health care lies in the direction of supplementation with wild omega 3 fish oil and high dose vitamin D3 along with a low carbohydrate and high fat program.  But a study along these lines will never take place.  After all, you can't get a Patent out of such a program, therefore, pharmaceutical companies will never fund it.  
    I am a study of one for the last 9 months.  My forward thinking nephrologist,www.nephropal.blogspot.com  who follows your blog intently, put me on the above mentioned program while reassessing and stopping many of my medications.   One in particular is Staten's. I have achieved a loss of 50 pounds, my Trig/Hdl ratio is 2.73. My hbA1c diabetes type 2 score dropped from 5.9 to 4.6.  Many other health markers have greatly improved.  I tell you all of this because I can't get the notion out of my head that if the above mentioned was a national policy,  Diabetes essentially cured along with heart disease and many other metabolic syndrome diseases brought on by the western healthy diet, would not the financial difficulty plaguing universal health care be over.

    Bravo to doctors like you that step out of the box and treat patients with the goal of cure not just a prescription and see you in 3 months.  You doctors are the unsung heroes of the medical profession.

  • Dr. William Davis

    6/24/2009 8:04:00 PM |

    Great results, Billye!

    And thanks for the kind feedback.

  • Roger

    6/25/2009 12:12:55 AM |

    What timing for your post!  I live in Texas and I am scheduled for my first CT heart scan...tomorrow.  I don't have any outward risk factors, except age and family history, but my doc thought it was a good idea.  I'm glad to know insurance is covering it!

  • stern

    6/25/2009 6:14:57 PM |

    you never seen hearth atach with hearth scan and no calcium even with lpa high?
    other dr had never seen hearth atack when magnesium hydroxide was taken routinly is it corelate each other meaning it digests the calcium?

  • Roger

    6/25/2009 11:31:32 PM |

    I posted yesterday that I was about to have my first CT heart scan...well, it was an interesting experience for reasons I coudn't possibly have anticipated.  Dr. Davis has commented in the past on the confusion in the media about the difference between a CT calcium score scan, and a CT angiography, the latter requiring a far higher dose of radiation.  I assumed this was a source of confusion only among patients and lay folks, but, lo and behold, I discovered today that doctors--or at least their helpers--can be just as confused.  

    Here's my story:

    After checking in, I asked the receptionist to see if she had any information on whether my medical insurance was covering the scan.  She called someone, and I heard her say over the phone, "he's here for a CT angiogram."  At that point my ears perked up.  I explained I wasn't here for a CT angiogram, only a regular CT scan.  "Well, do you want to call your doctor and talk about this?" she asked.  No, I said, I would like to ask one of their folks to verify exactly what test my doctor had ordered.  As luck would have it, the technician was walking by at that point.  "Is this a CT angiogram?" the receptionist asked.  "No, it's just a CT calcium score scan" was the reply.  But apparently the technician had been unclear herself, and had called my doctor just to verify.  In other words, the "default" procedure they were accustomed to doing at this august Houston vascular clinic was a CT angiogram.

    In fact, my appointment was even listed on their calendar as a "CT angiogram."  For all I know, my insurance will be billed for the same. Later, during the procedure, the technician acted surprised I wasn't doing the "full test."  I explained I had minimal risk factors (actually only one, an HDL of 34 a couple of years ago, which has since been raised to 50 partly as a result of taking advice from this site), but that my doctor was progressive (he is an MD for the Houston Astros) and thought it was a good idea since there is heart disease in my immediate family.  My doctor did indeed prescribe only a CT calcium score scan, but it seems to have been an order that this clinic, at least, wasn't all that used to seeing.

    So, I guess the message is: we have a lot of educating to do.  Had I not been a faithful reader of these pages, I certainly wouldn't have known what kind of test I was about to get, or what questions to ask!

    As for the heart scan itself, a piece of cake.  If you can hold your breath, you can take this test.  Just be sure it is the right one!

    Keep up the good work, Dr. Davis.

  • Dr. William Davis

    6/26/2009 3:18:54 AM |

    Thanks, Roger. And thanks for telling about your near-miss with a CT coronary angiogram!

    Your comment is so helpful that I'd like to use your story as the focus for a Heart Scan Blog post.

  • buy jeans

    11/3/2010 10:29:04 PM |

    All in all, while I am not a fan of legislating behavior in healthcare, the blatant and extreme ignorance of this simple tool for uncovering hidden heart disease makes the Texas action a huge success for heart disease prevention. I hope that this success will raise awareness, not just in Texas, but in other states and cities in which similar systemic neglect is the rule.