American Heart Association acknowledges the power of Heart Scans to predict heart attacks!
TYP REPORT
After years of political battling and resistance to CT scanning for coronary calcium scoring, the American Heart Association (AHA) has finally released a formal position paper acknowledging the ability of heart scans to predict heart attacks.1
"The majority of published studies have reported that the total amount of coronary calcium (usually expressed as the 'Agatston score') predicts coronary disease events beyond standard risk factors [emphasis ours]. . . These studies demonstrate that coronary artery calcified plaque is both independent of and incremental with respect to traditional risk factors in the prediction of cardiac events."
In essence, the AHA finally agrees that CT heart scans provide information about risk for heart disease that is not revealed by conventional cholesterol testing or other risk predictors. It doesn't seem like a lot, but that statement alone has been the spark for many heated debates and would never have been included in any official AHA release before now.
UCLA cardiologist, Dr. Matt Budoff, is lead author of the position paper and a long-time advocate of CT heart scanning. Notably, Dr. Budoff has been a pioneer and champion of the original EBT scanners. He was also the principal author of the controversial statement paper on CT heart scanning slated for release in 2004, but blocked by the AHA, ostensibly because the media had obtained premature warning of its release.
Because it represents an "official" position statement for the AHA, Dr. Budoff and panel members admittedly wrote the document conservatively. "Asymptomatic persons should be assessed for their cardiovascular risk with such tools as the Framingham Risk Score. Individuals found to be at low risk (<10% 10-year risk) or at high risk (>20% 10-year risk) do not benefit from coronary calcium assessment." Much like the suppressed 2004 position statement, the 2006 guidelines focus on the application of coronary calcium scoring on the so-called "intermediate-risk" person, i.e., a risk of heart attack or other cardiovascular event of 10–20% over a 10-year period. Many authorities, however, have stated that intermediate-risk should be redefined as 6–20% 10-year risk.
There is actually nothing new in the position statement. It simply collects and reports the "consensus" that has been reached by the thousands of scientific publications that have brought CT heart scanning to the forefront of cardiac risk determination. It does serve as an in-depth summary for the cardiology community and lends an air of "legitimacy" to a technology that has encountered resistance ever since its introduction in the 1980s.
Should the AHA position statement affect your decision-making about CT heart scanning? We don't think so. If you've been following the Track Your Plaque concepts, the AHA statement will tell you nothing new. Don't be confused by the low-,intermediate-, and high-risk distinctions made in the statement. These are concessions made to the political powers in the AHA who continue to resist the idea that imaging like CT heart scanning is vastly superior to risk predictors like cholesterol or the Framingham risk equation. We continue to advocate use of CT heart scans in any male 40 years of age or older, females 50 years and older, but starting at younger ages if any high-risk feature is present in your history (e.g., heart disease in young family members, substantial smoking history, diabetes, severe lipid or lipoprotein disorders).
The AHA statement does, without a doubt, represent a big step forward in broadcasting the application of CT heart scanning to the public. Your neighborhood physician is also more likely to consider ordering heart scans for his patients, provide less resistance when a patient requests one, and may even perhaps learn what to do with the results!
Editor's Note
Perhaps the growing acceptance of heart scanning across the U.S. forced the AHA into releasing its guidelines. No doubt, the political pressure of major scan manufacturers General Electric, Siemens, Toshiba, and Philips—all industrial powerhouses with $10's of billions in revenues—was also part of the motivation. In past, when the only scan device was the EBT scanner manufactured by little Imatron Inc., such pressure was not possible. But General Electric purchased Imatron several years ago and then promptly scuttled the EBT scanner and, in essence, consolidated the political pressure they could exert to support the multi-detector scan technology. (Many EBT scanners are still in operation and perfectly up to the job; GE will simply not continue to manufacture any new EBT devices.)
What does this mean for the Track Your Plaque program? It could mean that, sometime in future, insurance coverage may become a reality for CT heart scanning. AHA endorsement is something insurance companies have a difficult time dodging. Up until now, insurance companies have fudged by saying that no official statement was available. That's now all changed.
The AHA statement does mention the use of repeat coronary calcium scoring (i.e. the basis for the Track Your Plaque program), though they hedge by saying not enough scientific data is available. "Continued progression of CACP [coronary artery calcified plaque] appears to be an independent risk factor for future events, but future studies are needed."
It's taken the AHA statement years to reach broad consensus on the use of a single scan. I suspect it will be another several years before they endorse the idea of serial scanning to track disease.
Circulation editor-in-chief, Dr. Joseph Loscalzo, was the man who single-handedly withheld publication of the original 2004 guidelines on coronary CT scanning, ostensibly because of a leak of the guideline details to the media. (A story was published in the Wall Street Journal about the forthcoming guidelines just weeks before their anticipated release, prompting Dr. Loscalzo's decision.)
In my mind, the responsibility should have been to publish the guidelines despite the leak—perhaps even more so in an effort to clarify what was partially misreported by the Wall Street Journal. In fact, Dr. Loscalzo's delay in publication for over two years I believe has been responsible for the death or disability of tens of thousands of Americans who may have otherwise been made aware of the value of CT heart scans had the original guidelines been published.
Dr. Loscalzo stated "Circulation is concerned about the sanctity of embargoed information to be published in the journal and the importance of not releasing embargoed information until the article is ready to be published. When individuals provide information to the media in advance of statement publication, there is risk that the individuals' perspective on an issue may influence the coverage of that issue and may not accurately reflect the synthesized message intended by the statement."
Does that make sense to you? If there was indeed a leak, track down where and who it came from. Don't punish the public by denying them a statement that could dramatically influence access (via insurance reimbursement) and justify the use of heart scans to physicians who remain uncertain or undecided about the role of this technology.
It's worked out in the end, but I fear that political maneuvering by people like Dr. Loscalzo, for noble reasons or not, delayed the broader acceptance of a technology that had a rational scientific basis for use years earlier. Likewise, I am simply unwilling to wait for "official" endorsement for serial scanning like that advocated by Track Your Plaque, an approach that has proven, in my experience, to be the single, most powerful means to track, and potentially reduce, coronary plaque. A burning fuse can only burn so long before the bomb explodes. You can literally die waiting for consensus seekers to decide that they're happy with the weight of evidence.
References:
Budoff MJ, Achenbach S, Blumenthal RS et al. Assessment of coronary artery disase by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006;114:000–000 [e-publication]
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