An "Ah-Hah" Moment on "Real" Heart Attack Risk Assessment
Cardiologist Dr. Warrick Bishop had an enlightening experience of helping resuscitate an individual on the side of the road from a cardiac event only to find out later that this person had been a patient of his which he had cleared from significant cardiovascular risk two years prior with a stress EKG. This challenged him to look at what really needs to be done to evaluate someone's true risk of a heart attack and intervene accordingly. He became aware of and began to utilize the three dimensional CT scan (xray) of the heart for coronary calcium accumulation (without contrast dye) and with contrast (CT angiography) as excellent low risk, low cost tests that could tell the practitioner and patient the status of the plaque in the coronary arteries and what specific treatment approaches to employ, and to what level of intensity, to reduce the patients heart attack risk. The analogy of the coronary artery calcium testing would be analogous to that of the routine mammogram for breast cancer. The difference is heart disease is the number one killer in men AND WOMEN and many more women's lives are lost to heart disease than breast cancer so this raises the question of why not screening all women starting at 60 for heart disease with this technology (and men at age 50)?
Coronary Calcium Screening
It is Dr. Warrick's belief that coronary calcium testing (noninvasive, without contrast dye) is the "gate keeper" in that if no coronary calcium is found in the coronary arteries (and if the patient has no cardiac symptoms i.e. chest pain, shortness of breath, or significant risk factors like elevated lipids, family history, diabetes, etc.) then no further study is needed, nor treatment for coronary arterial plaque accumulation. But if there is ANY calcification found then a CT angiogram is warranted because he has seen cases where the calcification is small but the non-calcified "soft" plaque is large, and/or the plaque is located in a dangerous place anatomically in the coronary artery, and/or there is significant stenosis (narrowing) of the coronary artery warranting more aggressive treatment.
Hard (Calcified) and Soft (Non-Calcified) Plaque
The coronary calcium test without dye is a 10 minute, three dimensional scan (xray) of the moving heart that measures the calcium buildup in the coronary arteries or the "calcified plaque". This calcified plaque may be a protective response by the body to seal off small "microvascular" ruptures of plaque with calcium to prevent penetration of the inner artery wall. This is usually a smaller percentage of the total plaque burden (i.e. generalization 20% calcified plaque and 80% non-calcified plaque; % can vary). To "see" this soft, non-calcified plaque (amount, location), which is thought to be the more dangerous plaque because it can rupture leading to clot formation in a coronary artery (heart attack), artery in the brain (stroke), lung (pulmonary embolism/thrombosis) or leg (DVT - deep vein thrombosis) the CT angiogram with dye is needed. The soft plaque (generally 3 types - unstable necrotic core or low attenuation plaque of inflamed lipids more likely to rupture; a more stable fibro-fatty plaque, a mixture of lipids and fibrous material; and a fibrous plaque or fibrous cap that is more stable that might turn into more calcified plaque) is measured by the CT angiogram which requires dye to be injected prior to the exact same test and machine (scanner) that gave you the original calcium score.
Biochemical Testing
While Dr. Bishop uses biochemical markers of cardiometabolic status such as cholesterol, triglycerides, LDL and HDL cholesterol, homocysteine, fasting insulin, Lp (a), HS-CRP among others, the bottom line is what he sees in the coronary arteries really is the main determinant of the extent and aggressiveness of his cardiopreventive approach for that individual patient.
Lifestyle, Central Weight and Insulin Resistance
Dr. Warrick feels that insulin resistance and central weight (adiposity) and the diabetic "leaning" patients should be treated with a lifestyle program focused on weight reduction and reduction of carbohydrates, especially processed carbohydrates. He uses dietician counseling to support his medical program.
Nutraceuticals
He uses some nutraceuticals such as coenzyme Q10 for some statin users with some anecdotal benefit and for some types of heart failure; fish oil for elevated triglycerides and insulin resistance; and slow release niacin (500-1000 mg daily) for low HDL levels and high Lp (a).
Professional Awareness of Coronary CT Scanning
Dr. Warrick wishes there was greater receptivity with his professional colleagues both general practitioners and cardiovascular specialists to this technology (coronary calcium scoring and CT angiography). He continues to try and educate professionals on this technology.
Patient Education
An educated patient gets the best medical care according to Dr. Bishop. So being able to tell them the real status of their plaque and anatomy of their coronary arteries using coronary calcium testing and CT angiography, along with some biochemical determinants and lifestyle, allows him to create with the patient a specific heart attack prevention program.
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About Cardiologist Dr. Warrick Bishop
Doctor Warrick Bishop is a practicing cardiologist, bestselling author and key-note speaker who has a passion to help prevent heart disease on a global scale by early detection. Assessment tools he champions are coronary calcium screening and the appropriate use of CT angiography (CTA). With a detailed assessment of what is happening within the coronary arteries an individualized preventive strategy can be employed.
Dr. Bishop graduated from the University of Tasmania, School of Medicine, in 1988. He completed his advanced training in cardiology in Hobart, Tasmania, becoming a fellow of the Royal Australian College of Physicians.
He is the author of: “Know Your Real Risk of Heart Attack” 2018, pages 158.
Warrick Bishop, MD, Calvary Hospital Consulting Rooms, 49 Augusta Rd, Lenah Valley TAS 7008, Phone: (03) 6278 9220 warrick@drwarrickbishop.com www.drwarrickbishop.com
Be and Stay Well,
Kirk
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