February 16th, 2015
Case: Rising Coronary Artery Calcium in a Patient Who Has a Normal Stress Echo with an Abnormal ECG
Ethan J Weiss, M.D.
A 74-year-old physically active man exercises daily, takes a statin for hyperlipidemia, and has no other risk factors aside from a mildly elevated hemoglobin A1c. His most recent lipid profile, in January 2015, was:
- Total-c: 144 mg/dL
- LDL-c: 84 mg/dL
- HDL-c: 48 mg/dL
- Triglycerides: 59 mg/dL
His coronary artery calcium scores were 109.5 in the year 2000 and 400.4 in 2008.
Stress tests in 2002 and 2006 were normal with good exercise tolerance, but the ECG portion of both stress tests was abnormal. The nuclear perfusion scans were normal both times. His cardiologist at the time told him to continue his medical therapy, which included aspirin 81 mg and atorvastatin 10 mg.
In 2014, a new cardiologist repeats the stress test and again finds discordant results: The echo is normal, but the ECG is abnormal. An exercise nuclear perfusion scan is ordered. Again the perfusion is normal, but the ECG is abnormal. The new cardiologist increases the atorvastatin to 40 mg. The patient continues to exercise and remains asymptomatic.
The patient is sent for a CT angiogram, but the test is not done because the patient has a calcium score of 756, which is felt to be too high to exclude CAD by CT angiography.
Questions:
1. Do you agree that nuclear perfusion imaging and treadmill echo are more specific than treadmill ECG alone without imaging? Does an abnormal exercise ECG with normal imaging raise a concern?
2. Should an increasing calcium score in an asymptomatic individual raise concerns?
3. Would this patient have met the enrollment criteria for the COURAGE trial? Should the data from COURAGE help guide decision making for this patient?
4. What would you do next to care for this patient?
16 Responses to “Case: Rising Coronary Artery Calcium in a Patient Who Has a Normal Stress Echo with an Abnormal ECG”
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Leave him alone , keep him out of the cath lab , continue exercise regimen, and lipid management, stop checking his calcium score, and don’t make him crazy!
Succinct but accurate. This case invokes Loeb’s Law of Medicine:
1. If what you’re doing is working, keep doing it.
2. If what you’re doing is not working, quit doing it.
3. If you don’t know what to do, don’t do anything.
4. Above all, don’t let a surgeon touch your patient.
1. Do you agree that nuclear perfusion imaging and treadmill echo are more specific than treadmill ECG alone without imaging? Does an abnormal exercise ECG with normal imaging raise a concern?
In this case the patient had abnormal exercises ECG since 2002 for 13 years he continues asyntomatic and no mayor cardiac event. So I agree with the result of the nuclear perfusion imaging test. Hig probability of No high grade coronary stenosis.
2. Should an increasing calcium score in an asymptomatic individual raise concerns?
Yes, This patient with a score of 756 is at high risk for a coronary event.
A positive calcium scan indicates atherosclerosis, but most often, no significant stenosis.
The published studies demonstrate a high sensitivity of CAC for the presence of coronary artery disease but a lower specificity for obstructive CAD depending on the magnitude of the CAC
The total CAC score measured represents an anatomic measure of overall cardiac plaque burden. Exercise testing or pharmacologic cardiac imaging (nuclear or echo) will only diagnose high grade coronary stenoses. They will fail to identify a vast number of asymptomatic patients at risk because an obstructive coronary plaque (stenosis in the artery of >50% severity) is most often NOT the site of the cardiovascular event (MI or sudden cardiac death)
Then the prognosis of CAD, is more closely related to atherosclerosis plaque burden and stability than the extent of a particular stenosis
The presence of CAC in asymptomatic persons does not provide rationale for revascularization, but rather risk factor modification and possible further functional assessment
3. Would this patient have met the enrollment criteria for the COURAGE trial? Should the data from COURAGE help guide decision making for this patient?
Yes, the presence of CAC in asymptomatic persons does not provide rationale for revascularization, but rather risk factor modification and possible further functional assessment.
4. What would you do next to care for this patient?
Look for inflammation, risk factor modification, close follow up.
Would like to know more about family history re Diabetes, and definitely will discuss diet re portion size, content ragarding % of refined carbs and intensity and type of exercise to see if the Hemoglobin A1C elevated corresponds or not to his age. Some dietary modifications and exercise could lessen a pre diabetic status that could better be assessed adding fasting blood sugar and Insulin to the A1C while you also check for inflammation as very well suggested by Dr.Guadiana. Could a prediabetic status incide in he Calcium deposition that is postulated?
Dr. Guadiana is correct.
1. I do not know why we are doing a stress test of any kind in this asymptomatic person. There are now 7 or 8 prospective, randomized trials demonstrating no improvement in coronary death or Mi with revascularization and 0 trials published over the last 20 years showing a value. The only indication for revascularization is symptom control, and this subject has no symptoms.
2. An increase in the calcium score >14% annually was associated with a 17X increase in MI incidence in a study of 495 asymptomatic subjects with positive calcium scores, all treated with atorvastatin. Another study out of UCLA found a 3X increase in all cause mortality based upon plaque progression >15% annually.
ACCF/AHA 2007 Expert Consensus Document Circulation Jan 23, 2007 “CAC progression increased the associated cardiovascular risk across all levels of CAC severity. Furthermore, the detection of stable CAC was associated with a low risk of cardiovascular events even among those with extensive CAC.”
3. Courage, Rita II, Stitch II, etc… Why does it matter, this person needs more effective medical preventive strategies. Nuclear stress and angiography can only expose him to increased radiation and risk for no expectation of benefit.
4. He needs a better diet with increased amounts of fruit, veges, pigmented berries, and beneficial fats such as fish oil, olive oil, avocado, and almonds and walnuts.
He should do meticulous dental care with daily flossing and he should see a dentist for x-rays if he has not had them recently.
He should be screened for sleep apnea.
Considering his glucose intolerance, I am not sure that increasing the statin was a good idea. Adding colesevelam would improve glucose tolerance while improving lipid levels and improving calcified plaque progression.
I would add niacin in a dose up to but not to exceed 1,000 mg slo-niacin daily.
I would check a homocysteine and if elevated, treat with methyl-folate 400 mcg daily.
I would consider adding vitamin K-2 as studies have demonstrated stabilization of calcified plaque.
I would check a vitamin D level and replace to a level of 50 mcg/dl.
I would then recheck a CAC after enough time has passed to allow the technology used to give a meaningful result. EBT or 256 slice dual source helical could be repeated in 12 months, 64 slice probably should not be repeated before 3 years due to increased scan acquisition time.
1. In this case the treadmill ECG appears as a false positive test; the normal perfusion imaging is enough to reassure about the absence of myocardial ischemia.
2.The increasing calcium score is certainly of concern, but what to do with it in our current knowledge.
3. In COURAGE, patients were required to present objective ischemia. This patient would not have met the enrollment criteria for this trial and results cannot of this study cannot guide decision making.
4. Continue statin tt.
Isn’t time to stop checking such asymptomatic well being people with multiple,costly and perhaps ominous explorations which contradict each other ??
Change to new Case Western diet that reduces artery atherosclerosis….I think it is vegetarian -like .
Calcic score i.e. “classic unsolved problem”
Do you want a bet? Calcic-score will soon join Intima Media Thickness on the shelves of oblivion!
I totally agree with dr Gordon’s opinion “Leave him continuing his asymptomatic life…”
If he does a coronary angiogram (some like it!)be sure he will have an active stent somewhere and double anti agregant whole life
Worse a brand new one: a scaffold! Which make him to consider he is 100% cured:
“Had I ever an arterial problem? It was before…”
I Wonder if Oncologists have the same soul-searching during their pluridisciplinary concertation meetings?
Enhance OMT.
Drs Usdin and Gordon. You seem to be comfortable with the fact that he is currently asymptomatic. Have we forgotten that the first symptom of coronary disease is usually an MI. Over half of the people who die from heart attacks had no symptoms until their first symptom which was also their last symptom.
Why would we not want another calcium score as serial calcium scores so strongly predict MI risk as well as mortality risk. My experience has shown that progression of calcified plaque results in improvement in patient compliance with treatments (including diet and exercise), and awakens me to that fact that we need to treat more vigorously. I have often found sleep apnea, dental abscesses, or subclinical diabetes is subjects with plaque progression where the only stimulus to look for these illnesses was the plaque progression.
I am looking forward to the day that calcium scores will be replaced by a better technology. However today, no such technology exists. A calcium score of 0 is associated with an MI risk of 300 is associated with 10X the risk that all risk factors combined would calculate.
Calcium progression >15% annually is associated with a dramatic increase in MI risk and all cause mortality. Why is this information not important?
Those who think their job is done when they have prescribed a high dose statin are sadly mistaken. The best studies show that statin therapy reduces heart attacks by <30% and coronary death by <20%. Even where I went to school these grades were considered failing. In the world of cardiology, they are considered the top grades in the class. I beg to differ.
Some text was lost.
Paragraph 3 should read:
I am looking forward to the day that calcium scores will be replaced by a better technology. However today, no such technology exists. A calcium score of 0 is associated with an MI risk of 300 is associated with 10X the risk that all risk factors combined would calculate.
WTF, it lost the text again, I will try once more.
Paragraph 3 should read:
I am looking forward to the day that calcium scores will be replaced by a better technology. However today, no such technology exists. A calcium score of 0 is associated with an MI risk of 300 is associated with 10X the risk that all risk factors combined would calculate.
I give up. Your blog keeps removing (A calcium score of 0 is associated with an MI risk of 300 is associated with 10X the risk that all risk factors combined would calculate. )
I think what we have to consider here is what does this patient have and what are we trying to achieve. He has coronary artery disease and he is at risk of having a cardiac event based on his age, and his hyperlipidemia. However, he does not appear to have angina or exertional symptoms. That being said, as we know, sometimes people do not identify their functional limitations from angina and thus in these setting objectively assessing functional capacity with a stress test (even if the patient maintains that they are asymptomatic) is not unreasonable- for example we are not told in this case report how much or how little the patient can actually do.
But if the patient is truly asymptomatic, then lets try and address the next issue which is reduce his risk of having a cardiac event- again, he is at risk of having a cardiac event, so we should introduce treatment options that will modify that risk. To lower his risk, the patient could adjust their diet- of course the Mediterranean diet was studied in patients at high risk (average age 67 yo) and found to decrease cardiac events. Additionally another way to decrease his risk is by introducing statin therapy- the question comes up however as to what statin trial we use to support the introduction of statin therapy in this case of an asymptomatic man- the St. Francis Heart Study demonstrated that atorvastatin 20 mg lowered events in asymptomatic patients with CAC >400 (8.7% vs. 15.0%, p = 0.046 [42% reduction]).
I agree with Thierry that the patient would likely not qualify for COURAGE trial if they are truly asymptomatic. I would respectively challenge Dr. Blanchet however- as the niacin, colesevelam, vitamin K-2 etc have not been shown to improve clinical outcomes and could potentially detract from the options with a stronger evidence base- exercise, diet and statins. Additionally, I am not sure that there is any further role for follow-up CT scans, in the absence of available treatment that can modify the risk associated with CAC (aside from those already presented).
I want to thank everyone for contributing to this case and in particular to Ethan for sharing it with us.
Thanks John! I thought it was an interesting one and really value everyone’s input. The story is not yet over. I will fill in details as I learn what happens.
Thank you for this beautiful case discussion. I agree with many of the opinions of the discussants. InterScan variability can be high by 64-slice scanning. EBT or more of the detectors with MDCT could be better for calcification determination.
I don’t agree that nuclear perfusion imaging and treadmill echo are more specific than treadmill ECG alone without imaging. Moreover, it is necessary to forget the nuclear perfusion imaging of radiation exposure.
It’s important to be asymptomatic patient. Patient should be examined for masked hypertension. If there is hypertension, should be treated.
I do not find it important to glucose intolerance. Because a growing atherosclerotic plaque burden in this patient present. Therefore statin should be continued to be used. But I think it is enough that the use of 20 mg doses. I do not think of vitamin K and niacin would benefit. Vitamin D’s benefits is also very controversial.
I think it is more appropriate patient follow up instead of interventional procedures.