MEDICAL BREAKTHROUGHS RESEARCH SUMMARY TOPIC: MAMMOGRAM FOR THE HEART: CORONARY CALCIUM SCORE REPORT: MB #4014

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1 MEDICAL BREAKTHROUGHS RESEARCH SUMMARY TOPIC: MAMMOGRAM FOR THE HEART: CORONARY CALCIUM SCORE REPORT: MB #4014 BACKGROUND: Heart disease is a term that can refer to several types of heart conditions. Coronary heart disease is the most common heart disease within the United States. Other heart disease conditions include arrhythmias and congenital heart defects. Heart disease tends to be used to refer to conditions that cause blockages in the arteries, reducing blood flow to the heart and ultimately causing a heart attack. About half of all Americans have at least one of the three major risk factors for heart disease. These risk factors include high blood pressure, smoking and high cholesterol. Other factors like obesity, diabetes, alcohol abuse and an unhealthy diet can increase the chances of developing heart disease. (Source: TREATMENTS: The most common and effective treatment for heart disease and the best way to prevent it is through dietary and lifestyle changes. Eating a low-fat, low-sodium diet and exercising a minimum of 150 minutes a week can help patients reduce their chances of having a heart attack. Doctors also recommend quitting smoking and limiting alcohol intake to help regulate blood pressure. Depending on the severity of the heart disease, surgery or medications may be prescribed to help reduce the risk factors of having a heart attack. However, doctors do advise that surgery does not cure heart disease. Patients who receive heart stents, angioplasty surgery, heart bypass surgery or ablation due to coronary artery disease are advised to make the lifestyle changes required to reduce high blood pressure and high cholesterol. Though some patients have normal blood pressure and still have heart attacks, aerobic workouts help the heart become stronger and less susceptible to heart attacks. (Source: NEW TECHNOLOGY: Cardiac computerized tomography (CT) scan for coronary calcium scoring is a new technique to locate any calcified plaque in the coronary arteries. The process is noninvasive and can help detect the presence of coronary artery disease in patients with little or no symptoms. The CT scan is similar to other X-ray examinations. In CT scanning, there are several X-ray beams aimed at the body and X-ray detectors rotate around the body allowing the machine to take a set of images in only a few seconds. For calcium scoring, a negative cardiac CT scan would mean there is no coronary artery disease seen by this technology and the chances of having a heart attack is very low. The calcium score can go to 400 or higher, indicating extensive evidence of coronary artery disease. (Source: FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT: Ashley Paskalis Asp2011@med.cornell.edu If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com

2 James Min, M.D., Professor of Radiology and Medicine at Weill Cornell Medicine and Director of the Dailo Institute of Cardiovascular Imaging at New York Presbyterian Hospital talks about the calcium scoring technique for heart risk assessment. Interview conducted by Ivanhoe Broadcast News in September 2015 I wanted to ask you about the risk assessment. It s something that maybe not everybody has heard of before, can you just give us an overview of what happens when you re doing risk assessment test? Dr. Min: Yeah, sure. We try to do patient-based risk assessment in our Heart Health Program and what we are trying to do is transition people over from population-based health to patientspecific health or personalized health. What we know is that there are some very alarming factors that it turns out if you look at these risk factors that we have, such as high cholesterol or high blood pressure, about 80 percent of the people who present having a heart attack, have normal cholesterol. That s because the cholesterol that s high is a good risk factor. When you look at populations of people, it s not a good risk marker, so it s not something where you can pinpoint and just point to that person say, you have disease or you don t have disease and we need to aggressively treat you, to that sort of tailor-made approach to care and that is what we are trying to do in risk assessment. We try to stratify somebody s risk and say, are you at risk of a heart attack, because more than half of the people present what the heart attack didn t have in any of the systems before. They were just a systematic walking around and boom they had a heart attack. There are millions and millions of us out there who are at risk for a heart attack but who don t know it. May have a normal cholesterol or normal blood pressure, feel just fine, running in the park on the weekends but they are still at significantly at higher risk so that s what we are doing with our risk assessment programs. Talk to me a little bit about calcium scoring? Dr. Min: Coronary calcium scoring is a great method for personalized risk assessment because what it does is it looks at the calcium plaque buildup in the heart arteries to see the extent, the severity, the location of all of these kinds of plaque buildup. And it turns out it s the best risk stratifier that we have out there. If you took a bunch of test that we have available cholesterol levels, blood pressures, if you look at the plaque buildup in the neck arties, or this coronary artery, calcium turns up and that s the best predicator of who will have a future heart attack or not. You ve described possibly to your patients, this kind of testing and they may not be so familiar with it, most people are probably not. How do you describe it to them, how do you bring it to them? Dr. Min: The coronary calcium score is a simple test. It s an X-ray, an X-ray of your heart. Somebody comes in, it doesn t take long, maybe a total of 10 minutes but the actual scan

3 probably takes about five seconds or so. You come in, take off your shirt, somebody puts three EKG leads on so that we can monitor the heart rhythm, and somebody asks you to hold your breath a couple of times and about five minutes later you re out the door. There s no contrast, there s no medications, it s just a simple X-ray to look at the white calcium buildup, the plaque buildup, in the heart arteries. In terms of screening tests, what is it comparable to that people might be familiar with? Dr. Min: I think people are always concerned about radiation dose because it s an X-ray, but the radiation dose is very low. It s on par with like a screening mammogram. So, women get yearly mammograms and this is recommended as a one-time test. It s not a yearly test, what it is the integrated sum of all the things that happened to you in your life to cause what kind of plaque buildup and how severe. So that one-time assessment really helps us figure out who s at risk and who s not. Now you ve done some research into this and is there a trial going on or are you studying this specific testing? Dr. Min: Yeah, we ve done a number of studies on this coronary calcium scoring simply to figure out who it s best suited for, or if it is too good for anybody. It turns out to be the best test predicator of who s going to have a heart attack or who s going to have an adverse event going forward. We published a paper recently, a couple of papers, looking at what is the warranty period. So everybody always like to talk about the sick person but they always compare the sick person to the healthy person. Nobody ever really thinks about the healthy person and more than half of the people who come in, who are appropriate for this test, should have a normal study. If they have a normal study, we want to say how long is that normal study good for so we looked at a group of people, about 10,000 people, and we followed them for about 16, 15 years ago or so, and it turns out that the warranty period of this test is 15 years. It s probably longer but we only had 15-year follow-ups so we only reported out to that length of time. But it s such a strong test, not only is it predictor of risk but as a guarantor of safety as well. In that regard, I think that this test offers both sides of the coin, it can tell you if you re sick and you need aggressive treatment and it can give you some diagnostic certainty and assurance that you are in fact healthy if you have a normal study. How accurate is this test? How comfortable can a patient feel going in this when they get their results? Dr. Min: So it s a 100 percent sensitive, meaning if you see it, it s there. If you don t see it, it s not there and that s the best part of this test is that it is a marker of disease. It is not a factor that puts you at risk of disease but it is actual disease itself. So, no calcium buildup in your arteries is good for you. If we see it, then you have some disease that should be aggressively acted upon and effectively treated, and if you have no disease you don t have any disease. Who s this best suited for, I know you kind of touched on this, I wanted to just ask it again, who should be looking at this kind of a test? Dr. Min: I think, as you know, a field we generally categorized people to: low, intermediate, or high risk patients. And I think this fits the intermediate risk patients, somebody who s so low risk, a 20-year old, healthy, college student, that person doesn t have the risk of heart disease.

4 They re too young. Somebody who has severe heart disease and had bypass surgery, that person doesn t need this test. But in the person whose intermediate risk, maybe has turned 50 recently, maybe has a history of high blood pressure in the past, and now is on some medications, the intermediate risk group does very well with this and if you want a simple age cut-off probably, you know 45 for a man and 50 for a woman. Is there anything from your recent research that you think is really important for viewers to know, I mean any highlights we didn t touch on? Dr. Min: I think there are a couple of things: the first is just that I want to re-emphasize that this is the best re-stratifier that we have. We have no better test in asymptomatic person to identify the risk of future heart attacks than this test. No better test, hands down. Not covered by every insurance, though? Dr. Min: In fact, it s not covered by most insurances. Which is a shame when you think about it. The cost of the test is roughly the cost of getting a cholesterol level, it s very cheap and it s very safe and it s the best test we have. I mean it can predict heart attacks better than any other noninvasive test that we have. Is there anyone who should not have this test, I mean it is an X-ray test, you had mentioned its low dose, everyone is always concerned about radiation. Is there anyone for whom this is not a good idea? Dr. Min: I think that people who are exceptional low risk do not need this test. I think age is a pretty good measure, so once somebody hits that 45 to 50-year old time frame, I think a onetime assessment for a very low cost, very safe, very low radiation dose test is not unreasonable. When you get the calcium score back are there numbers assigned? Dr. Min: Yes, so a zero is a normal, we talk about power of zero, the power of zero is that if you have a coronary calcium score of zero, you have normal coronary arteries in that asymptomatic person. Anything above zero is obviously more calcium and we generally look at categorization is zero, one to 100, 100 to 400 and greater than 400 puts you at a ten-fold higher risk of future heart attack than if you have a lower than normal calcium score. And that s based upon, again, what the radiologist is seeing on the X-ray, the areas that light up. Is there anything that I didn t ask you that you want people to know? Dr. Min: There is a randomized trial, or a randomized control trial, that we had performed a couple of years back that demonstrated that when you randomized patients into two arms, one just a standard of care, go see your doctor and we ll do a risk factor assessment, or go to your doctor and get a risk factor assessment as well as a risk marker assessment with a calcium score. It turns out that this patient population tended to slow down the progression of their Framingham risk score, meaning that they lowered their risk over the course of time. The reason that happened was because people lost weight, blood pressures came down and that s was simply from getting this test and looking at the results of this test and seeing the plaque buildup in their arteries. Is it the power of being able to see what s going on inside the body? Dr. Min: I think that really does make a huge difference for patients, it s one thing for us to say, oh you have some disease or oh you have some risk, it s another thing to see the actual

5 heart and see the plaque buildup in the heart arteries. I think that s a powerful thing to help patients become more compliant and adopt healthier lifestyle modifications. With plaque buildup that this test allows you to see, what happens after that? Dr. Min: Oh, there s a whole bunch of treatments that we can offer. I think based upon the results of the test your physician can really tailor a personalized approach to the treatment of your specific condition. So, if you have severe heart disease there are certainly medications that are highly efficacious but as importantly, or maybe more importantly, there are certain lifestyle behaviors that you can adopt or modify in order to really reduce your risk of heart disease going forward. Things that we don t generally think about. Turns out stress will increase your risk of heart disease by 30 percent, turns out snoring and obstructive sleep apnea will increase your risk of heart disease. Things like meditation or mindfulness or things like that can reduce your stress levels which should translate into a reduction in the risk of heart attacks, exercise, and when we talk about exercise we don t talk about running a marathon, but 30 minutes of walking every day goes a long way to reducing the risk of heart disease. There s a whole bunch of pharmacologic, as well as non-pharmacologic approaches, and that just requires working with the patient to figure out what works best. And again, when you talk about personalized medicine it s also personalized treatment then? Dr. Min: Exactly. The extent of the calcification does that put the heart at risk? Dr. Min: Absolutely, so with this test, what we like to do is pinpoint the person who has disease and then tailor-make their approach to their therapies. Yes, you mentioned the study that you had 15 years worth of data. So, it s nothing new, but it s not anything most people heard of? Dr. Min: It s not. Well, it s something most people know about but don t know enough about. And I think that part of that is the lack of reimbursement, which to me is a shame, because it s the best test we have and people should be able to undergo. If we can do screening for colon cancer and breast cancer, and heart disease kills more, 40 percent more people than all of cancers combined, then we should be offering this test to everybody. END OF INTERVIEW This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

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