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Do Heart Scans Help Prevent Coronaries?
Proponents Have Built an Industry on It
By THOMAS M. BURTON
Staff Reporter of THE
WALL STREET
JOURNAL
Can a medical test foretell whose life will end in a fatal heart attack?
An entire industry is emerging based on the argument that CT scans can do just that. In the Clearwater, Fla., area, home to many retirees, 20 CT-scanning companies have sprung up in the past two years. This year about 400,000 Americans will receive an electron-beam heart scan, the most accurate variety, a 20% jump from last year. And sales are booming for scan makers like Siemens AG, General Electric Co. and Imatron Inc., which GE recently bought. Imatron estimates it sells three new $2 million electron-beam machines each month, the "vast majority" of them to screening centers.
But inside the halls of American cardiology, debate is raging about whether these heart scans -- which cost $200 to $400 or so and typically aren't covered by insurance -- are a good idea. An American Heart Association/American College of Cardiology expert panel doesn't recommend the scans because of the high "false positive" rate. A heart CT scan "will save some people, but I suspect it will hurt more," says Michael F. Roizen, an internist and the dean of SUNY Upstate Medical University in Syracuse, N.Y.
The rapid ascent of heart scans can be largely traced to Oct. 2, 2000 -- the day Oprah Winfrey got scanned on her daytime talk show. Scanning companies all over the country were besieged. "We had 500 or 600 phone calls the next day," says Gina W. Johnson, president of CATScan 2000 in Clearwater. "It was insane. People went nuts."
The scans don't necessarily detect heart disease, but rather calcium in the coronary arteries. Calcium is related to coronary-artery disease, and its presence can indicate what may become a problem. Former Illinois Sen. Paul Simon, for one, says a heart scan possibly saved his life by detecting a blockage that was fixed with bypass surgery.
But the presence of calcium isn't a sure warning of an impending attack, or even of clinically significant disease. Consequently, many heart-scan customers get positive results that cause undue alarm, according to a wide range of cardiologists, while other customers receive comforting assurances that can turn out to be false and even lethal.
A positive scan often leads to an angiogram, in which radioactive dye is injected into the arteries to visualize blockage. But there is a risk of stroke, heart attack and death from the angiogram. Dr. Roizen estimates this risk as one in 200 at typical U.S. hospitals. Arteries can be punctured, and people can have allergic reactions to the dye or develop infections. More commonly, follow-up procedures are simply expensive, worrisome and painful, though insurers will often cover them.
Harvey M. Morris, a 51-year-old commercial airline pilot from Mansfield, Ohio, recently got a positive calcium score and was advised he is at "moderately high current risk" of getting "manifest coronary heart disease."
"By the time you get this letter, you think you're dying," says Mr. Morris. "My family doctor goes, 'Holy cow, you're in bad shape.' " But an angiogram at the Cleveland Clinic showed that Mr. Morris had a 100% functioning heart and no coronary-artery obstruction. "I was the healthiest guy the clinic had seen in a month," he says. Still, the angiogram cost $8,000, and Mr. Morris is still is awaiting more bills from doctors.
{Test showed OK but
actually had 95% blockage}
Diane C. Snyder had an altogether different experience earlier
this year. A 51-year-old flight attendant from Granville, Ohio, she began having
chest pains while returning home from Beijing, and decided to get an
electron-beam CT. The scan showed "no measurable atherosclerotic
plaque," the imaging center informed her in a letter. "The chance that
the patient's symptoms are due to advanced coronary disease is very low,
probably less than 5%." But the pains recurred, and other diagnostic tests
revealed a 95% blockage of a coronary artery by soft plaque that doesn't show up
on CT screening images. The artery was cleared using angioplasty and a stent.
Defenders of cardiac screening say excessive procedures and wrong interpretations are caused by bad doctors, not a bad test. "This is picking on a technology because the doctors are idiots," says Ohio State University cardiologist John A. Rumberger.
He and other proponents of the test point to some scary numbers. Half a million Americans die suddenly of heart disease each year. It is the country's No. 1 killer, and about 50% of those who die weren't known to have cardiac disease. About 35% even had total cholesterol levels lower than the widely accepted standard of 200.
But increasingly, there is evidence that inflammation of the arterial wall -- more than artery blockage itself -- plays a role in causing heart attacks. Inflammation appears to play a role in causing soft, fatty plaque to break off from the wall and dam up an artery even when it wasn't badly blocked before. About 68% of heart attacks occur in people with arterial blockage of less than 50%.
Over time, plaque tends to harden and calcify. It often causes the artery to expand, so the blood channel isn't narrowed. Eric J. Topol, chief of cardiovascular medicine at the Cleveland Clinic, says calcium may even hold plaque in place and be protective.
Yet some CT customers who learn they have calcium in their arteries demand action, doctors say. One patient at the Cleveland Clinic was so shaken by his positive calcium score that three doctors at the clinic couldn't reassure him, even after other tests showed him to be healthy. "He was in almost full-body tremor," Dr. Topol says.
Write to Thomas M. Burton at tom.burton@wsj.com
previous references at Skyaid:
http://my.webmd.com/content/article/1728.55434
scam?
http://www.cnn.com/HEALTH/9902/16/heart.scan/
critics
http://www.heartpoint.com/ultrafastct.htm
1999 overview
http://heartdisease.about.com/library/weekly/aa081500a.htm
Scam?