Mila Veledar, 61, of Miami learned she had high cholesterol 10 years ago. She started taking statins, which reduced her cholesterol, but raised her liver enzymes. For a few years, she went on and off the medicine.
In 2014, Veledar underwent a coronary calcium scan, also known as a heart scan, which looks for calcium deposits in the arteries and is a predictor of heart disease. Because she had no calcium deposits, her doctor took her off statins.
“My doctor told me my risk of having cardiac problems in the next 10 years was 2 percent. If I take statins, it lowers it to 1.6 percent,” Veledar said.
She stopped taking the statins, which had raised her liver enzymes and brought on headaches and insomnia.
A coronary calcium scan is a CT scan that detects small flecks of calcium in the arteries, said Dr. Gervasio Lamas, chief of the Columbia University Division of Cardiology at Mount Sinai. During the scan, the calcium is quantified and given a score. The lower the score, the better.
The more calcium you have, the more likely you are to have a heart attack.
Dr. Gervasio Lamas, chief of the Columbia University Division of Cardiology at Mount Sinai
"The more calcium you have, the more likely you are to have a heart attack, but it goes beyond being a predictor because it tells you that you have coronary heart disease,” Lamas said. “At some point or another you had a fatty plaque and then your body's own healing response deposited a little calcium there. The more times your body has had to do that, the more likely you are in the future to have a heart attack."
Dr. Robert Hendel, a cardiologist with UHealth — the University of Miami Health System, said the score range is from zero to the thousands.
“A score of zero means there is no calcium in the coronary arteries, but the scores do increase with age, so there are ‘age-adjusted normals,’” he said. “For an 85-year-old, a calcium score of 40 or 50 may be OK, whereas that score in a 30-year-old would be very concerning.”
The problematic range is anything over 400, with numbers over 1,000 being at extreme risk, Hendel said. “Between 100 and 400 is a gray zone that identifies hardening of the arteries, but it's a continuum. As the score increases, so does the risk.”
Who should be scanned
The best candidate is someone with moderate risk of heart disease, Lamas said.
“The typical patient that I scan is in their 40s or 50s whose cholesterol is just a little high. They take care of themselves, maybe there was heart attack in a family member years ago," he said.
A doctor might look at the cholesterol and recommend a statin, Lamas said, but the patient wants another opinion. A scan can give more information to determine if a statin is necessary.
Generally, the criteria for taking statins are high-risk factors such as cholesterol and weight. “Then you are prescribed a lifelong pill to reduce the risk,” said Dr. Khurram Nasir, medical director for the Center for Healthcare Advancement & Outcomes at Baptist Health South Florida. “But emerging evidence is suggesting that people we thought are high risk are actually low risk, and we never had a way of identifying them.”
A study led by Nasir found that about two-thirds of adults 45 and older with no established cardiovascular disease are eligible to take lifelong statins.
“But when we did heart scans, about half of the individuals had no calcium scores, and their 10-year risk was below the level at which you should consider taking a statin,” he said. “The scan is providing patients more information so they can make a better judgment of whether the risk is high enough to take a pill for the next 10 years.”
The heart scan is not a routine test, and there's a controversy about whether it should become one, Hendel said. “Many physicians think it should. Currently, the American Heart Association and the American College of Cardiology have taken a conservative stand, not recommending it as a routine screening measure,” he said.
The scan is not covered by most insurance, and costs $75 to $100. It exposes the patient to about the same radiation as a mammogram.
“What it helps to do is reclassify patients who seem to be an intermediate risk,” Hendel said. “It does a good job of either dropping them into a low-risk category that doesn't need treatment, or putting them in a higher-risk category that needs more intervention.”
Patient Veledar, who has a normal blood pressure and weight, now watches her diet, exercises and doesn’t worry so much about her high cholesterol.
“I think this is the best for me, because I don’t have to worry about my liver and I don’t have any [calcium] deposits,” Veledar said. “I feel well, and not taking any medication is making me feel well. That, I like.”