How to check the age of your arteries and risk for heart attack and stroke
“A man is as old as his arteries.” Thomas Sydenham
The Problem- Cardiovascular Disease aka Atherosclerosis
- Cardiovascular diseases- including heart attack and stroke- remain the number 1 cause of death in the USA of men and women. They are currently responsible for more deaths than the next 3 leading causes of death combined, including all deaths from any form of cancer and any type of accident.
- Every 34-40 seconds an American will have a heart attack or stroke.
- The average number of years of life lost because of a heart attack is 16.
- 64% of women and 50% who die suddenly from a heart attack are never aware that they have cardiovascular disease.
- 60% of those who died from heart attack or stroke were asymptomatic prior to the event.
- One million Americans were expected to have a new or recurrent heart attack in 2018.
- 65 million Americans require lifestyle management and 37 million are candidates for drug therapy.
- More patients will be at risk for arteriosclerosis disease due to the increased incidence of Metabolic Syndrome and Diabetes Mellitus.
Traditional screening tools have not been effective
- The medical system has done a better job of treating acute heart attacks but not in preventing heart attacks and strokes.
- The presence of the traditional top 5 risk factors are not good predictors. These are cholesterol, diabetes, smoking, obesity, and high blood pressure. It is thought they may explain only about ½ of the causes of heart disease.
- 40-50% of all heart attack patients have a normal cholesterol or lipid profile.
- Screening calculators like the Framingham Risk Score or the Reynolds Risk Score fail to adequately identify who will have an event.
- Stress tests are not good screening tools. They measure arterial flow, one needs to have a 70% or higher blockage of the artery or lumen to be positive but most heart attacks and strokes (86%) occur in those with < 70% blockage -subclinical atherosclerosis which acutely rupture.
- Newer advanced markers that I routinely use and include measures of inflammation, endothelium, oxidative stress, and advanced cholesterol subfractions like particle size and lipoproteins provide valuable data but remain surrogate markers that don’t measure actual arterial health and disease.
“Atherosclerosis is much smarter than the technology that has historically been designed to find it.” Amy L. Doneen, DNP, ARNP
Or this one?
Better screening tools
Subclinical atherosclerosis enhances cardiovascular risk prediction- identifies healthy individuals at increased risk for an adverse cardiovascular event (heart attack or stroke).
Heart Scans aka Coronary Artery Calcification (CAC) are a tool that I have found helpful, but with some significant limitations.
- Although CAC scans measure calcium deposits in the heart arteries that correlate to plaque, they miss the soft plaque (the more unstable or dangerous type), which is more common in younger patients < 55 y/o- thus, a normal scan or CAC score of 0 does not rule out disease.
- Calcification is a late manifestation of atherosclerosis.
- Radiation exposure from the CT scan is not insignificant.
- They can’t measure arterial inflammation, disease progression, or plaque burden.
IMT of Carotid
American Heart Association Expert Panel – Circulation 2000
“Carotid Artery ultrasound imaging is a safe, non-invasive and relatively inexpensive means of assessing subclinical atherosclerosis. The technique is valid and reliable.”
Which one do you guys like better; the bottom one has the docs name on it
Carotid Intima Media Thickness (CIMT)
- CIMT is a structural test using noninvasive ultrasound technology to measure the amount of disease found in the wall of your carotid artery which is found in the neck.
- Carotid arteries serve as a window to systemic atherosclerosis – reflects the health of arteries throughout the body, including the coronary arteries supplying the heart.
- Carotid arteries are an easily accessible sample of a massive vascular supply system.
- Different from a carotid duplex (Lifeline screening or carotid radiology scans), which measures stenosis and flow to justify a procedure.
- CIMT also is very good in the young- predicts CV event risk in adults < 45 yo (independent of other risk factors).
- Measures:
- Thickness of the arterial wall- the thicker the wall, the more inflammation, the sicker the artery, and the higher the risk of plaque and cardiovascular events.
- Plaque presence and type or stability (soft vs hard)- soft is more dangerous.
- Arterial age- the thickness is compared to other people your age and gender as a population sample; this reflects the age for which your thickness would be in the 50th percentile or average.
- Can monitor disease progression- thickness (or inflammation) of the arterial wall and plaque burden and type to see progress or regression to help produce future risk analysis.
The “Pregnancy Test of Heart Disease”- Picks up Heart Attacks Before They Happen
- CIMT predicts heart attack and stroke risk with high accuracy. In a 10 year, 100,000 person study, it caught 98.6% of the heart attacks and strokes before they happened. Has been called the “pregnancy test of heart disease” because of its accuracy.
- More valuable and less expensive than the Lifeline screening tests.
- Has been used in clinical trials for over 20 years on hundreds of thousands of patients, including many of the cholesterol medicine studies to see if there were clinical responses.
- Motivates patient adherence- image-based information has been demonstrated to be an effective tool in compliance and CIMT images have been shown to improve adherence to treatment plan and reduce cardiovascular disease in a 1 year follow up.
“…there is nothing more powerful than asymptomatic individuals
experiencing a real-time image of their arteries showing atherosclerotic deposits.” -Dr. A.Nicolaides
Scheduling your CIMT
We welcome everyone, patients and non-patients alike, to have a CIMT scan done in our office. For any in the area who are interested, please reach out to the office to coordinate an appointment.
Some important CIMT FYIs:
- We are currently offering CIMT scans once per month, always on a Friday.
- The scan takes only 15 minutes.
- There is no need to fast.
- Wear light-fitting clothing and have your neck exposed.
- We receive results within two weeks. Our active patients will receive Dr. Pappas’ interpretation of their report by way of our patient portal. Those who have not established care with our practice will receive their detailed reports via email. Should anyone have any questions about their results, we welcome anyone to schedule an appointment to discuss their results with Dr. Pappas.
- Last but not least, the CIMT scan fee due at the time of service is $199.00. We provide a document which the patient may submit to insurance to pursue reimbursement.
Insurance coverage: At Pappas Health, we believe in proactive, personalized, and preventive care that doesn’t depend on the whims of a 3rd party to dictate a “one-size-fits-all” model. It remains unclear if the CIMT is fully covered under all insurance policies; like the aforementioned CAC scan, most insurances do not believe in preventive testing and usually only offer limited coverage. We have had some patients receive full reimbursement from insurance while most receive at least partial reimbursement or an amount put towards their plan deductible.
Who Should Get Tested?
- We believe that any adult over 30 should have a baseline CIMT.
- Adults concerned about their risk of heart disease.
- Adults with a family history of heart disease, including: heart attack, bypass heart surgeries, stents or blockages, strokes, aneurysms, poor circulation, dementia (vascular dementia is the 2nd most common type of dementia), diabetes, and obesity.
- Adults with present or historical traits of the traditional causes of heart disease: abnormal cholesterol, high blood pressure, diabetes, obesity, and smoker status.
- Adults with any cardiovascular disease: prior heart attack or stroke, history of stents or angioplasty, prior heart bypass surgery, vascular dementia, peripheral arterial disease in the legs, aneurysm (thoracic or abdominal), atrial fibrillation, enlarged heart, chronic kidney disease, “MILD” plaque found on any screening test like Lifeline testing and Carotid duplex scans, any positive calcium score on a CAC scan, any diseased heart catheterizations, and erectile dysfunction (most common cause is from poor circulation).
- Adults exhibiting poor lifestyle choices such as inadequate sleep, poor diet and regularly dining out, excessive intake of alcohol, lack of exercise, long work hours, high levels of stress.
- Adults with emotional or behavioral conditions such as anxiety, depression, isolation, divorce, and Type-A personality (impatience, aggressiveness, difficulty relaxing).
- Adults with the presence of certain illnesses such as sleep apnea, osteoporosis, inflammatory arthritis such as Rheumatoid Arthritis or Psoriatic Arthritis, gout, gallstones, kidney stones, chronic kidney disease, inflammatory bowel disease, gestational diabetes, pre-eclampsia, menopausal hot flashes, breast cancer, Polycystic Ovary Syndrome (PCOS), asthma, and poor oral health especially periodontal and endodontic disease.
- Adults with the presence of increased waist circumference or central adiposity, increased Body Fat.
- Adults with the presence of fatty liver and abnormal liver tests.
- Adults with physical findings such as increased resting heart rate (>75), consistently increased blood pressure > 120/70, low lean muscle and decreased muscle strength, male pattern baldness, and a diagonal crease on the ear lobes.
- Any adult with evidence of more advanced markers on their labs: elevated glucose and/or insulin resistance, inflammation markers such as CRP and fibrinogen and protein in the urine, high triglycerides and/or low HDL, abnormal size or amount of LDL and HDL particles, any abnormal findings in the comprehensive Cleveland Heart Lab panels, low Omega-3 fats or abnormal Omega-6/3 ratios, elevated homocysteine, low testosterone, low vitamin D, low levels of magnesium, genetic markers such as ApoE4 and MTHFR, and any thyroid disease.
Not just president; also member of the club
As can be seen by this detailed write up, heart disease is an area I am passionate about. Some of you may know that I have a strong family history of heart disease- my father had a heart attack at 42 and died of stroke complications at 66 and my maternal grandfather died of an acute heart attack at the age of 68. I had presumed that my healthy lifestyle protected me from any cardiovascular problems but a prior CIMT showed I had some markers of thickness and arterial inflammation. The findings motivated me to take a deeper dive into my lifestyle and optimize the laboratory markers that were off and has resulted in improved overall health. Now that CardioRisk Laboratories, the leading company of CIMT imaging, is able to bring their technology to our office I have become very excited about sharing this with all to aggressively screen those in need.
It is my belief that atherosclerosis is a dynamic process that is modifiable by a healthy lifestyle and appropriate medical treatments and that no one should suffer from the consequences.
One final note
We believe that anyone who has worked with us in the past can benefit from this testing thus you do not need to be a current patient to have the CIMT in our office. In addition, we feel so strongly about this test we want to make it available to the community-if you have any family or friends who you think may benefit from such screening please have them contact us. Lastly, we hope to make it available to organizations and other groups who may benefit from this essential screening. In all of these scenarios, no one needs to be an established patient. All will get a detailed report and recommendations that they can take back to their physicians or health care provider. However, our patients will always get first priority in scheduling.
Please contact our office at 703-734-8271 to schedule your CIMT.
Yours in health,
Sam Pappas, MD and the Pappas Health team
