Since the release of the 2018 ACC/AHA Cholesterol Guideline that suggested computed tomography (CT) coronary artery calcium (CAC) testing to better assess intermediate-risk patients, there has been a rising number of health systems offering this as a low-cost screening service.[1] These exams are often priced between $50-$150 to encourage patients to be scanned, even if paying out of pocket.
The scans make business sense for many centers where CAC exams are often used to fill open CT slots during slow periods. And when a patient's calcium score is high, they are brought onto the system's cardiology program for additional long-term care.
Northwestern Medicine began offering CAC scans a couple years ago. Cardiovascular Business spoke with Nauman Mushtaq, MD, an interventional cardiologist and medical director of cardiology for the west region of Northwestern Medicine in the Chicago suburbs, who explained the value of low-cost calcium scoring for patients by adding additional diagnostic information to better risk stratify them and decide which patients need more aggressive preventive therapy.
"We are very excited to be able to offer this low-cost screening to our patients. I think it's a really powerful tool that allows us to risk stratify our patients and provide them with actionable information. It really is able to tell us who is at higher risk of cardiac events ... the scan allows us to identify those patients so that we can do something like lifestyle modifications, exercise regimens, dietary modifications, and also, importantly, directed cholesterol management, especially with statin therapy," Mushtaq explained.
Northwestern offers CAC scanning at 12 clinic and hospital locations throughout the Chicago area. From a business perspective, the low-cost screening has proven beneficial for Northwestern Medicine. Mushtaq explained higher calcium score thresholds would prompt further diagnostic testing, including stress tests and anatomic imaging such as coronary CT angiograms. The decision to use CT angiograms depends on factors like the density of calcification, with considerations for using coronary CT fractional flow reserve (CT-FFR) to determine if a lesions that appears to be flow limiting anatomically is actually impacting hemodynamic flow. He said there is also a role for nuclear perfusion scans and exercise stress echo to assess blood flow to the heart muscle.
Use of FFR-CT for improved risk stratification
Mushtaq said a coronary CT angiogram can show the arteries and plaque build up inside the vessels to identify how much luminal narrowing a particular plaque is causing.
"The FFR-CT technology allows us to figure out if a particular plaque or lesion is causing inadequate blood flow, and it's something that we can do right at that point of care," he explained.
Calcium scoring helps determine when patients need daily aspirin or statins
Calcium scoring can be used to decide if a patient needs statin therapy, more aggressive lipid drugs or even if daily aspirin. This idea has also spread to using CAC to determine which patients need to be placed on aspirin therapy for the primary prevention of heart attacks,.
In recent years, some studies have suggested aspirin therapy may cause more harm through increasing bleeding events than it helps with preventing heart attacks, so being more selective in which patients really need aspirin should be considered. Mushtaq said patients with high calcium scores may benefit from aspirin therapy for primary prevention.
Mushtaq added that CAC screenings often attract proactive patients who, despite having a strong family history of heart disease, may not exhibit traditional risk factors.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com