What to ask your doctor if you don’t want to die of a heart attack

Cardiologists want this simple test to be used more widely to prevent the most common cause of death in Australia.

In women, dying from coronary disease is more than twice as likely as dying from breast cancer.

‘Hi Brett, I’m sorry to bother you but can I please ask for some advice? I’ve read about all these celebrities dropping dead without warning and I’m worried about my husband.”

I often get asked this by friends or staff and I’m always delighted. If you do medicine to save lives then I’ve found, after nearly 50 years’ practice, that I can save more lives by answering this question or by contacting relatives of people at risk than by treating hundreds of patients in my rooms. Or even better by spreading the word through the media.

Here’s why.

Heart attacks are the most common cause of death in Australia. In women, dying from coronary disease is more than twice as likely as dying from breast cancer. In men it’s nearly three times more likely than dying of prostate cancer but coronary disease occurs at a younger age. Nearly 50 men and women die every day in Australia due to heart attacks, and 30 per cent of these die suddenly without any warning.

Is it possible to prevent these disasters? Well, first question is can we predict those that are at risk? The next question is do we have effective treatments that can reduce the risk of death and heart attacks?

The answer is absolutely Yes and Yes. The recommended approach in Australia is to do a risk calculation using one of several calculators. These use factors such as age, sex, blood pressure, cholesterol, HDL cholesterol, diabetes and smoking.

A patient being prepared to undergo the CT calcium score scan. Picture: Glenn Ferguson

In Australia it is recommended that if your risk of developing heart disease symptoms (or death) is greater than 10 per cent over five years, then you need to change your lifestyle. And if that doesn’t achieve the desired effect, you should get on medication, starting with statins to lower cholesterol.

The treatment with statins and other medications is remarkably effective. Lowering the LDL cholesterol to less than 1.4mm/L is generally associated with shrinkage of the plaque and reversal of the disease.

However there are several problems with the risk factor approach. First, many of these people actually are at low risk and therefore will end up taking medication possibly for life when they don’t need it.

Second, the risk factor approach would only pick up 55 per cent of the clinical events that occur. This is because the number of people with lower risk of less than 10 per cent is very much higher than the number of people at high risk.

Third, it is hard to motivate someone to take medications based on a predicted risk, because this assessment doesn’t tell us if they actually have the disease that causes coronary events, which is atherosclerosis or a build-up of fat in the arteries.

Some studies show more than half of patients prescribed statins for high risk stop taking them within two years. Drugs don’t work if you don’t take them!

But wait. There is an effective test that can answer all these issues. The CT calcium score (CTCS) scan.

When someone has atherosclerosis, the body reacts to the fat in the arteries which results in scarring and this process leads to calcium being deposited in the artery. This can be detected by a simple CT scan. This test only takes a few seconds and does not involve any injections. It is relatively cheap, and totally non-invasive.

In general, calcium only appears in the arteries when atherosclerosis is present. Normal people will have a score of zero.

A study in the US showed that in a large cohort of people with a CTCS score of zero, the cardiac death rate was less than 1 per cent over 10 years. This is an extraordinarily good result. Another study showed that 30 per cent of people on statins had a CTCS of zero and were therefore able to stop their medication. Any score above zero from 1 to 1000 indicates atherosclerosis, and the higher the score the greater the risk.

So the CT scan tells us if we actually have disease present. Once they know that they have disease, both the doctor and the patient will be a lot more active about treatment. Some studies have shown that the majority of people treated on the basis of their risk score stop the medication within two years. Compliance with medication is also much greater if they use a CTCS which shows they have disease.

Unfortunately, Medicare does not pay for anyone to have this test. Understandably, the authorities are concerned about cost. However, a recent study published in the Medical Journal of Australia and headed by Professor Tom Marwick showed that in certain groups of patients, CTCS is cost effective, increased the appropriateness of treatment, and reduces unnecessary treatment.

The National Heart Foundation states CTCS can be useful in patients at borderline low risk but is unnecessary in the higher risk ones. However it is clear that doing the test in the high-risk group further improves management by confirming the presence of disease and quantifying the extent.

So, when I am asked this question about what my friend’s husband should do, I recommend doing a conventional risk factor assessment and, unless the risk is very low and less than 5 per cent risk over five years, then I recommend they pay the $200 or so to get a CTCS.

If the risk is high or very high I still prefer the score to help me manage and motivate the treatment.

Dr Brett Forge is a Victorian-based cardiologist