469720?1388149949
Lee Kirksey, MD  
Male
Cleveland , OH

Specialties: Peripheral Arterial Disease, PAD

Interests: vascular, specialist, treatment options
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Heart Scan-Painless but not Harmless- Is it worth the risk?

Jul 04, 2008 - 25 comments
Tags:

heart scan

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calcium score

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philadelphia

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heart specialist

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penn

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university of pennsylvania

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Heart Attack



I must admit that I believe the jury is still out with regards to heart scan, CT angiography and calcium scoring.
After Tim Russerts death, I must have received 5-10 question a day feom concerned patients and friends. They all wanted to know if they needed a scan. People who were relatively healthy wanted to know if they were going to die suddenly.

The following NY times article does a good job of painting different sides of the story. In my mind, I think that calcium scoring is a very important motivational tool for someone who would change their life style of diet, exercise and nutrition if they had a compelling reason. Some people genuinely need that kick in the butt. But for the person who is doing exactly what they should be in terms of lifestyle and medical risk reduction for cholesterol or hypertension, there is little to be gained.  

Now lets look at a particular exception. You are a 45 year old male. Healty 5'10'' 160 lbs. You eat well. Vegetarian who hates sweets. You exercise 5 times per week. However, your father died at age 55 and lived just as healthy.
This might be a case where someone recommends the scan with calcium scoring to see if there is any apparent reason to begin early statin therapy.

The problem with imaging modalities is that even if they are noninvasive without the risks of cardiac catheterization, there are still risks associated with radiation exposure. A scan is roughly equal to 1,050 chest x ray doses. Not a small amount

I would like to know how many people would get a heart scan if there were no considerations of cost or convenience.
Read the link and provide some feedback

http://www.nytimes.com/2008/06/29/business/29scan.html?ex=1372737600&en=f2b667f06d165ac1&ei=5124&partner=permalink&exprod=permalink



Comments
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21064 tn?1309312333
by Momto3, Jul 04, 2008
Interesting article...certainly leaves us with something to think about.

Despite the consideration of no financial or convenience issues, count me out until further data suggests the test is worthwhile.  Absent any significant outward symptoms (ie: chest pain, uncontrolled cholesterol), I would just as soon skip the test.

Since there are no large studies to support the need for this expensive, and somewhat invasive, test, I would prefer to rely on older, equally accurate, testing methods. Honestly, I assumed (my mistake) that the government better regulated the introduction and continuing use of medical equipment without substantial positive data to support its use/cost.  

If I am presented with the option to have a CT scan in the future, I'll be sure to ask about, and compare, available options.  Assuming the evidence remains the same, I'll discuss more tried and true tests with my physician.

Thanks for sharing the article.

Curious - How do you feel about this type of test in your own practice?

connie

Avatar universal
by Rob2008, Jul 04, 2008
"A scan is roughly equal to 1,050 chest x ray doses. Not a small amount"

Dr. Kirksey,  is this the estimate for a calcium score,   or is that for the CTA with contrast?

377012 tn?1283969035
by motherofan18month, Jul 05, 2008
if cost was no problem i would most definetly have a CT scan as i feel that i was miss diagnosed with anxiety attacks! there are many life threatening ailments in my family history to be very worried  (heart attacks, cancer, diabetes, etc.) but now days you cant even afford a yearly check-up if you don't have any type of insurance or medical aid!

469720 tn?1388149949
by Lee Kirksey, MDBlank, Jul 05, 2008
1050 chest x rays is for a calcium score. Less for CTA

Avatar universal
by Steveeca, Jul 05, 2008
personal experience- as result of Tim Russets I just had cal score and CTA  All clear except LAD shows 197 cal score and mild to mod steniosis proximal and mid  artery. MD want thalium stress nxt. Could that cause plaque to break off and cause MI/ Should next step be regular angiogram since stress test will not measure amt of stenosis anyway and Im not sure I could sleep at night not knowing the chances of this blowing anyway

366811 tn?1217426272
by JSGeare, Jul 06, 2008
"I would like to know how many people would get a heart scan if there were no considerations of cost or convenience."

I'm not sure how many have actually answered that question, and one of the reasons is the lack of other conditions. If we assume that I am otherwise disgnosed and tested as healthy, then NO, no CT scan, not for free and not even if you pay me and bring it to my house. But if there are other factors -such as the family history you portrayed for the vegan who hates sweets (obvious psychological issues there, but that's another problem) then YES, I guess I'll have the test IF THERE IS NOTHING ELSE THAT WILL DO AS WELL WITH LESS RISK. Same thrill as going to the shoe store when we were kids to look at our feet through the Xray machine.

HTH



460185 tn?1326081372
by lonewolf07, Jul 06, 2008
This is going to sound like a bizarre or simplistic question but when you mention "plaque" is it in any way similar to the plaque found on our teeth which, if not corrected, can cause gingivitis and damage to the gums and teeth?

I know you're not a dentist but I'm trying to understand what you're saying.




213044 tn?1236531060
by AR-10, Jul 06, 2008
I'm a lot less willing to have one after reading the story.

I've had three CT scans of my adrenal glands, and nobody mentioned any risk with the procedure or the contrast dye. Later I found out the contrast dye was not healthy and now I'm learning a scan is like five or six hundred X-rays?

I would have followed the doctor's suggestion prior to learning all this. Now I would have serious reservations. Without research or foreknowledge, I would be inclined to endure any test the Cardiologist suggested. The heart is serious business and who am I to question an expert?

That was my thinking process when I submitted to an angiogram. I was observed overnight before the procedure and the doctor probably knew by the time that I was on the table that I was going home with a lolipop and a clean bill of health, but I got the angiogram anyway. In hindsight I believe they collected enough information overnight to negate the need to run the test, but since I was there and on the schedule anyway...better safe than sorry, doctor doesn't want to be sued, yada yada.

Most people are going to do any test the Cardiologist suggests. Period.

168348 tn?1379360675
by ChitChatNine, Jul 06, 2008
After battling numerous kidney stones, gallstones, and recently thyroid surgery, I have learned alot about exposure via CT Scan vs. MRI vs. Ultrasound and have always opted for the least invasive, least risk procedure first and only gone on to the next if the least doesn't give us the answer we need.  

All tests have the risk/benefit factor .. yet many Dr's don't ask what prior CT's one has had before entering his/her office.  it is a cumulative thing I would assume so having one CT may not be bad, having that test + maybe 3 others does change the story.

Personally, having had serious thyroid concerns (including papillary microcarinomas) and knowing what I know now, and I thank you so much for writing this journal, we do have a say in our well-care and that is half the battle.  The other half is that our physicians need to take into effect the total picture and not just their own speciality when they suggest a test.

If I am not in a higher-risk category .. I will opt out for this test.  But, that is my own personal opinion as you were looking for feedback and cannot answer for others.

Cheryl - Co-CL Thyroid Disorders Communities
Partial thyroidectomy 1/07 - MSK w/calcium oxalate stones



Avatar universal
by toby45, Jul 06, 2008
Yes it's me again Dr. K!

First - thank you for your opinions and your candor. Rare qualities amongst your peers...so you better watch your back!

I posted on your blog and another thread. I am and have been a vegetarian, bordering on Veganism all my adult life with none of the "traditional" risk factors (family hist, BP, overweight, stress, bad food habits, lack of exercise. I bike about 80-100 miles/week and do an annual 150 mile bike ride in a day.

And yet, I had an acute MI at the age of 45, 5'9 ,155-160lbs, never smoked, no alcohol, no drugs.

When I had strange chest "discomfort" a month before my MI, I was hospitalized overnight with stress and blood tests...and they checked me out the next day with a clear bill of health and an assurance that it was NOT my heart. In   fact when I asked them if they need to do an MRI or CT scan - did not know about CCTAs and nuke MRI's of the heart in Dec. - they reassured me that I was worrying about nothing and that I likely had a PINCHED NERVE!

Yes, hind sight is 20/20, but when the patient is willing to even pay for it out of their own pocket as I was willing to do at the time, I was dismissed as a worry wort. Well, 3 weeks later I nearly died from 3 acute MI's in 8 hrs!

I'm learning now that the methodology of diagnosis is nothing but a process of elimination. It's a game of probability based on estimations.

The frustrating part for someone like me who falls in the "oops we missed that one" category is that prior to the MI 3 Cardio's saw me the preceding month and spoke with such self-assurance and confidence that I likely had a PINCHED NERVE not a heart related issue! So no meds, not even asprin. In fact they prescribed me Ibuprofen to take as needed for the pain...it's laughable Dr. K... laughable if it weren't a question of life or death. The night I had my MI's, I was doing the doctor recommended standing pushups at 1.30 am to relieve the excruciating pain they said was more than likely a pinched brachial nerve.

When I don't know something, I say "I don't know". When the tools that I'm using/recommending may not solve the customers' issues, I always let them know their limitations - and mine. When I work with customers I always set clear expectations and help them make the most informed decisions. And I'm only in the computer biz...where the worst thing that can happen is a computer shuts down.

What seems to be singularly lacking is hubaris with a healthy dose of candor. Wish there were more like you Dr. K who're willing to present your postulates and discuss them publicly. You're indeed an exception!  I've seen a total of 13 cardio's since Dec. (9 of them were part of teams treating me) and you are the first to break the Confederacy of Silence!



468015 tn?1218723380
by sadie1246, Jul 06, 2008
I have heart problems and a venous angioma in my head I have had so many scans I can't count them and they want me to have another,  can these cause cancer of your pancreas or somewhere else, this is scaring me they told me nothing of this my doctors told me they were harmless.  I live in fl.  

I can't believe what i am reading.  would mri's be better or worse what are you supposed to do.  i became very ill with pain in my chest and my stomach.  my kidney is killing me and I don't know what to do.  my lipase level was 785 now they thick i might have cancer.  my last was about 6 weeks ago and i am still sick.

484583 tn?1230608692
by al1953, Jul 07, 2008
Thanks for these Posts. In 7 months from 10/07 to 05/08 I underwent 2 CT scans, 1 Nuke stress test, a Cardiac CTA with calcium score and a few regular chest x-rays. I had chest pain one time. This all totals as best I can tell about 104-105 m Sv of radiation exposure. I am experiencing eye and mouth dryness, anxiety, depression, and a horrible outlook on the future. Thing of it is I requested some of these test without knowing what I was doing. There are MRIs and ultrasound that do just as good as CT scans.

These test are way over used and nothing is ever mentioned about rasiation. They do tell you about contrast dye which very seldom is a problem. My exposure of rasiation is about 2.5 times the average dose recieved by the survivors of the atomic blast of Japan in WW2. I am a walking dead man!

Avatar universal
by Rob2008, Jul 07, 2008
Listen for those of you who are concerned about radiation exposure, you're not alone.   Myself, I've had about 7 head CT's,  3 were with contrast (I guess those count double),  then I had an abdominal and pelvic scan (a real biggie there),  and finally a cardiac CTA (another biggie).    Not to mention my nuclear bone scan, nuclear stress test, gastic emptying scan, 2 barium studies, and a bunch of chest xrays.     And I'm only 30 years old;  The longer you live, the more time your cells have to mutate into cancer.   Over 60?  have all the scans you want.   But us younger ones really need to watch out and stop giving in to every paranoid health concern that comes along, because it will be our undoing in the long run.       On a positive note, I remember reading a figure along the lines of a 1 in 5,000 chance of a 30 yr cancer death from radiation for each head CT,  and maybe 1 in 1,000 per cardiac CTA...that's not too bad I don't guess, considering the nuts that drive down the urban freeways at 80 mph, yet we still drive around everyday?

367994 tn?1304957193
by kenkeith, Jul 07, 2008
A week or so ago I had a CT angiogram and my total score (Agatston Method) of 1207, and there are individual scores for each of 4 vessels (RCA, LM, LAD, CX).

Unlike the cath angio the CT views and provides an image of each slice (cross section) that provides information on the anatomy of vessel.  The cath only views the lumen and is able to observe any obstruction to blood flow, and provides little if no information regarding the soft plaque that may reside on the outerside of the lumen.

It is the soft plaque not viewed by the cath that presents a high risk of a fatal heart attack or stroke.  The plaque rutures the intima and forms a clot within the lumen and that can be the source ot thrombosis.  Cardiologists know vessels that appear to be harmless (less than 50%) are at a higher risk for a heart attack.  Early plaque grows and expands outward remodeling the vessel.  It has been postulated the vessel remodeling is compensatory permitting an unobstructed blood flow.

My calcuim score is high (greater than 1000, expect 25% of the populatuion a heart event a year) as I have a totally blocked LAD and the RCA is stented 4 years ago after a heart failure.  The RCA was not viewed, but the report states there is normal flow of blood to the stent and out of the stent,  Cardiologist stated the collateral vessels bypassing LAD were not visible.

There is another procedure that, IVUS, that competes with CT.  IVUS uses ultra sound on the tip of cath and provides the same information as the CT, but very expensive and requires specialized knowledge to perform the procedure that many cardiologists don't have.  If one quantifies the harmful effects, I have been told it is not very harmful.  So the question should be is the information provided by CT angiogram worth the risk of exposure?  Or stated another way is the anatomy of the vessel useful information as a cath angio doesn't reveal the unseen dangers.  It certainly is useful information if the vessels appear clear, and there is a high calcium score.

390388 tn?1279639813
by Me967, Jul 07, 2008
Hi.  The "no considerations of cost or convenience" isn't really the issue here; but, the exposure to radiation is.  
If I had to have one I would if they felt that it was my ONLY option.

I have had a TON of test done on myself and have also been given injections in which I was exposed for medical reasons.  

I also worked at a hospital years ago that over 1/2 the time we were short on protection vest (lead aprons) or were rushed into test where I had taken 1000's of pictures over the years w/o protection.  That I'm not proud of.  It was a long time ago though and I was young and stupid.

What most people do not realize is how much radiation they get without having any test done.  The NRC has a great calculator for determining how high of dose you get.  It might be cool for some of you to check out.  It is based off a article in the 89 PDR I believe.  
It is:  http://www.nrc.gov/about-nrc/radiation/around-us/calculator.html

As far as putting this post up:  I think that is great!  I think to many Doctors rush into test; but, I also think to many people push them into it also.  I think it is a great test, and technology is moving fast.  I just think a lot of tests that are done are not really necessary and should be more on a need to bases.

Sorry I made this so long.  Thank you for the blog.

Avatar universal
by BLM_56, Jul 08, 2008
"1,050 chest x ray doses"
Sounds like a large number.  But how much radiation is that really?  Acccording to this article I found with a quick Google: - http://www.radiologyinfo.org/en/pdf/sfty_xray.pdf - a cardiac CT for calcium scoring yeilds an effective exposure of 2 mSv (millisieverts - a measure of effective does of radiation) which is equal to the amount of radiation people living at/near sea level receive in 8 months.  Since folks living up high such as in the plateaus of Colorado or New Mexico get almost that much (1.5 mSv) extra a year anyhow just by living where they do.  Flying round trip between New York and L.A. is worth .03 mSv.  How many executives and entertainment types do that every week or more? A CT of the abdomen, body or spine gives a dose of TEN mSv - FIVE TIMES as much as CT with calcium scoring.  But even that is not bad compared to the exposure many people experience jst by doing their jobs.  It is all a matter of perspective and you have to judge things in context.  Giving a number with out giving the context is just literary terrorism.  In isolation many things look bad.  PUt in context they often look OK.  I baby crying in church can be nerve wracking.  One little baby can make an absolutely ear splitting noise in a quiet time in a worship service.  Let the same kid cry two seats away in the 4th quarter of a close game in the NBA finals and nobody can even hear it.  Why?  Same kid, just as upset - maybe MORE upset.  But the context is different.  

Look, no test should be done unless there is a good reaswon for it.  But then as someone said, we Americans tend to got for the newest latest and greatest.  We frequently over-engineer the heck outta things.  I have a nice pulse generator in my chest.  It has lots of bells and whistles - some of which I appreciate such as automatically checking stimulation threshold and setting itself to as low a voltage as possible.  Some of the features I am not entirely sure of.  One thing I do NOT like is that when the device's battery runs out it will be discarded.  Why does it not have rechargable batteries? According to my EP it is because by the time the batery runs down there will be much better technology available.  Now this thing can do a boatload of processing already.  It has to have a microprocessor on board just to do what it does.  Why the heck didn't they put a PROM in it so new functionality could just be downloaded to it as a program update?  It has a communications capability built in.  BUT NO!  They have to replace the whole thing.  

Bionic Bill




390388 tn?1279639813
by Me967, Jul 09, 2008
Lee Kirksey M. D.

I was wondering when would you recommend a CT considering the risk of radiation exposure?  

How would you decide what was safest way to test and/or who qualified?

I don't think considerations of cost or convenience is an issue with alot of people that are worried about there life.  If a Doctor says you need it; most people don't even question it, they just make do and pay any way they know how.

As a great speaker once said:  “In America, public opinion is everything. With it, nothing can fail. Without it, nothing can succeed.”   Where do you stand?  Technology is moving fast, what are the pros and cons?

I along with others would love to hear your response though as to what guidelines would be used in the decision of having a CT done considering the risk.  Thank you in advance.

Avatar universal
by mary1000, Jul 09, 2008
So helpful.  A doctor wanted me to have a scan, it seemed largely on basis of age and (sadly) overweight.  But I'm losing weight, am a vigorous exerciser, my bp is well controlled on minimal medication at about 115/75, LDLs cholesterol and triglicerides are low, VLDLs are very low. HDL is high (80-90), and I have had no heart symptoms.  I asked the question the here doctor asked"  what would be done differently medically.  The answer was really nothing.  So I passed on the high radiation exposure test.  So helpful to hear that doctors support this concern, depending on the medical context, of course.

Avatar universal
by laura78, Jul 14, 2008
Thank you Dr. Kirksey for your time in educating us all!     I've recently posted my information and have not recieved  a"professional"  opinion.   I'm new to this site and think I might have mistakenly used a product name.
Tell me please about "trivial anterior wall defect"       When on treadmill at 162 heart rate  100% of max for me. (age 59  fish eating vegetarian since '86,   no meds, moderate excercise,average weight )  results were from my request to have a "full physical" not symptomatic!     Both treadmill and Cardiolite stress/rest showed " anterior wall defect"  NORMAL: left ventrical size, normal left vent. wall motion and systolic wall thickening.   LVEF+ 71%      Normal Myocardial perfusion.
ABNORMAL : Perfusion in the anterior wall.  
Impression:  abnormal stress Gated SPECT Sestamibi myocardial perfusion study consistant with a possible small degree of anterior wall ischemia which can not be ruled out.
Cholesterol:  256......triglycerides 177......  Have started aggressive cholesterol lowering natural options.

Avatar universal
by Dave2436, Jul 14, 2008
I had a heart scan about 12 years ago. I was a police officer at the time and the hospital set up a program for police officers over the age of 45 at a discounted rate. If I remember correctly, the normal cost for this procedure was around $600. The discounted rate was $250. Not bad. Another officer and I thought it would be a good idea to spread the word of this test and the discount to everyone else on the department and a number of other officers took advantage of it. I went with one of my coworkers and both of us came back with a score of "0". About 7 other guys in our district had the test as well and we compared scores. A few guys had scores of around 75, and this got them concerned enough to rethink their lifestyle choices. I remember one guy in particular wrote a note in our monthly bulletin advising that his calcium score was found to be extremely high, which resulted in his doctors doing followup tests and determining that he had major heart problems. He was very grateful to have found out about the heart scan program and said that without it, he may have ended up having a heart attack and dying.

Avatar universal
by Emaki, Jul 22, 2008
Hi!  I have just come back from a long trip overseas.  I am 51 and am late for 14 days.  I had an ectopic 15 years ago.  Can I test for positive if it is an ectopic.  I also have pains now and again and pinches in my abdomen and pain low right and pain at my back same position.  I have no stains.

Avatar universal
by gazzaman, Jul 22, 2008
hi  there just  on this to see if i have a std .

just that i have a red penis head

spots on my chest and i get black bits on the side of my to toenails  .

and when i look and the std pics i get para a bout it :( :(

and start lookin for things on my body .
   and have redis knuckles -

Avatar universal
by zbeckerd, Jul 23, 2008
I had the scan this year on advice of a cardiologist.  It came back that my risk was 75% greater than people of my age ( I am 53).  I had gone in for general feeling of weakness and my thyroid tsh was well above normal, so the feeling was that thyroid was probably the issue.  After the local MD got the results back from the CT angiography that afternoon He called me late that night and told me to take a asprin and come in for another blood test in the morning.  The next day after I got home from my blood test he called and asked me to come back in.  I was life flighted to a medical center and had a stent that afternoon.  My blood test indicated that I had a MI overnight.  I had had the troponin enzyme blood test the day before and in the morning.  The morning test was absolutely positive.  

So have the CT angiography, calcium scoring?  I think yes.  No one told me about the amount of radiation at the time, I may have said no.  And may have died.  I now know that a nuclear stress test has about the same amount of radiation.  I had refused a ekg stress test the previous day as my local hospital does not have the facilities for angioplasty.  I felt that if I collapsed during the stress test I would probably die before I could get to a hospital with a cardiologist.

I had no symptoms of a MI.  I was 95% blocked in one artery.  Without the CT angiography (which I payed for out of pocket $200.00 , cheap due to small rural hospital) I would have been taking my thyroid medicine and probably collapsed at home alone.  In my case it saved my life.

Avatar universal
by Judy9245, Apr 28, 2009
I am a female, 66 years old.  Thirty-Six years ago, at the County Hospital I had an x-ray for a stomach ulcer, the machine malfunctioned and I could feel pain and discomfort like my organs were really hurting, the x-ray technicians badge went registered a large amount of radiation.

The doctor told me not to worry because it would take decades (at least thirty years to develop)  I now am having the following symptoms:

1.  nausea
2.  excessive thirst/urination
3.  extreme blood pressure fluctuations
4.  headaches
5.  anxiety/nervousness/insomnia
6.  tremors and chills nighttime/and daytime
7.  swollen ankles/retaining fluids/difficulty walking
8.  shortness of breath
9.  24 hr. ambulatory blood pressure monitoring diagnosis:  Malignant essential hypertension

What can be done, if anything, to slow this process?

Thanks,

Judy - California

Avatar universal
by Desertengineer, Dec 04, 2012
I was shocked at the dose I received from a routine calcium scan. 182 mGy! That's equivalent to 1800 chest x-rays. 18 rads center chest. Of course when I started asking what happened, why the machine had to be so unnecessarily high, no one can give me an answer. Cardiologist didn't seem to care, even when I explained this was an insane level for even CT. The radiology supervisor seemed to care less as well. This is a serious issue.

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