Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I'd like to welcome you to my podcast and videocast station and of course I'd like to welcome you to the Healthy Heart Network. Today I'd like to talk a little bit about repeat scanning of the heart. I had a couple of patients in the last few weeks who have just given me an insight into a conversation that is worth sharing. So, two patients. The first of them was someone who I saw about eight years ago. We scanned this gentleman in his mid to late 40s because of some family risk. He had some risk. He wasn't hypertensive, not a smoker, but carried a bit of extra weight. We put this gentleman through the scanner. Back then, and we found no problems at all zero calcium score remember my practice is to use super fine slices for calcium score to make sure that we're not missing any calcification whatsoever i use a calcium score as a gatekeeper to further evaluation well this gentleman at my recommendation came back at about eight years or thereabouts you'll remember that A lot of our data tells us that a zero calcium score has a very low risk, almost regardless of all other factors. This gentleman though, he carried a bit of weight and his lipid profile wasn't perfect with some slight elevation of his triglycerides in keeping with insulin resistance, i.e. that sort of weight that you put around the tummy. We see this in people who don't metabolise glucose that well. We call that insulin resistance. These people may progress to diabetes or represent a pre-diabetic form. He came back and we did repeat his scan. Interestingly, he had a low calcium score. I can't remember what it was off the top of my head, but well under 100. The most recent scan, though, showed significant non-calcific plaque in one of the major arteries down the front of his heart. It's not causing any narrowing, so he wasn't going to have any symptoms, but it's a large plaque, it carries a high risk, and there's no question that left another decade, this gentleman would be running an unacceptably high risk of an event. Well, what's my learning from that? My learning is that I've started to shift a little bit in terms of inviting people to re-scan, particularly if we don't put them on medication in that first... Now this gentleman, based on standard cardiovascular risk assessment, didn't warrant therapy at that stage. He was an intermediate risk patient at best. So the plan for him was for him not to start medication in keeping with guidelines, supported by the fact that he had a zero calcium score, but I should have been more tuned into him having more weight than was ideal. and a worse lipid profile than was ideal. My learning from that is that if people have adverse other risk factors we need to see them a bit earlier and the guarantee that a zero calcium score carries can't be applied to that individual who's not average in all ways because our low risk applied from a zero calcium score is to an average population of people. Not people with adverse lipid profiles, not people with central adiposity or a propensity to diabetes. Anyway, nothing untoward has happened to this gentleman. He's now on all the appropriate therapy. We've got a strategy in place. We've really been able to nail down appropriate therapy, and it's a great story at the end of the day. But my learning is it might have been. On reflection, a good thing to have reviewed him somewhere between three, four or five years after the first scan. Don't know the answer there. In fact, there isn't an answer in the literature to clearly guide us. And there's certainly not an answer in the literature to clearly guide us between different individuals. But my feeling is, instead of giving people between, say, five and ten years on a zero calcium score, if they've got other risk factors, I'll be bringing them back sooner. I had another case as well in the last fortnight, a gentleman who we'd scanned back in about 2013. He'd had some funny chest pains and bits and pieces. We did a scan. In fact, I think he had a rebatable scan because we used contrast at the time. He had patchy plaque around the place, nothing really that bad. And we had him on appropriate risk modification at that time. He's also diabetic, which I should let you know. Since 2013, he had seen a colleague of mine only a year or thereabouts ago who put him through a treadmill test for reassurance. I'm not exactly sure what the presentation was at that time, but he basically was put through a treadmill test. I think he had presented with non-specific chest pains. The chest pain was negative for any problems, which is some reassurance. More recently the patient had a funny turn while on holiday he was overseas or traveling and had a funny turn which really may have been his heart and it seemed to me a reasonable thing to get on and have another look. We used CT imaging because he wasn't acutely unwell. The features did need to be resolved. We did know there was some plaque in his arteries previously. and so we wanted to see where we were now. That intervening six years had led to significant deposition of further plaque and calcium within his arteries. He had moved from a relatively low or intermediate risk set of findings based on his imaging to high risk features. He didn't have a critical narrowing. but he certainly had progression of plaque in such a way that left unattended there's no question this gentleman would have run a very high risk of event over the next decade. Well the lesson from that for me is that even though we can have people on some therapy that the underlying status of the coronary arteries can change, that things can progress in spite of our treatment. We've now cranked up his therapy, we've increased the intensity, and we're going to keep a close eye on him. And he may actually be a candidate where I may suggest repeat imaging, say at three years, just to see where we are. It's an interesting space, this idea of repeat imaging patients. I've certainly got a number of patients. where we have repeat image. And I do have a patient in mind who I've seen just recently as well, who's a young patient with a known large plaque in one of the major arteries. That patient is now an intense therapy. And I have to say that because of the nature of the plaque that we demonstrated on CT imaging, I think it's going to be a really valuable thing to re-image that plaque and see if we've brought stability to that. either by reduction in its size or its conversion to a calcium-based plaque rather than a cholesterol-dominant plaque. Nonetheless, repeat scanning. It's a really interesting space. And a zero coronary calcium score has a guarantee. But how long does that guarantee last? Well... For the average person at the average age, we think it's about five years. But if you've got other risk factors, predisposition to diabetes, high blood pressure, smoking, maybe a family history, maybe a bad lipid profile, then that guarantee will not hold as well. We need to bear that in mind. This is a process that we don't fully understand, and so in my opinion, having another look and seeing what's going on... Seems the most sensible way to deal with it. Anyway, I think it's absolutely fascinating. The patients I've seen just lately have benefited from their repeat scanning. I've learned a bit along the way. They're on the right therapy. It's a good story. I hope I've given you something to think about. I hope you've really enjoyed listening to this podcast. As always, if you've got any questions, please drop us a note and let us know if you've got any ideas for any future podcasts. Again, Please tell us. I'd like to wish you the very best until next time. And of course, please don't die from a heart attack. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
