Let’s talk about an important cardiovascular (CV) endpoint, specifically atherosclerosis or plaque, that usually appears before ever having a heart attack, stroke or sudden cardiac death. This is the case of a 54 year old male who’s been on a whole foods, low carb high fat diet for over 15 years. Because his lipid profile and all biomarkers had improved, he decided it was time for a heart scan to see if this matched the biomarkers. It turns out the result was a perfect calcium score of ZERO! You may know this man, as he’s yours truly Dr. Jeff Gerber and is not to be confused with that ‘Lobby Boy‘ from the Grand Budapest! ???? Have a look at these beautiful images:
Vascular imaging of any kind provides invaluable information relating to CV risk. Atherosclerosis, plaque (hardening of the arteries) or inflammation of the arteries is the new endpoint and visualizing plaque’s presence or not using tools like coronary artery calcium scoring can provide powerful and useful information that will motivate individuals to make change.
Normal, non-inflamed arteries do not contain calcium. As plaque develops (first soft plaque, then hard), calcium builds within the inflamed blood vessel wall, and this can be detected using high speed computerized tomography (CT) imaging. Although no test is perfect and radiation exposure (equivalent to a mammogram or slightly greater) is an important consideration, coronary artery calcium scoring is a great direct method to estimate plaque burden and cardiac risk. The more calcium that you have (especially if you’re in the unlucky ≥75th percentile for age and sex), along with calcium progression (≥15% per year,) the greater your risk. Even with a positive calcium score, stabilizing that score greatly reduces your risk.
| Calcium Score | Presence of Plaque |
| 0 | No evidence of plaque |
| 1-10 | Minimal evidence of plaque |
| 11-100 | Mild evidence of plaque |
| 101-400 | Moderate evidence of plaque |
| >400 | Extensive evidence of plaque |
Adapted from Rumberger JA et al. Mayo Clinic Proceedings March 1999: 74:243-252
To illustrate, with a score of zero your likelihood of having a cardiac event is <1% yearly compared to a high score of >300 making you at least 8 times more likely to suffer from a cardiac event. Progression of ≥15% per year for any given score is particularly ominous as this can cause one to be 17.2 times more likely to have a cardiac event and 3 times more likely to die from any cause. Halting progression is most imperative and will greatly reduce risk.
| Calcium Score | FRS Equivalent | 10-Year Event Rate, % |
| 0 | Very low | 1.1-1.7 |
| 1-100 | Low | 2.3-5.9 |
| 101-400 | Intermediate | 12.8-16.4 |
| >400 | High | 22.5-28.6 |
| >1000 | Very high | 37 |
J Am Coll Cardiol Img. 2015;8(5):579-596 FRS=Framingham Risk Score
What’s really important is that calcium scoring actually surpasses Framingham risk assessment that traditionally uses age, sex, cholesterol, HTN, smoking, diabetes and history of previous MI to determine risk. Calcium scoring does truly excel at predicting CV risk better than any other non-invasive tool available today.
Vascular ultrasound is another useful technology to look for plaque burden in larger vessels like the carotids and the aorta. Because coronary arteries (supplying blood to the heart muscle) are relatively small and always in motion, other technologies beyond standard ultrasound had to be developed to properly visualize these small vessels. There are several competing technologies including CT angiogram, heart catherization and intravascular ultrasound, but they are all invasive and expensive relative to CT calcium scoring.
Just to clarify, I don’t own a CT scanner nor do I get compensation to refer people for testing. After further study and peripheral involvement with The Widowmaker movie (a must watch) it’s clear to me how powerful and important cardiovascular imaging is especially for anyone who wishes to know their risk.
Regarding proper prevention, it’s different for everyone, but I am not the only one who can boast of a ZERO calcium score while being on a LCHF diet. Ivor Cummins, Gearóid Ó Laoi, and some of our patients are just a few examples of people who have been lucky when it comes to achieving that perfect calcium score of ZERO. Others have been able to stabilize and improve their calcium scores. Certainly there are many factors to consider including genetics, but we have all chosen the low carb high fat dietary approach to address CV risk and health, and so far this approach appears to be working. I find it important to monitor all CV markers when it comes to addressing any lifestyle approach.
Unfortunately, calcium scoring has been underutilized for reasons spelled out in The Widomaker movie and mostly ignored by primary care doctors. I am, however, optimistic that CV imaging will gain momentum in the next several years, thanks to the movie and the various medical institutions that have finally endorsed the test. Most hospitals and other outpatient facilities actually do offer the test. In Denver, Front Range Preventive Imaging is by far my favorite because my trusted colleague, Dr. Bill Blanchet is the medical director. They do calcium scoring testing accurately, reliably and using minimal radiation. What’s difficult is finding the right doctor who knows how to interpret the results and provide proper advice, addressing prevention as it relates to diet, exercise and medication. That’s where our office comes into the equation.
Do you have a story related to lifestyle and CV imaging? Please share it with us.
So what’s Lobby Boy characters real name? Answer=ZERO!
Is Coronary Calcium Scanning The Mammography of the Heart?
Zero CAC Score Confers 15-Year “Warranty” Against CAD related mortality
Dr. Matthew J. Budoff review article: Screening for Ischemic Heart Disease with Cardiac CT: Current Recommendations
Budoff et al.: Long-Term Prognosis Associated With Coronary Calcification
Zero Calcium Score, No Statin?
Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring . No statin benefit for zero scores.
MESA 10-Year CHD Risk Calculator
Updated Nov 2018: Additional references and links.
