January 20, 2018- by Steven E. Greer, MD
President Trump made news this week by having his doctor, Admiral Ronny Jackson, MD, answer questions from the press about his annual medical exam for more than an hour. In December of 2016, President Trump was heard on camera slurring his speech badly. The press then began to speculate whether he had Alzheimer’s or some other brain disease that could be the grounds for impeachment.
According to Dr. Jackson, the president had remarkably good cardiac health despite being overweight and eating fast food high in cholesterol. However, CNN’s resident brain surgeon, Sanjay Gupta, made a controversial comment that in fact President Trump had “heart disease” He based this on this Coronary Artery Calcium (CAC) score of 133. Gupta also pointed out his weight, lack of exercise, and high total cholesterol as risk factors.
However, is the CAC score alone a definition of “heart disease”? Was Dr. Gupta conflating this score with a diagnosis? Is the CAC even a valid screening tool that accurately predicts future risk of myocardial infarction? Should it have been administered at all? No one in the press questioned this other than The Healthcare Channel.
In 2009, the U.S. Preventive Services Task Force advised against the routine use of the CAC, citing the lack of predictive value, risk from radiation exposure, and unnecessary anxiety and medical treatment that it could generate.[1] In a 2012 New England Journal of Medicine article summarizing the Task Force conclusions[2], it stated:
“The association between CAC scores and cardiovascular events, which has been well documented, is not unexpected, since the presence and extent of CAC reflect the actual presence and severity of atherosclerosis, whereas risk factors, risk scores, and biomarkers are merely markers for the likelihood of the disease.
However, it remains unclear whether CAC scanning has a favorable effect on clinical outcomes…
Knowledge of the CAC score does, however, lead to more anxiety, more hospitalizations, and more revascularization procedures…
and there are concerns regarding the associated radiation exposure. The usual radiation burden associated with CAC scanning is small but real (generally, 0.6 to 1.0 mSv for EBCT and 0.9 to 2.0 mSv for MDCT), and some MDCT imaging protocols are associated with estimated radiation doses higher than 10 mSv. In comparison, the standard chest radiograph yields a radiation dose of 0.01 to 0.02 mSv. An effective dose of 2.3 mSv is estimated to result in a small measurable increase in the risk of cancer, and this estimate would need to be considered if CAC testing (and repeated testing) were used for widespread population screening.
There are also uncertainties with regard to how, when, and in whom the test should be performed, what CAC-score threshold should trigger more aggressive treatment of risk factors, and what the most appropriate treatment is once that threshold is crossed. In the absence of data on outcomes, the CAC score does not meet the criterion for population screening established by the U.S. Preventive Services Task Force. That criterion specifies that screening and treating persons for early-onset disease should improve the likelihood of favorable health outcomes (e.g., reduced disease-specific morbidity or mortality), as compared with the treatment of patients when they present with signs or symptoms of the disease.
Widespread CAC screening of the asymptomatic adult population is not currently recommended
because of the lack of prospective data showing that such screening ultimately results in improved outcomes and reduced coronary events, as well as the inherent limitations of screening. The U.S. Preventive Services Task Force recommends that adults at low risk for coronary events not undergo routine screening and has found that there is insufficient evidence to make a recommendation for or against routine screening of those at high risk for events.
The scientific statement from the American Heart Association and the expert-consensus document from the American College of Cardiology-American Heart Association conclude that it may be reasonable to consider CAC screening in asymptomatic persons identified as having an intermediate risk of coronary events on the basis of an assessment of multiple risk factors; this view is based on the possibility that such patients might be reclassified in a higher risk group on the basis of the CAC score and that the management of risk factors might then be intensified. As noted previously, no studies have shown that improved outcomes are associated with this approach. The lack of supporting data is reflected in the report on the appropriate use of cardiac CT developed by the American College of Cardiology and partner organizations, which concluded that CAC screening is inappropriate in asymptomatic patients who are at low risk for coronary events according to the ATP III criteria; the authors of the report were uncertain about the appropriateness of screening for those at intermediate or high risk.
A broad population-based strategy of CAC screening does not appear to be warranted. It is not clear whether it is reasonable to consider CAC scanning in persons whose global risk assessment places them in the intermediate-risk category or whether the findings from such testing will lead to a beneficial increase in the intensity of treatment. This issue needs to be addressed in future trials focusing on clinical outcomes and cost-effectiveness.”
William Boden, MD of Boston University, prominent cardiologist who has led large trials of various coronary interventional therapies, wrote to us, “Yes, Sanjay Gupta went way overboard, but what might you expect from a neurosurgeon? It’s almost as laughable as Mehmet Oz spouting medical wisdom on TV and in countless tabloids on any number of topics well outside his subject matter expertise as a cardiac surgeon.
Calcium scoring and coronary CT scans are nothing more than a money grab for cardiologists who are looking for any potential justification to do a cardiac cath and PCI. The small subset of patients who may truly be at risk for subsequent CV events are the very small percentage of subjects with calcium scores above the 300-400 range – at most, no more than 5-10% of all those who undergo calcium scoring and coronary CT angio.
Trump has no symptoms, he had a negative stress test and echo, and very good functional capacity—and an HDL of 67. To state categorically that a 71 yo man with a Ca++ score of 133 “has heart disease” or is a “moderate risk for an MI” for the next 3-4 years is patently absurd, and an opinion made in the absence of sound scientific evidence.
Regarding how the CAC become part of the ACC and AHA guidelines, the same cardiologist stated, “I believe that all the data are observational and it emanates from sites that use CAC scoring heavily.
CAC proponents, such as Drs. Matt Budoff and Harvey Hecht, you might want to search these two individuals. As you know, what gets into guidelines is 60-70% “consensus opinion”, and much of this is Level C evidence – if you can call expert opinion that may be biased “evidence”.
The entire Guidelines Committee processes and membership is so incredibly biased and selective. The folks who are chosen are chosen to preserve the status quo.”
[1] Preventive Services Task Force. Screening for coronary heart disease. (Accessed July 21, 2009, at http://www.ahrq.gov/clinic/3rduspstf/chd/chdrs.htm.)
[2] Bonow RO. Clinical practice. Should coronary calcium screening be used in cardiovascular prevention strategies? N Engl J Med. 2009;361:990–997.