Coronary Artery Calcium Score


Coronary Calcium Score

Calcium is a chemical element that is essential for living organisms.

Most of the calcium within the human body is found in teeth and bone. Small amount, about one percent of total body calcium, is dissolved in the blood.

Undissolved calcium is metallic and hard and is difficult to break or cut with a knife.

When we age, calcium deposits can be found in many parts of our bodies. Calcification of the walls of the arteries is common in people aged 65 and older. Calcification of the breasts is often seen in women after the age of 50.

So, to a certain extent calcification of arteries and internal organs can be regarded as a normal part of aging.

Due to their metallic nature and density, calcium deposits are easily detected by X-ray images. In the early days of cardiac imaging, doctors relied on detecting calcium, as it often was the only feature that stood out on radiographs of the heart.

If arterial calcification is abundant, the aorta and coronary arteries can be outlined on a plain radiographic image. Today these methods have been replaced by more sophisticated modern imaging techniques.

Coronary Artery Disease

The coronary arteries are important vessels that supply blood to the heart muscle. To be able to function normally, heart muscle cells need a continuous supply of blood, delivering important nutrients of which oxygen is most important.

Atherosclerosis, is a chronic inflammatory condition that may cause narrowing of arteries, and rupture of arterial plaques, resulting in blood clotting (thrombosis) and sudden disruption of blood flow. Due to several different reasons, the coronary arteries are very prone to atherosclerosis

If the supply of blood is disrupted, parts of the heart muscle may die, and will be replaced by scar tissue. This can compromise the ability of the heart to pump blood to the organs of the body.

The term acute heart attack (myocardial infarction) refers to a situation where there is sudden blockage (occlusion) of blood flow in a coronary artery.

In the early 1960’s several risk factors for atherosclerosis and coronary artery disease were defined. Since then it has been repeatedly documented that smoking, lipid disorders and high blood pressure are associated with increased risk. Other conditions that predispose to coronary artery disease are family history, insulin resistance, physical inactivity, mental stress and depression.

Identifying individuals at risk is very important in order to reduce the risk of coronary artery disease. Therefore, knowledge of risk factors and how to reduce their influence is of key importance.  The declining death rate from coronary disease seen for the last 35 years can to a large extent be explained by reductions in major risk factors such as blood cholesterol, blood pressure and smoking (1).

Atherosclerotic coronary heart disease is still the most common cause of death in the Western world. Thus far, our ability to screen for this disease has been limited.

Although the usefulness of screening is still debated, assessing the amount of calcium within the walls of the coronary arteries may provide important prognostic information.

Coronary Artery Calcification

Although calcification of the coronary arteries can be regarded as an aging phenomenon, extensive calcification appears to reflect more intense atherosclerosis, higher risk of heart attack, and worse prognosis.

Coronary calcification can be seen in adolescents, although it usually starts later in life.

The calcification is composed of calcium phosphate which is similar to that in bone.

For a long while, arterial calcification was thought to be the result of a degenerative process, but recent evidence suggests a that a more active process is involved, possibly resulting from injury or inflammation within the vessel wall.

In June 2000, the American College of Cardiology (ACC) and American Heart Association (AHA) Consensus Panel wrote in the Journal of the American College of Cardiology: “Coronary calcium is part of the development of atherosclerosis; …it occurs exclusively in atherosclerotic arteries and is absent in the normal vessel wall.”

Coronary Artery Calcium Score

In the 1980’s US cardiologists lead by Dr. Arthur Agatston defined a method to assess the amount of coronary artery calcium by using electron beam computed tomography, otherwise known as ultra fast CT scan.

The density of calcium is assessed by the so-called Hounsfield scale which measures density in Hounsfield units. The weighed score multiplied by the area of the coronary calcification provides the calcium score, commonly termed the Agatson score

The amount of calcium within the walls of the coronary arteries, assessed by the Agatston score, appears to be a better predictor of risk than standard risk factors (2).

A recent study found that progression of coronary calcification, assessed by two scans in 2.5 years, was associated with increased risk of cardiovascular events during a follow-up of more then 7 years (3).

The presence and extent of coronary calcium is first and foremost a marker of the extent of atherosclerosis within the coronary arteries. Nonetheless, it is important to understand that the coronary calcium score does not necessarily reflect the severity of narrowing (the degree of stenosis). Still, a patient with high calcium score is more likely to have a significant narrowing of a coronary artery than a patient with low calcium score.

An individual without coronary artery calcification is very unlikely to have a severe narrowing of a coronary artery (4).

Although cardiovascular events can occur in patients with very low calcium scores, the incidence is very low.

Based on a number of studies, the following definitions are used to relate the coronary artery calcium score to the extent of atherosclerotic coronary artery disease:

  • Coronary calcium score 0: No identifiable plaque. Risk of coronary artery disease very low (<5%)
  • Coronary calcium score 1-10: Mild identifiable plaque. Risk of coronary artery disease low (<10%)
  • Coronary calcium score 11-100: Definite, at least mild atherosclerotic plaque. Mild or minimal coronary narrowings likely.
  • Coronary calcium score 101-400: Definite, at least moderate atherosclerotic plaque. Mild coronary artery disease highly likely. Significant narrowings possible
  • Coronary calcium score > 400: Extensive atherosclerotic plaque. High likelihood of at least one significant coronary narrowing.

When interpreting coronary artery calcium score it is very important to consider age and gender. For example 50% of white males aged 70 have a calcium score higher than 14,5 and 50%  of white females aged 70 have a calcium score above 13. There is a calculator available here that provides coronary calcium score distribution based on age, gender and ethnicity.

How Is Coronary Calcium Assessment Performed?

Coronary Calcium Score

To begin with, coronary calcium assessment with CT was made possible with the development of the electron-beam CT scanner in the late 1980’s. The speed of this machine was much higher than that of existing scanners. The high speed made it possible to “freeze” heart motion to allow measurements of calcium in the coronary arteries.

Lately, ultrafast spiral CT has been used to assess coronary calcium. This technique makes the scanning time very short. Often a scanning length of around 10 seconds is used.

The patient usually needs no specific preparation. Fasting is not necessary. As high heart rate may reduce imaging quality, patients are often asked to refrain from smoking and drinking coffee before the scan. Sometimes beta blockers are administered to slow heart rate.

Many experts have expressed concerns about the radiation involved with the CT scan. It has been estimated that there may be an increase in radiation-induced cancer risk with repeated procedures (5).

What to Do About Extensive Coronary Calcification?

There is no specific treatment available that lowers coronary calcium.

One randomized placebo controlled trial (6) did not find any significant benefit with atorvastatin (cholesterol lowering drug), vitamin C and vitamin E in patients with high coronary artery calcium score.

Although blood levels of cholesterol were reduced, there was no effect on progression of coronary calcium score. Atherosclerotic cardiovascular events were fewer in the drug treatment group compared with placebo, but the difference was not statistically significant. However, there was a greater treatment effect in a subgroup with coronary calcium scores above 400.

Treatment of individuals with high calcium scores should aim at reducing risk. This involves treating lipid disorders, high blood pressure and diabetes if present. Refraining from smoking is essential. Regular, moderate exercise is advised. Due to the overwhelming evidence of benefit in individuals with atherocslerotic heart disease, treatment with aspirin and statins is generally advised.

If extensive calcification is present, further evaluation may be needed. Stress test associated with nuclear and echocardiographic imaging techniques is often performed. Coronary catheterization with angiography of the coronary arteries may be indicated to assess the severity and extent of coronary narrowing.

Comments

  1. says

    I had one of these done last year, 49 years old, score was 37, so I guess that’s pretty good. I had it done for my own personal interest.

  2. Edith Nir says

    So which is it – should we use statins to lower risk (with score under 400) or will it not have an effect on the calcification progression???

    • Axel F Sigurdsson says

      @ Edith Nir

      There is no evidence thus far that statins will reduce the progression of coronary calcium.

      The rationale for their use is based on the assumption that individuals with high calcium scores have extensive atherosclerosis, and the fact that statins have been shown to improve outcome in patients with established atherosclerotic cardiovascular disease.

      • Don C says

        I am being advised to commence “statin therapy”…strongly! using phrases like ‘The risk of death is greater than any other side-effects’, but I am far from convinced. I am 64; my CT Coronary Calcium Score was 3; my Carotid IMT Score was “1.1-1.3″; I am a non-smoker for the past ~30-40years; I am quite fit (swimming ~1km every day) to the point where the cardiologist was unable to stress my heart during a Stress Echocardiagram; and my diet is good, high in veg, fibres and fish with only token (perhaps once a week) red meat. Admittedly my Father died of a heart attack at 74, but I am a lot fitter than he was at my age. So…if there “is no evidence that statins will reduce coronary calcium”, why am I being so strongly pressed to take them, with all their recognized side-effects?!?

      • Axel F Sigurdsson says

        Thanks for the comment Don.

        Although statins don’t appear to reduce coronary calcium, they may reduce the risk of future cardiovascular events. However, a coronary calcium score of 3 is fairly low and clearly below medium for your age. You can use the calculator here.

        In order to see the whole picture it would be interesting to have some information on your lipid profile. Do you have high blood pressure?

    • Axel F Sigurdsson says

      Thanks for the links Ted.

      I really enjoyed reading the review on K2. Its promising role for preventing or modulating vascular calcification is of great interest.

      The question whether the anti-inflammatory effects of vitamin K and vitamin D may be important when it comes to preventing vascular calcification is also of great interest. Both these nutrients appear relatively safe and they’re certainly not expensive.

  3. Jkart says

    It’s not clear what CT measuring of arterial calcification really means. Is it the measurement of the length of arterial vessel affected by calcification? Or is the measurement of arterial narrowing from calcification?

    If one has a score that puts them at the 50th percentile for their age/sex, then how frequent should CT technology be used to monitor the progression? Every year? Every 3 years? ???

    • Axel F Sigurdsson says

      @ Jkart

      Coronary calcium score reflects the total amount of calcium within the walls of the coronary arteries, taken together to provide a single number. It’s based on density and area.

      Coronary calcium score tells you nothing about arterial narrowing. One can have a high calcium score without any narrowing or blockages being present. However, a patient with high calcium score is more likely to have a significant narrowing affecting blood flow than a patient with low calcium score.

      Regarding your last question the only thing I can tell you is that nobody really knows how to use coronary calcium score in clinical practice. Whether, or how often progression should be monitored is still a matter of debate.

      • Jkart says

        Thanks for the clarifications. For whatever reason, it was in my mind that the calcium score was directly related to the level of vessel blockage.

  4. says

    Thanks for the post Axel. In our reports Volume130 is also reported an it is suggested that it be used to measure progression from year to year rather than AJ scores.

    There has been some debate regarding the essence of calcium scores and its ability to predict risk.

    Glad you posted because I wanted to discuss with you. Comments?

    Jeff

    • Axel F Sigurdsson says

      Thanks Jeff

      I think there are several things to discuss and many unresolved issues when it come to coronary artery calcium score (CACS).

      One thing worth mentioning is that CACS is probably not very useful as a diagnostic tool. By that I mean that if you have a patient with chest pain, breathlessness or other symptoms, you’ll have to use other methods such as exercise testing with or without nuclear or echocardiographic images and then, if positive,coronary angiography.

      I don’t think CACS is a useful screening tool for large parts of the population. In that respect, it’s probably not cost-effective. Radiation is involved and there are cheaper methods available.

      However, CACS may be helpful when assessing individuals at intermediate risk. There may be situations where you’re wondering whether to treat with statins or not. If there is extensive calcification, you might want to recommend statins while on the other hand, if there is no calcification, risk is low (even in the case of high LDL-cholesterol) and you might want to refrain from statin treatment.

      What’s your experience in Denver and among general practitioners in the US? Is CACS being used to assess risk?

      • says

        Axel,

        In the US insurance is not paying for CACS, this usually means that insurance concludes that it does not provide useful information. However, many pay out of pocket for the screen and I agree as you stated above there may be some usefulness.

        We do CIMT’s with limited doppler in our office as a competing technology. I am not sure itima thickness correlates with risk but I like to visualize plaque. I suppose that using these tools in the right context can be useful.

        Jeff

  5. John wagner says

    I suspect a calcium score will turn out to have a practice value other than measuring it like the length of a fuse on a time bomb, and having no treatment to stop this progression. If a person has a high score and angina/significant block, then surgical treatment might be more indicated, as compared to same person except low calcium score. This person might respond better to medical treatment, ie statins, etc. bottom line, use it to help decide surgical versus medical treatment of coronary disease.

    • Axel F Sigurdsson says

      John.

      That’s a hypothesis that is still to be tested.

      I don’t now of any evidence so far suggesting that calcium score is useful when deciding whether to go for surgery or medical therapy. Usually these decision are based on the number of arteries with significant narrowing (stenosis) assessed by coronary angiography, the localization of the narrowings and the extent of myocardial ischemia.

  6. Don A says

    I would appreciate any comments/advice from the experts on this blog. I am a 62y.o. male at 5’11’ and weigh 213 lbs after losing 20 lbs since Feb 2014 and have started exercising and cycling regularly since March of this year. I plan to lose another 20 lbs. I have mild asthma and take asmanex 220mcg
    2 puffs daily. BP is well within normal limits. In Sept. 2000 I had aCAC of 11. LMA: 0, LAD: 9,CFX: 0, RCA: 2. IN 2007 I had an angiogram due to a thallium stress showing a possible problem but cardiologist thought was false positive. Results of angiogram was RCA – mild diffuse disease , left main – no disease, lad proximal <30%, Mid < 30%, D1 no obstruction, Lcx – no obstruction. No treatment rendered. After blood workup my cardiologist put me on 20mg of lipitor. I have been on 20 mg lipitor since early 2008.
    Now for my concern, Sept 5th I had a stress echo. Negative findings except for showing pac on exercise. His concern was that the width of pvc ( recovery period ) was wider than usual. I am asymptomatic on 24 mile road bike trips and exercise. Sometimes on strenuous exercise take pulse and feel extra beats every 8 – 16 beats.
    The kicker here is that I had a repeat CAC score November, 2013. Cardiologist told me via email that it was significantly higher, but nothing to worry about and didn't give me the number. Recommended stress/echo which I took my time about. At office visit I asked for test result, what a shock. Total CAC score 1693. LM- 0, LAD- 1141, D1 – 37, CX – 27, RCA – 488, PDA – 0. This shook me to my core. I questioned my cardiologist who is well respected in NYC and he assured me not to be worried. Told me about studies showing Lipitor helps soft plaque become more stable by hardening it and this causes deposition of calcium causing higher score. I have searched internet for this phenomena and found nothing but came upon your blog.
    My cardiologist reiterated over and over not to worry but to be on safe side and not for elevated CAC score but for exercise induced pvc width referred me for a virtual angiogram ( cat of heart).
    Needless to say, I am extremely concerned about the CAC score which is virtually off the charts.
    Any recommendation/clarification you can give would be greatly appreciated

    • Axel F Sigurdsson says

      Don A.

      Some studies have suggested that there is an association between statin use and coronary artery calcification. Furthermore, there is no evidence that statin treatment halts the progression of coronary calcification.

      However, this does not mean that statins accelerate the progression of atherosclerosis. In fact, as your cardiologist suggested, calcification of plaques may indicate healing. In theory, a calcified plaque may be more stable and less likely to rupture than a non-calcified plaque.

      It is possible that there are different mechanisms behind coronary calcification and coronary artery narrowing. In one meta-analysis, coronary calcification was not affected by statin therapy although there was a consistent moderation of progression of coronary artery narrowing with statins.

  7. Don C says

    Thanks very much for your reply (22 Oct at 08:22) Axel. I am answering here because there was no “REPLY” link in your reply.

    I should admit I am feeling way ‘out of my depth’ here. My understanding of all this feels incredibly superficial. My instincts tell me I am in good health and I should seek another opinion before I embrace statin drug therapies, but I live in a country area where specialists are few and far between. So your blog (and, even more so, your input re my circumstances) is hugely appreciated…and I will do my best to answer your questions…

    My blood pressure is “120 over 80″ and my Serum Lipid studies appear as follows:

    Cholesterol 6.5 mmol/L
    Triglyceride 0.8 mmol/L
    HDL Cholesterol 1.5 mmol/l
    Cholesterol/HDL-C Ratio 4.3
    VLDL Cholesterol 0.4 mmol/L
    LDL Cholesterol 4.6 mmol/L

    My other details are in my earlier (22 Oct at 00:29) Comments.

    • Axel F Sigurdsson says

      Don.

      Although your LDL-C is rather high there are positives. Triglycerides are low and so is TG/HDL-C ratio. This is an indirect sign of LDL-particles being large rather than small which is positive.

      Generally speaking statins lower the risk of cardiovascular risk. When the risk is low, like it appears to be in your case (coronary calcium score of only 3, not smoking, no hypertension and regular exercise) the likelihood of benefit from statin treatment is probably very small.

      • Don C says

        Thanks Axel
        Your comments are reassuring, not only because they appear to confirm my instincts, but also and especially because they give me another independent and very expert source that is looking at (at least some of!) my particulars.
        My current cardiologist appears to be relying heavily on the Carotid IMT results. He suggests that those results effectively forecast a deterioration in my coronary calcium — His words were along the lines of ‘There is now a sludge, rather than hard calcium in my heart, but soon (as in the next couple years) the thickness in my carotid will be reflected by hard calcium in my heart’ — which made me a strong risk of heart attack or stroke within the next few years…all of which could be solved by “taking a little pill”. He also suggested I was now at a point where the process flagged in my carotid results could be reversed (by statin therapy) BUT once it moved on to the next phase in my heart, nothing could then be done.
        My readings about Carotid IMT results are mixed. Not surprisingly, they confirm some of what my cardiologist is saying, but it also appears (to my VERY amateur understanding of the technical articles!) that there is confirmed thickening of the carotid with age anyway and the exact, age-adjusted risk range of results is not clear; that, plus there appears to be some uncertainty in the consistency of those results, leads me to pause at the suggestion that my results point without doubt toward statins for me. What is your ‘feel’ for Carotid IMT results? in general, but more importantly in my particular case with results of (in the cardiologist’s words as I did not actually see the results) “1.1 to 1.3″?
        Then further, when I hesitated at the direction toward statins, the cardiologist went on to suggest an angiogram, with the prospect of the insertion of stents as a preventive measure. I believe I understand this process, but again it seems to me to be unwarranted by my current state of health?

      • Axel F Sigurdsson says

        Don
        Unfortunately I have very limited experience with Carotid IMT.
        I’m also reluctant to go into much detail regarding your health. That would be irresponsible of me. The only thing I can do is discuss these issues in general terms as I did in my previous comment.
        Of course I think you should listen to your doctor. I have no doubt he wants what’s best for you. However, the question when to use statins is often difficult to answer and experts don’t always agree.

  8. Rich Frontera says

    I am a 60 year old male. My cholesterol is and has been low for 30 years (with statin). I exercise regularly. My blood pressure is normal and I am in excellent physical condition-low body fat- no lipid issues Went for a Calcium score which was 426. Which falls under extensive cardiovascular disease. Any comment or suggestions

    • Axel F Sigurdsson says

      Rich.
      A calcium score above 400 implies that your risk for having a cardiovascular event is elevated. However, it doesn’t imply that you have any significant narrowings/blockages in your coronary arteries. Sometimes other tests are performed to check for that.
      I think you should focus on limiting your risk by not smoking, eating healthy and exercise regularly (which you already appear to be doing). In my opinion there’s no reason to stop the statin treatment. Although statins don’t appear to affect the calcifications per se they may help lowering your cardiovascular risk.
      Discuss with your doctor whether he believes further testing is needed.

      • Rich Frontera says

        Thank You for your response. As a follow up to the calcium score I had a nuclear stress test and was told the result is “normal”.

        I don’t know what that means. Since a score of 426 means “severe cardiac artery disease” (where I was)……does a “normal” nuclear stress test mean I don’t have “severe cardiac artery disease”. Just feel like I have no idea where that leaves me.

      • Axel F Sigurdsson says

        Rich
        I presume the nuclear stress test shows that blood flow to the heart muscle is normal which indirectly suggests that there are no blockages/narrowing in the arteries affecting blood flow.
        But, keep in mind, this is only my presumption based on the limited amount of inormation.
        Your doctor should be able to explain it all to you.

  9. andy says

    I just received the results of my calcium scoring test. I am 44 years old, 100 pounds overweight. My cholesterol is “borderline”. My calcium score is zero. Does this mean that cholesterol isnt a problem for me, or just that it hasn’t effected my coronary arteries yet? Considering my weight, high blood pressure and eating habits, I was surprised to have such good results.

    • Axel F Sigurdsson says

      Andy
      That’s good news. However, remember that you’re quite young. A calcium score of zero is fairly common at your age. I think you should do what you can to improve your lifestyle and try lo lose weight.

  10. Scott says

    Hi,
    Quick question….I just had a Calcium screening test done last week. Im 42 years old. All my vitals are good BP 110/60, cholesterol in normal range. My HDL has always been a little borderline low (42). Anyway, my Calcium score was 7. Id never even heard of Calcium scoring before this so im a little nervous and unsure what this all means. From what I know 7 is low, but perhaps not so low for my age. Im confused. Any light you can shed would be great. My Doctor and I are supposed to talk about beginning statins, but i feel uneducated on this whole thing. Am I code red? or am i over reacting?

    • Axel F Sigurdsson says

      Scott.
      No I don’t believe your code red and as I see it you’re probably overreacting. I just wonder why you had a calcium score performed. In fact I think there’s limited data available for your age group. Anyway, a score of 7 is low. The sensible thing is to discuss the findings with your doctor.

      • Scott says

        Thanks Axel for the reply. That makes me feel better. To answer your question about why I had the test done…..Last weekend I had a very uncomfortable feeling in my chest, so after no relief for 12 hours I went to the Emergency Room where they did every test under the sun….EKG, Echocardiogram, x-rays, blood panel etc. It turns out that I have Pericarditis which im finishing up my treatment for with Colcrys. Feeling much better. So in running all those tests the calcium score was something they picked up in passing. I went to my primary care physician this week as a follow up and he strongly recomends I start a Statin. To me that sounds like a big deal so it got me a little worried which made me question how serious my score is or isnt.

  11. Scott says

    I guess my main worry wasn’t so much in the current score of 7. It was more because my understanding is that if you have a positive calcium score, even if its low at the moment, will continually increase to a significant # as time progresses. Thats what my confusion and sort of worry is.

    • Axel F Sigurdsson says

      I understand Scott. However, it’s very hard to tell how and if arterial calcifications will progress. You may still have a score of 7 after ten years although it’s likely to be higher just because you’ve aged.
      Take this as a positive thing and tune your lifestyle so you may be able to reduce the likelihood of future disease.

  12. Scott says

    Thanks Axel, thats comforting. Are there any lifestyle tips you can give me. I plan to up my cardio vascular exercise. I’ve mainly mostly done only weight training with a little cardio mixed in. As far as dietary are there things that are most desirable to eat aside from the obvious, staying away from bad fats and simple carbs.

  13. Scott says

    Im also very confused about the statin thing. My Dr wants me to start it. But ive read so many conflicting things about the side effects and being only 42 years old, i feel that if I were to be on them now, that it would be a lot of years ahead of me for those side effects to happen as opposed to if i was 70 years old now. I kinda would like to know if lifestyle changes and habits at my age and score would be something to seriously consider as opposed to a life commitment to statins

    • Axel F Sigurdsson says

      Scott
      Your reasoning is sensible and rational. When prescribing statins it’s important to be sure that the benefits outweigh the risks. Most people tolerate these drugs very well, even for long periods.
      Of course you should focus on lifestyle issues. The question is whether statins will bring additional benefits. Your blood lipids, family history and other risk factors will have to be taken into account. Discuss the pros and cons of statins with your doctor. This is where shared decision making (between you and your doctor) is important.

  14. Terry Stahly says

    I am 62 and my score just came back and is 912 and it was 800 three years ago. My cholesterol is 106 and labs are excellent, my stress test is wonderful I exercise 35 min on treadmill daily at 4.0 mph look and feel great for my age and am very active, I quit smoking 17 years ago do not drink anymore but eat sub sandwiches, bacon eggs butter and double cheeseburgers fries etc. I take Vytorin for cholesterol my doc says not to worry but the web says my chances for a heart attack are one in four within one year. Who should I go get a second opinion from and what are my options and risks for a heart attack?

    • Axel F Sigurdsson says

      Terry
      The calcifications are not necessarily the problem by them selves although they may predict risk. Your target should be to lower your risk of cardiovascular events. Of course it’s mostly about lifestyle issues and like in your case, statins are frequently prescribed to lower risk. From your description it looks like you could do a bit better with your diet. Great you quit smoking because that’s a huge issue. I also believe regular exercise is often underrated as a preventive measure.

  15. Leigh says

    My 53 husband was originally given a calcium score of 960, which was then taken down to 640 following an angiogram. He is on statins, angina medicine, aspirin and carries a spray in case he has a heart attack. He has osteoporosis in his knee and I suspect in other places too. Thinking of putting him on Vit K2 as my other fear is a link between calcification and dementia if the plague starts to build up on the brain. This is one condition where there are multiple organs that you really need look at in treatment options, as treating the osteo could make the calcification worse and vice versa. Is there a time when you would not advocate the use of statins in someone with calcified arteries?

    • Axel F Sigurdsson says

      That’s a a difficult question Leigh. I suppose statin treatment may reduce his risk of cardiovascular events. However, more information is needed in order to have a say on that, for example his lipid numbers, information on smoking, blood pressure and family history.

  16. christian says

    Hello, I had a heart scan performed about three weeks ago.I am 48 about 15 lbs over weight but, I’m working on that . My calcium score came back at a 59. To be honest it has me shaking in my boots. The lower left descending artery has 58 and I have 1 in another.. Does this mean 58% of my artery is closed ? This has my children very upset.. Any and all advice would be appreciated…thanks and God bless you..Chris

    • Axel F Sigurdsson says

      Christian
      No this doesn’t mean that there is 58% narrowing or blockage. Coronary calcium score only reflects the amount of calcium within the walls of the coronary arteries. If I understand it correctly, in your case the calcifications are mainly found in the left anterior descending artery which is quite common. Although calcium score is a marker of risk it doesn’t really tell you anything about the degree of blockage or narrowing.
      Speak with your doctor about whether further work-up is indicated and if any treatment is necessary. Focus on reducing your risk by working on lifestyle issues.

  17. Joe says

    Hello.
    I have a calicum score of 450 at age 40. No significant blockages. normal weight and blood pressure.
    Suffer from PVC s. Curious to know if that is a cause or effect of the high calicum number.
    All I can get from my Doctor is this puts me at a high risk for a cardiac event and can’t predict if the plague will rupture. He said keep an eye on your risk factors. But no real advice on how to prevent a future event. I feel doomed. What can I do. Again not overweight. Excercise and blood pressure normal. Can the excercise cause the plague to rupture.

  18. says

    Correction to my previous Email. Typo. My age is 60 not 40.
    I am looking forward to any advice you can give me based on the above information. Seems to me that with the knowledge that I am at a high risk. Something could be done. Removal of plaque etc. There must be a reason why it forms in the first place. Inflamation but what causes the inflamation. Etc. Thanks so much.

    • Axel F Sigurdsson says

      Joe
      This is not something that can easily fixed. We don’t really know what causes arterial calcifications. Genetic factors play a role and probably inflammation as well. Why some people have low calcium score and some high is still not entirely known.
      Having calcium in the arterial wall is not the same as having narrowing of the vessel or a blockage. Calcified plaques are not more prone to rupture than softer plaques.
      However, studies show that high score is associated with higher risk of vascular events but it doesn’t mean you’re bound to have one.
      Discuss with your doctor whether further testing is needed.
      Do what you can to reduce your risk. Moderate exercise is usually not a problem. Don´t smoke. Eat healthy. Try not to get overweight. Have your blood pressure checked.
      Good luck

  19. Phil says

    Like many of the men in this blog, I was found to have a positive calcium score. The test was done as part of eval for atypical chest pain. I had no cardiac risk factors and was found to have a score of 330. I was started on aspirin and high dose lipitor. I had neg nuclear stress test. Not sure where to go from here as I run regularly, have normal baseline chol and BP and don’t smoke. Do I need to make a big change in diet ie The Dean Ornish low fat vegetarian diet? Are there false positive tests? Do they revert?

    Thanks.

  20. Denise says

    Oh boy! After reading about calcium scores in the single and double digits, and people are concerned, now I am really concerned. I have severe rheumatoid arthritis and fibromylagia, along with a few other issues that don’t really bother me. Sept 14, I passed out in the shower, cold. i woke up on the floor of the bathroom. I ended up seeing a neurologist and then a cardiologist. The neurologist said my brain was fine. The cardiologist I saw was not my regular cardiologist because mine was out on disability. The temp cardiologist ran a number of tests – echocardiogram, stress test, day heart monitor,etc. I also had a calcium scan that came back at at 248. My lab work was prefect with the exception of elevated liver enzymes and an increased SED rate – both normal considering the meds I am on for my RA. The temporary docs advice was to drink 10 glasses of water a day and avoid the heat – and oh “take an aspirin a day just in case one of these pieces of calcium should break free”!!! Water and aspirin was his answer. All other indicators that would lead to a high score did not apply, no diabetes, good cholesterol, low blood pressure, plenty of exercise, no drinking or smoking. I finally saw my regular cardiologist last week and he put me on a statin to lower my risk of a heart attack, even though I do not have a cholesterol problem. What other treatment is there? Am I doomed and will I be paranoid about having a heart attack at any moment? Is there anything I can do? According to my doc,I am already doing everything. I am afraid to get upset or get angry because that might raise by blood pressure and cause a heart attack? Can anything be done to remove the calcium? I just want it all taken out.

    • Axel F Sigurdsson says

      Denise.
      Although high calcium score is associate with increased risk, removing or reducing the amount of calcium isn’t necessarily a good thing. For example it’s possible that calcium deposits may result from healing of inflammation within atherosclerotic plaques. High calcium scores should be approached by general risk modulation which includes healthy diet, regular exercise, not smoking, taking care of high blood pressure, avoiding obesity and treat lipid disorders.

      • Denise says

        Please correct me if I am wrong. The calcium could be a result of the inflammation? from my RA? I have had RA for about 12 years.I am just so physically and mentally tired from all of this.

  21. Andrea says

    High cholesterol runs in my family and I have had it all my life. I am 29 years old and it has finally hit me what great risk I have. I have been on statins for 10 years but cholesterol levels are still high. I am scheduled for a calcium score test tomorrow morning, hoping to find out I’m not too late to make life long life style changes. Would you think this is a good idea to get this procedure done?

  22. says

    Hi Axel,

    I actually had a bit of an issue with this portion of the article.

    Treatment of individuals with high calcium scores should aim at reducing risk. This involves treating lipid disorders, high blood pressure and diabetes if present. Refraining from smoking is essential. Regular, moderate exercise is advised. Due to the overwhelming evidence of benefit in individuals with atherocslerotic heart disease, treatment with aspirin and statins is generally advised.

    Before getting started I should begin by saying I’m extremely skeptical of the lipid hypothesis and that saturated fat is bad for you and that taking statins is beneficial in terms of all-cause mortality for anyone except a very small portion of population – men under 45 who have already had a heart attack. It’s also my belief that insulin resistance and elevated blood sugar are the most likely causes of CAD/CHD (as well as a host of other chronic diseases).

    With that in mind, I’m wondering what the evidence is that you think is so overwhelming that aspirin and statins are beneficial for treating heart disease. The NNT for statins to prevent a heart attack is tiny, one’s risk of contracting diabetes from a statin is actually higher. I know that NCEP has developed a standard of care for heart disease that is based upon a statin to lower LDL but I also know that 8 of the 9 members of NCEP have taken money from drug manufacturers. I know this post was about CACs but I think it’s important to point out that are many doctors/researchers now think statins are ineffective at best and detrimental at worst with the skeptical number growing all the time. (Forgive me advance if you’ve covered this in prior posts, I’m fairly new to this blog).

    Thanks,
    Bob Johnston

    • Axel F Sigurdsson says

      Hi Bob.
      That’s a vey good question.
      In fact you’re right that I have written a lot on statins on my blog and probably share some of your skepticism.

      Due to the overwhelming evidence of benefit in individuals with atherocslerotic heart disease, treatment with aspirin and statins is generally advised.”

      Firstly, this is not about my personal opinion. This is the view of most cardiologists and experts on the issue.

      In fact there is strong evidence for the efficacy of statins in secondary prevention. This is why clinical guidelines are very clear on the issue; statin treatment is recommended for individuals with established cardiovascular disease. The NNT for lives saved is approximately 83 for five years of treatment. For heart attacks it is approx. 39 and for strokes approx. 125. Here is my reference.

      Patients with high coronary calcium scores are at elevated risk and they can be considered to have established cardiovascular disease. However, very few studies have directly addressed the efficacy of statins in individuals with high scores.

      So, if high calcium score is regarded as established cardiovascular disease, it should be approached and treated as such. That means stepping on all available breaks in order to halt the progression of disease.

      Personally I think lifestyle recommendation is immensely important. Of course, when it comes to medical therapy, it’s about shared decision making. The clinician has a duty to the patient about the pros and cons of statin therapy.

      Furthermore, it’s not only about the LDL-cholesterol. Statins have other mechanisms of action which may be helpful.

      Personally, if I was diagnosed with a coronary calcium score above 400 before the age of 60-65 I would choose to be treated with statins.

  23. says

    Axel – thanks for the response and it certainly wasn’t my intention to draw attention away from coronary calcium scans, a test I think has strong benefits and is a much better indicator or coronary health than a treadmill stress test.

    I think you make an important distiction between primary and secondary care which most people tend to gloss over. If a person has never had a heart attack the course of action for prevention should be very different than the course people who have had heart attacks should take. But the difference oftentimes seems to be blurred and people in both categories are lumped together with the resulting advice being to get on a statin. But this is a topic for another post and I apologize for taking this comment section off course.

    Bob

  24. says

    Again I was hoping that you could shed light on what type of diet is most beneficial for someone with a positive calcium score (330) at age 50 and no other CAD risk factors. I have read Dean Ornish’s books and would like an opinion regarding the need to severely restrict fat from the diet. Thanks

    • says

      Hi gspappaPhil,

      Here’s my $.02 on the topic of diet:

      Before I start I should warn you that my ideas go against the mainstream but I believe I have an exceptional amount of evidence to back them up. I believe most doctors and nutritionists who promote a low fat, high carbohydrate diet don’t have a clue what they’re talking about. Most people are skeptical of what I tell them but if you have an open mind I think I can persuade you to go against the grain.

      To me it seems quite apparent that heart disease is caused by chronic, low level inflammation, which in turn is caused by elevated blood sugar, insulin resistance and free radical damage. The key to heart health is to stop focusing on LDL cholesterol and simply stop eating foods that cause inflammation. The way to do this is to adopt a high fat, low carb diet. If you’re a believer in conventional wisdom then this way of eating sounds insane, if you look at the actual evidence it begins to make sense.

      Carbohydrates are the drivers of elevated blood sugar, something your body normally maintains in a very narrow range. A meal full of carbohydrates will spike your blood which causes your pancreas to produce insulin, the hormone that is responsible for dealing with elevated blood sugar. It also has the role of fatty acid storage in the body – the more insulin the more fat is locked away in your ft cells and is unavailable to access for energy. A lifetime of eating carb-heavy meals causes insulin resistance, where it takes incresing amounts of insulin to knock down those blood sugar spikes. Eventually the insulin resistance becomes so marked that blood sugar levels become permanently elevated and this excess blood sugar does tremendous damage all throughout your body. Everydody’s seen what happens to a piece of meat that gets left in a can of Coke – this is the same thing that happens to your body’s cells shen blood sugar is high.

      When blood sugar is elevated, inflammation occurs. In your arteries this inflammation results in damage to the endothelium, the single-layer of cells that form the inside. When a breach of the endothelium occurs LDL cholesterol and macrophages get trapped beneath the fibrous cap (essentially a scab) that forms over the breach. If the inflammation subsides then healing can fully occur but what generally happens is that blood sugar remains elevated, the breach never heals properly and the fibrous cap grows larger and larger over the trapped LDL and macrophages. After awhile the fibrous caps hardens and will either block the artery (CAD) or the fibrous cap breaks off and lodges downstream when the artery narrows. This is a heart attack. If that scab goes to the brain it’s a stroke (ischemic). People have the idea that LDL builds up on the inside of your arteries like minerals do inside a water pipe and that interpretation is totally incorrect.

      So how do you prevent your blood sugar from becoming elevated? Stop eating carbohydrates. I’ve pretty much completely ditched them for over 3 years now, I’ve adopted what’s called a ketogenic diet. This means that my body is mainly fueled by fatty acids and ketones (a by-product of fatty acid metabolism). My diet is roughly 70% fat (saturated and mono-unsaturated), 25% protein and perhaps 5% carbohydrates. Wen testing my blood sugar after meals I’ve never seen it over 90 mg/dl. After a meal most people will routinely see values north of 140 mg/dl for several hours. Most people aren’t aware of this but when blood sugar is in normal range you have roughly 5 grams of glucose in your blood. This is roughly a large teaspoon. Eating a couple pieces of bread is about 70 grams of carbohydrate, or 14 times the amount of glucose your body wants to have. A typical person will eat 300-400 grams of carbohydrates per day, 7 days a week, 365 days a year. That’s a lot of sugar to metabolize, something we aren’t genetically eveolved to do. A small amount of glucose is needed to survive but your liver is more than capable of manufacturing this from protein, it’s totally unnecessary to consume carbohydrates.

      Anyway, I realize I haven’t offered anything in the way of evidence yet and rather than make this comment into a novel I’ll direct you to the log of Dr. Peter Attia, who has done an excellent job showing research on low carb diets as well as documenting his own personal story about how he came to embrace a low carb diet (he is an endurance athlete who was getting fatter and fatter despite working out 3-4 hours a day). If you give it a read I’m sure you’ll find it fascinating.

      http://eatingacademy.com/start-here

    • says

      One more thing – I should have posted this last night but forgot.

      I like this study by Stanford researcher Chris Gardner called the A to Z Diet Study. He put a group of participants on the various diets to see which is most effective for weight loss and improvement of the markers for heart health. What makes this study special is that Gardner is a vegetarian and was fully expecting to see his diet win out. It’s to his credit that he didn’t try to fudge the results when they didn’t turn out as expected.

      Here’s a video recap of his results (the results being that the low-ish carb, high fat diet was by far the best for improving heart health.

  25. Denise says

    Back toy original question and please correct me if I am wrong. I am completely new to this. From what I have read and what my dr has told me, could my calcium be a result of my body trying to repair itself from inflammation caused by my RA, I have had high blood pressure in the past. I have had chest pains but no heart attack. All of my heart tests and lab work came back good. My dr put me on a statin to lower my risk dr a heart attack. I understand that that is what is done first. The second step is a stent. And the third is bypass. Can a stent work if it is calcium as opposed to fast? Should I be worried? Is calcium repairing my arteries a good thing? Could it have prevented something more serious? It seems like of it repaired itself that could be a good thing? Am I completely wrong? Is this very dangerous? My calcium score was 250 something if I remember correctly. I am trying not to be scared. All help is appreciated

  26. Kyle H says

    I am a 40 year old male that spent my 20’s to mid 30’s around 210 pounds (I’m 5’11”). Ate the wrong foods, etc. In the past 2 years I have lost 60 pounds and have been feeling fine.

    My dad just had a 4 way bypass 2 weeks ago and his calcium score was through the roof. They started to stent, but had to go the bypass route.

    I took it upon myself to have my GP order a calcium score for me. The result was 25 in RCA and 9 in LDA, 23 overall.

    With nothing more than family history, chest pains following meals, a “perfectly normal” EKG and now the calcium score my cardiologist is scheduling me for angioplasty! I feel we’re missing some other options and maybe pulling the trigger too fast on such an invasive procedure especially considering the risks and 10-year outcomes of the procedure.

    I’ve started on Vitamin K-2, started on all the E,D, Omegas, and resveratrol.

    Without health insurance I’m between a rock and a hard place as far as getting a 2nd opinion. Needless to say I feel like I may have a heart attack simply from the stress of this situation!

    Is a 23 score in a 40/M worthy of angioplasty, or could this be shooting a mouse with a shot-gun?

    • Axel F Sigurdsson says

      Kyle H.
      I assume your doctor has ordered coronary angiography. This procedure provides pictures of your coronary arteries in order to check there are any narrowings or blockages. If there are, angioplasty may be performed. Angioplasty is performed with a balloon and most often a stent is inserted in order to restore normal blood flow in the artery.
      In fact, a coronary calcium score of 23 isn’t very high and does not by itself call for an angiography. However if there are symptoms such as chest pain or if exercise testing or other tests have suggested that blood flow is limited in soma parts of the coronary arteries, coronary angiography is usually performed.

      • Kyle H says

        I sincerely appreciate your response.

        He’s basing this on an EKG and family history along with the calcium score. I’m apprehensive about anything this invasive (and expensive being self-pay). We have an imaging center that provides relatively affordable CTA scans (around $1,100).

        **Could that be an alternative until there is more reason for concern? The cost of angiography might as well be $1M to me right now.

        The chest pains I’ve described to him are more muscular, i.e. on top of the ribs than a deep pain.

        Again, I feel he’s pulling the trigger too quickly.

        Adding to my concern over the suggested procedure: my 45 year old cousin had the procedure done and they placed a stent on December 4th- same day as my dad’s bypass. They found him dead in his chair on 12/7 presumably from blockage.

        I honestly feel that my CAD is just as much a death sentence as the procedures to investigate it. :-(

        Thank you again.

  27. Deborah says

    I am a 61 year old female. Post menopausal, not taking estrogen (a family history of uterine cancer prevents that) with a severe anxiety disorder and fibromyalgia. The last few years have been very stress filled – things i have no control over, unfortunately – and this has led (in addition to the constant stress) to my eating poorly, not moving enough, some weight gain, etc. I just had my calcium score taken, and it is 74, all in my left anterior descending artery. My dr. is VERY concerned that it is all in that area, and wants me to begin statins. Because I already have pain issues, I’m reluctant to do this. My feeling is that first I should make dietary and lifestyle changes – there is little I can do about much of the stress, but some of that situation is about to end, and I feel like that will help tremendously.

    My dr. is making me feel as if I will have a heart attack any moment. My LDL is 125 – he wants me to get that down to 70 (!), and my triglycerides are also high. To be honest, he’s scaring me – something I admit is easy to do.

    Should I be be more concerned that all the plaque is in that one spot?

    • says

      Hi Deborah, I’m no Doctor so I’ll leave that aspect to Dr. Axel but you mentioned that you have a history of anxiety and feel you have no control over that. I’m also a pretty anxious individual and I think that deep breathing exercises and meditation, if done consistently, can help you lessen your anxiety. Just a thought.

      Good luck

      • Deborah says

        Thanks so much. I do both, and they do help, but the disorder is something I’ve had since a child, and sometimes leads to terrible panic attacks and as you know, just not fun. I’m one of those people who have to take meds daily. All that said, I appreciate your input – I have a feeling I’ll need to practice more meditation from here on out. It can only help. :)

    • Axel F Sigurdsson says

      Hi Deborah
      A calcium score of 74 puts you at the 85th percentile. This means that 85 percent of women your age have lower calcium score and 15 percent have higher score. It is quite common to have most of the calcium in the left anterior descending artery. I don’t know of any studies suggesting that the localization of coronary calcium is an issue in terms of risk.
      Of course lifestyle is important. Not smoking, healthy and regular exercise are key issues when it comes to lowering risk.
      Your doctor obviously believes you may lower your risk further by taking statins. In fact, most people tolerate statin drugs very well although some experience muscle aching. Ask your doctor to explain the pros and cons of statin therapy.

Let me know what you think!