And so it goes..

bbchien

bbchien

Touchdown! Greaser!
Joined
Feb 13, 2005
Messages
13,200
Location
Bolingbrook, IL
Display Name
Display name:
Bruce C
Older senior captain whom I've been taking care of for some years, advised that the doc thinks a Coronary calcium scan is appropriate. Score comes back 1,800. Went immediatetly to cath lab. Result- a single algebraic tomographic 8.4% lesion in the LAD. How do they detect 8.4%- I can't even see it on the angiogram!

8.4. REALLY? not 8.3? not 8.434? WTH does that mean? I upload everything needed for the FAA's CAD protocol EXCEPT I do not recommend he run the treadmill. Why? The TMT in this low range of "disease" is but a proxy for the Cath and the guy has the CATH!

FAA: "Well since the change in the rule...we've had many airmen enter the CAD protocol from new directions...."
ME: "We all know that CAD starts by age 12 (Wissler, et al, J. Path ~1968)...and is this even CAD?

Well, in the end he permitted the issuance.
Moral: DO NOT GET A CORONARY CALCIUM Scan. Enterprenurial medicine at its worst!
If you really want to know, run the treadmill....
 
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bbchien said:
Older senior captain whom I've been taking care of for some years, advised that the doc thinks a Coronary calcium scan is appropriate. Score comes back 1,800. Went immediatetly to cath lab. Result- a single algebraic tomographic 8.4% lesion in the LAD. How do they detect 8.4%- I can't even see it on the angiogram!

8.4. REALLY? not 8.3? not 8.434? WTH does that mean? I upload everything needed for the FAA's CAD protocol EXCEPT I do not recommend he run the treadmill. Why? The TMT in this low range of "disease" is but a proxy for the chat and the guy has the CATH!

FAA: "Well since the change in the rule...we've had many airmen enter the CAD protocol from new directions...."
ME: "We all know that CAD starts by age 12 (Wissler, et al, J. Path ~1968)...and is the even CAD?

Well, in the end he permitted the issuance.
Moral: DO NOT GET A CORONARY CALCIUM Scan. Enterprenurial medicne at its worst!
If you really want to know, run the treadmill....
Click to expand...
Yeah, sometimes carpenters must find nails to hammer.
 
“sometimes carpenters must find nails to hammer”

This is t-shirt worthy — even poster-worthy. It explains so much, in medicine and elsewhere.
 
As someone who Bruce helped get through this calcium score mess, I will confirm…don’t do this calcium scan.
 
My doc advised me to get one a couple months ago during my annual checkup. Didn’t say my blood work showed I was at risk or anything. Just said it was a good idea. Next thing I know the hospital is calling me twice to schedule. Seemed like this was a money maker for them. I never did schedule it.
 
I'm in the medical imaging field. Have to 100% agree with the good doctor. Also, if you want to add one to it, do NOT have a CIMT ultrasound for plaque accumulation either (carotid imtima-media thickness) ... and no EKG unless a cardiologist conducting it.

My wife had an "abnormal EKG" at PCP, referred to cardiology (we're not sure, let do a stress test) ...oh not sure again lets go to angio gram. Angiogram complete normal.

Timing was PERFECT so I got to meet my $4,000 deductible TWICE (all workup except angio before end of year and angio in start of new year):mad::mad::mad::mad::mad::mad:
 
bbchien said:
Older senior captain whom I've been taking care of for some years, advised that the doc thinks a Coronary calcium scan is appropriate. Score comes back 1,800. Went immediatetly to cath lab. Result- a single algebraic tomographic 8.4% lesion in the LAD. How do they detect 8.4%- I can't even see it on the angiogram!

8.4. REALLY? not 8.3? not 8.434? WTH does that mean? I upload everything needed for the FAA's CAD protocol EXCEPT I do not recommend he run the treadmill. Why? The TMT in this low range of "disease" is but a proxy for the chat and the guy has the CATH!

FAA: "Well since the change in the rule...we've had many airmen enter the CAD protocol from new directions...."
ME: "We all know that CAD starts by age 12 (Wissler, et al, J. Path ~1968)...and is the even CAD?

Well, in the end he permitted the issuance.
Moral: DO NOT GET A CORONARY CALCIUM Scan. Enterprenurial medicne at its worst!
If you really want to know, run the treadmill....
Click to expand...
So what is the minimum required treadmill time after reaching age adjusted heart rate … 9 or 12 minutes ?
 
Up through age 69 it's 9 minutes duration and peark hart rate to exceed 90% of (220-YourAge). after that the foumla is more complicated....
 
Dr. Chien,

What are your thoughts on getting a CT coronary angiogram?

I had one done last year.
Results were 3 main arteries totally clear, and a 20% blockage in the LAD.
Total calcium score of 8.

I will be 62 in January.
 
Still would not. Hugh, what you are doing is eating right, not getting fat, and controlling hypertension and lipids.
Now after the CT cor. angio you are doing the same thing. That's what you would do anyway. So what did you gain?

If you really want to know, Stress treadmill echo to the above parameters. At least it can tell you that you don't have disease. and the 20% blockage....you're still going to do the same thing. It's not until you get to sixty ish % that you'll even consider doing something like a stent.

B
 
bbchien said:
Still would not. Hugh, what you are doing is eating right, not getting fat, and controlling hypertension and lipids.
Now after the CT cor. angio you are doing the same thing. That's what you would do anyway. So what did you gain?

If you really want to know, Stress treadmill echo to the above parameters. At least it can tell you that you don't have disease. and the 20% blockage....you're still going to do the same thing. It's not until you get to sixty ish % that you'll even consider doing something like a stent.

B
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Yes Sir.
I do everything in your first sentence.

I guess what I gained is the knowledge/peace of mind that the most important coronary artery in my heart is only 20% blocked at age 62.
And thanks for the info that it’s not a concern until the sixty percent range.
 
Hugh Despenser said:
Yes Sir.
I do everything in your first sentence.

I guess what I gained is the knowledge/peace of mind that the most important coronary artery in my heart is only 20% blocked at age 62.
And thanks for the info that it’s not a concern until the sixty percent range.
Click to expand...
Doing right things ( eating right,taking care of yourself etc ) is never a wasted effort but unfortunately ,what happens with our hearts is mostly determined by our genes anyway and everything else is just relatively minor postponing/accelerating type of behavior.
 
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bbchien said:
Moral: DO NOT GET A CORONARY CALCIUM Scan. Enterprenurial medicine at its worst!
If you really want to know, run the treadmill....
Click to expand...
While I agree, things are a bit muddied by the American College of Cardiology. While they don't "strongly advocate" for a CAC, they do suggest the study is "reasonable...to guide clinician-patient risk discussion".


I've personally been on the other side of this conversation. I was 65 at the time and, although I can't find the lab results to confirm THOSE lipid studies, ones from earlier this year showed a total cholesterol of 197, HDL of 108, and LDL of 78 - pretty consistent for all of my life. My BP has always been around 110-120/60-70. On no meds, nonsmoker, non-diabetic, no family history. My physician (who I trust quite a bit) told me my 10-year risk calculated out to somewhere around 7.8%, slightly above the 7.5% threshold to consider starting a statin, so he recommended a CAC, to help guide a conversation about statins. He said I'd need to pay for it myself (and it wasn't a matter of them doing it in-house), which, as a physician who has worked with medical insurance on both sides for a bit, was a red flag: if it's clinically proven, insurance, especially Medicare/TRICARE, would cover it. I ended up getting the test and had a zero, which is great.

It would be easy to say that, in hindsight, I wouldn't have done it. The truth is, I put a lot of weight on the opinion of a physician I still trust quite a bit, so I'm not so sure. Granted, he's not an AME and doesn't understand the flying aspect of my situation.

Bottom line, while these do feel "entrepreneurial" at the moment, I suspect it's just a matter of time before the science gets refined enough for them to be more clearly indicated. And again, I think the ACC position on this makes it different than storefront total body scans, etc.
 
Llewtrah381 said:
..... The truth is, I put a lot of weight on the opinion of a physician I still trust quite a bit, so I'm not so sure. Granted, he's not an AME and doesn't understand the flying aspect of my situation.
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^^^ This is very important IMHO.

If you have a Primary Care physician who you think will scam you for a share of $95 you need a new PC. If my doc (who I trust a lot) recommended a test, I would be hard pressed to ignore it without understanding the risk tradeoffs.

I know CAMI follows their bureaucracy and is not interested in health of pilots so back before BasicMed, my PC would call my AME if I thought there was a possible conflict. Only once was there what I thought was a conflict. When I was first suspected for prostate cancer, my PSA score was on the line where watchful waiting and aggressive treatments were both viable options. I was told CAMI made watchful waiting difficult. Once I got the biopsy, it was clear I need to treat it quickly so there was ultimately a simple decision.

Health first seems relevant. A good doc is a really valuable source of information.
 
jbarrass said:
^^^ This is very important IMHO.

If you have a Primary Care physician who you think will scam you for a share of $95 you need a new PC. If my doc (who I trust a lot) recommended a test, I would be hard pressed to ignore it without understanding the risk tradeoffs.

I know CAMI follows their bureaucracy and is not interested in health of pilots so back before BasicMed, my PC would call my AME if I thought there was a possible conflict. Only once was there what I thought was a conflict. When I was first suspected for prostate cancer, my PSA score was on the line where watchful waiting and aggressive treatments were both viable options. I was told CAMI made watchful waiting difficult. Once I got the biopsy, it was clear I need to treat it quickly so there was ultimately a simple decision.

Health first seems relevant. A good doc is a really valuable source of information.
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Thanks for your response and concern. He's actually a peer (we're both Family Practitioners) and I'm 100% sure both that he got no kickback from the test and he does a superlative job trying to follow the best science - which is why I remain his patient. This is an ever-evolving area of medical care, with some aspects having unrecognized consequences on things like piloting.

Thanks again!
 
Llewtrah381 said:
Granted, he's not an AME and doesn't understand the flying aspect of my situation.
Click to expand...
Did you have a conversation with him about it? When my doc suggested I might get the test, I explained the situation with the FAA as far as getting results that he might not think are clinically significant, but the FAA might think warrant additional testing, and he said that being the case it's just not worth it.
 
Lindberg said:
Did you have a conversation with him about it? When my doc suggested I might get the test, I explained the situation with the FAA as far as getting results that he might not think are clinically significant, but the FAA might think warrant additional testing, and he said that being the case it's just not worth it.
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Sincerely appreciate the question.

I did, including a limited discussion re the flying stuff. Ultimately I completely owned the decision. Given my low risk, I figured the most likely risk was to get started on a statin. Yeah- I lucked out.

I’m not an expert re these tests. I do wonder if there’s significance we don’t yet fully understand. For the OP, while I realize in this case it didn’t correlate well with existing atherosclerosis as evidenced by a cath, I suspect it better correlates with the risk of future disease; I bet even this patient will have way more than one 8.4% occlusion within the next few years. A score above 400 means there’s over a 90% chance there’s a significant blockage; one of 1800 without a serious blockage is clearly the exception rather than the rule. Statistically he has a MUCH higher risk of a cardiac event within the next few years, even with a “normal-ish” cath today.


For the OP, again not being an expert, I still suspect the CAC better predicts his risk of a cardiac event within the next few years than the cath appears to. Towards the low end, I suspect there’s a range of test results with a fairly high rate of false positives - but I also think 1800 is well outside that range. Just my minimally educated guess. He may have needed to jump through FAA hoops because of the disconnect between the CAC and the cath but hopefully the CAC got him on to an aggressive medicine regimen which will reduce his risk.
 
The theory behind coronary calcium scanning is that when small atherorma erupt and then seal over, they get calcified. But that's ony one of the pathophysiological pathways to an occlusion. That is likely why rosuvastation (which has been observed to seal one over in about 10 days) aren't associated with increased longevity.

IN regulatory medicine, if one wants to KNOW about the range of ASCVD in which "it's time to do something" the discriminant value of the good old stess TMT is superior.

The population prevalance vs the "pickup" of disease is also, as yet unclear.
 
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