Heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States, and according to the CDC, about 697,000 people in the United States died from heart disease in 2020—that’s 1 in every 5 deaths. 1,2
Risk factors are traits and lifestyle habits that can increase your chance of having a heart attack so knowing them is very important if you want to try and improve those chances. Fortunately, there are many risk factors that you can control and change, but there are a few that you cannot. If you are able to know and understand your personal risk, you can take steps to improve your health.
Traditional risk factors for heart disease include:
Smoking
High Blood Pressure
High Cholesterol
Diabetes
Overweight or Obesity
Risk-enhancing factors include:
Family history of early atherosclerotic cardiovascular disease (men less than 55 years old, women less than 65 years old)
Persistently elevated LDL-C or persistently elevated triglycerides
Metabolic syndrome
Chronic kidney disease
Chronic inflammatory conditions (e.g., rheumatoid arthritis, psoriasis, HIV/AIDS)
High-risk ethnicity (e.g., South Asian ancestry)
Other biomarkers and lab values such as ankle-brachial index ABI, hs-CRP, apo-B
About half of all Americans (47%) have at least 1 of 3 key risk factors for heart disease: high blood pressure, high cholesterol, and smoking. 1
What is your risk of having a heart attack?
A heart attack can occur at any age so you are never too young to identify whether you have any risk factors that can be modified. The first step is to talk to your health care provider who can use one of several cardiac risk calculators to estimate your chance for a heart attack. If you are between the age of 40 and 75 and have never had a heart attack, a risk calculator can use data such as your lipid panel, your blood pressure measurement, and your smoking history to assess what your risk is for having a cardiovascular event in the next 10 years.
You can find an example of a cardiac risk calculator here
Aside from using a risk calculator, we have another risk assessment tool known as coronary artery calcium scoring. Coronary artery calcium (CAC) scores are obtained from a non-invasive procedure called a cardiac computed tomography (CT) scan. This cardiac CT scan can estimate the amount of calcium build-up (plaque) within the arteries of the heart, which can give us a sense of how blocked an artery is to the flow of blood. This test can detect coronary heart disease in its earliest stages in the arteries of the heart.
Who should think about getting a CAC score?
A CAC score is most useful in giving patients more information that might affect treatment decisions. Specifically, a CAC score can help decide if you should start a cholesterol medication or not. Specifically, it is recommended for patients who fall into an intermediate risk category, which is an estimated 40% of patients.
Patients who have a calculated risk score that is HIGH would not have as much of a benefit from the coronary calcium score because the guidelines are very clear on what treatments should be recommended to those patients. A coronary calcium score likely would not change those recommendations.
Similarly, patients who have a calculated risk score that is LOW do not have significant cardiac risks that need to be modified. Medications or more invasive treatments generally would not be discussed with patients who are not at risk for cardiac events.
An example of how a CAC score could be helpful:
Mr. X, a 45 year old white male, has never had any chest pain or cardiac symptoms, but he is a smoker. At a recent health fair, he had his blood pressure checked and it was 130/88 and his cholesterol was checked. His results were: total cholesterol 170, HDL-C 30, LDL-C 130. He doesn’t take any medications.
Using all the information above, his doctor calculated his cardiac risk score using a risk calculator and his 10-year risk was intermediate at 7.9% (he has a 7.9% risk of having a cardiac event in the next 10 years). His doctor wants to put him on a cholesterol medication to lower his risk. Mr. X doesn’t think he needs to be on a cholesterol medication because 7.9% doesn’t sound that high, he has no interest in taking a daily medication, he has heard bad things about cholesterol medications, and he can just “eat better.”
There are a lot of factors that will go into this discussion between Mr. X and his doctor. Ultimately there will be shared decision making but the more data that is available, the more informed that decision will be. A CAC score, in this scenario, would be a great tool to help decide if Mr. X already has plaque build up in his arteries or not, which might influence his decision in a different way.
How to interpret the CAC score
A “negative” calcium scoring CT scan will show no calcification within the coronary arteries. This suggests that atherosclerotic plaque is minimal at most and that the chance of coronary artery disease developing over the next two to five years is very low.
A “positive” test means that coronary artery disease is present even if you have no symptoms. The amount of calcification — expressed as a score — may help to predict the likelihood of a heart attack in the coming years.
What happens during a coronary artery CT scan?
There are no needles and no dyes and doesn’t require special preparation in advance. You may continue to take your usual medication but should avoid caffeine and smoking for 24 hours prior to the exam.
During the test, you will lie on your back on a table attached to the CT scanner. Electrodes will be attached to your chest and to an ECG (electrocardiogram) machine that records the electrical activity of your heart. These electrodes have no pain associated and make it possible to record CT scans at the best times—when the heart is not actively contracting.
As the table slides through the opening in the scanner, a cylinder at the opening rotates around your body to generate the needed images. The table will move forward slightly every few seconds so that you will be in the proper position for each new cross-sectional image of your heart. You will be asked to hold your breath for periods of 20 to 30 seconds while images are recorded. This process continues until all regions of the heart have been thoroughly examined. Coronary calcium scoring has equivalent radiation exposure to mammography, and similar to the level of background radiation exposure experienced over 3–4 months in most cities. 3
Is this covered by insurance? If not, how much does it cost out of pocket?
The American Heart Association and American College of Cardiologists released clinical practice guidelines in 2018 supporting the use of coronary calcium scoring in the management of cholesterol. Despite this, however, coronary calcium CT scans are still not universally included in standard screening guidelines for heart disease so many public and private insurance providers restrict coverage. Some insurance providers, like Medicare Part B, may consider covering this study if it is ordered to treat a medical concern but will not cover it if ordered as a screening exam.
The approximate out of pocket price for a cardiac CT scan is between $100 and $400.
If you have more questions about your own cardiac risk factors or whether a coronary calcium CT might benefit you, contact your primary care provider.
If you do not have a primary care provider, Cardona Direct Primary Care is still accepting new patients. You can schedule a meet and greet with Dr. Cardona to see if our clinic is a good fit for your healthcare needs or you can visit our website for more information about Direct Primary Care.
Centers for Disease Control and Prevention, National Center for Health Statistics. About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention; 2022. Accessed February 21, 2022.
Tsao CW, Aday AW, Almarzooq ZI, Beaton AZ, Bittencourt MS, Boehme AK, et al. Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8):e153–e639.
deGoma EM, Karlsberg RP, Judelson DR, Budoff MJ. The underappreciated impact of heart disease. Womens Health Issues. 2010;20(5):299–303.