Saturday, April 23, 2011

What if your heart scan score is ZERO?

What if your heart scan score is ZERO?
Tremendous confusion persists about the implications about a heart scan score of zero.

A zero score is great! In fact, it’s the best result obtainable. But does it allow you to do anything you want, free of danger for the rest of your life?
A zero score can mean many different things
A score of zero is not a rare thing: Approximately 50% of people who get a CT heart scan have a score of zero—no detectable calcified coronary plaque. It’s the best score you can get, since heart scan scores never go below zero. By age 65, only 25% of people will maintain a score of zero.

But what exactly does a zero score mean? How long does it remain at zero? What implications does a zero score carry for cholesterol and other sources of heart disease risk?

Here’s what we know. If you are without symptoms of heart disease and your CT heart scan score is zero:
  • Your risk for heart attack is very low, though not zero. Across all studies, if your score is zero, the likelihood of heart attack (or other major “event”) is in the range of 2-3% over the next 5 years, as compared, for instance, with a score of 100 in a 52-year woman carrying a risk of 20% over the same time period. Why isn’t your risk zero with a zero score? Well, statistically, nobody’s score is zero. That includes strapping 25-year old athletes and children. The exceptions (people who have heart disease with a zero score) include people who use cocaine or amphetamines, people with exceptionally high LDL cholesterol (“heterozygous hypercholesterolemia” with LDL cholesterols >225 mg/dl), those with severe hypertension, and some other rare disorders. In other words, for the vast majority of people with a zero score, your risk is indeed very low.
  • Starting with a score of zero, you are unlikely to convert to a significantly positive heart scan score within the next 3–5 years. Approximately 90% of people with a zero score will remain at zero over that time period. For example, say your score was zero in 2005. In 2008, it’s probably still zero. But if it has turned positive (>0), it will likely be a modest score of only 10, 20, or 30—not 300 or 400. Positive scores are, of course, important for your prevention program, but they are rarely dangerous at a level of 10,20, or 30. This is the rationale behind recommending a heart scan score in 3–5 years if you have a zero starting score.

What a zero score does not mean
While a zero heart scan score is great short-term news, it does not mean that you are free of risk for a lifetime.

A heart scan score of zero does not mean that:
  • You can ignore lipids and lipoproteins—These issues do, indeed, assume less urgency. Rather than weeks or months to correct your abnormalities, you may have years to do it. Since you are in far less imminent danger than, say, someone with a score of 700, you will likely not be treated with the same intensity. Your LDL target, for instance, might be 100 mg/dl, rather than <70 mg/dl. Perhaps you don’t need to reach an HDL of 60 mg/dl, and 50 mg/dl may be acceptable. (Your target values should be discussed with your doctor.) You may be less inclined to rely on prescription medication and can depend more on long-term lifestyle and nutritional approaches, as well as nutritional supplements. But a score of zero does not provide an open invitation to ignore lipids or lipoproteins.
  • You can ignore other health issues—We’ve seen this happen: Someone has a heart scan score of zero, then completely neglects health, or becomes very lax. They skip exercise, eat unhealthy foods, over-snack, etc. Next thing you know, they’ve got high blood pressure, diabetes, bowel cancer, or any number of other diseases of lifestyle. Though our focus is heart disease risk, having no measurable coronary plaque does not provide license for health abuses.
  • You are free of carotid or other atherosclerotic processes—With a heart scan score of zero, you’re far less likely to have carotid atherosclerotic plaque or plaque in any other artery, such as the aorta (causing stroke) and leg arteries. But you are not immune. Occasionally, someone with a substantial risk profile (e.g., smoker, diabetic, small LDL, low HDL, hypertension, etc.) will have no detectable coronary plaque but have a moderate quantity of carotid plaque. Should everyone, including people with zero scores, have carotid ultrasound to settle this question? Given the ease and safety of this test, we feel that this is actually a reasonable thing to do, though it is not yet conventional practice to screen people without symptoms for carotid disease. Should you prove to have carotid plaque of some degree but with a heart scan score of zero, then we feel that your prevention program should assume the same intensity as someone with a high heart scan score.
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  • Do you know what’s even better than a heart scan score of zero? A second score of zero several years later. This means that, given your level of preventive efforts, no detectable plaque has developed. Two successive scores of places you into a very low-risk group. It means you have succeeded!
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