Cardiac Imaging & The Latest in Preventive Medicine w/ Q&A |Webinar with Dr. Daniel Karlsberg
Recorded Live 6:30PM, February 4, 2021
Join us as Dr. Daniel Karlsberg, Associate Medical Director at Princeton Longevity Center, discusses how the intersection of healthcare and technology empowers and educates patients for better outcomes. Review cases and advanced cardiovascular images with Dr. Karlsberg and learn how he can detect heart disease before a heart attack happens including live Q&A with Dr. Karlsberg to follow immediately after.
Below please find the answers to the questions that were asked during the live webinar. Please note that we did group similar questions into one questions so the exact question as it was asked may not appear. Also note that any questions that could be construed as personal medical advice or business protocols were not able to be answered.
Q: Is it possible to reverse arterial calcium deposits?
A: Calcification is the body’s generic response to chronic inflammation and happens in many settings other than just plaque. Once something has calcified, it generally does not un-calcify. However, the calcification is just one small component of the plaque that happens to be a convenient marker that shows up easily on CT scans. It is possible that the non-calcified components of the plaque will be more reversible. So while we generally do not expect to see calcium scores decrease even with effective treatment, it is still possible to dramatically decrease heart attack risk with treatment and to slow the progression of plaque that would continue to occur in the absence of treatment.
Q: Is vitamin K2 useful to help arterial health?
A: This remains an open question. On the one hand, it has been frequently observed that treatment with the blood-thinner Coumadin, which blocks vitamin K, leads to rapid increases in arterial calcification and increasing coronary calcium scores on heart scans. However, it is not clear that this calcification is the same process or has the same significance as the calcification that occurs within pre-existing plaque. Also, I am not aware of any large, controlled studies that have looked at whether vitamin K2 will actually result in a decreased cardiovascular risk. The risks of supplementing K2 at reasonable levels is small. So we do sometimes recommend it but with the caveat that we don’t know for sure if it actually makes a difference.
Q: I read an article recently that stated “total cholesterol is a poor predictor of heart health – half of people with high cholesterol never have a heart attack and half of people who have a heart attack don’t have high cholesterol”. It stated that LDL particle size (smaller is worse) and the Triglyceride/HDL ratio (3.0 or higher is bad) are much better predictors. Do the statics support the first statement and what is your view of the TG/HDL ratio as a predictor? How should a high levels of small LDL particle size yet a low TG/HDL ratio (e.g., <2.0) be interpreted?
A: The statement is basically correct. Cholesterol is not a great predictor of either heart attack risk or the presence of plaque. Fifty years ago it was the best thing that we had- those with very high cholesterols are a little more likely to be the ones who have heart attacks. This might be because of cholesterol itself or it might be because high cholesterol is also a marker for other unhealthy lifestyle habits.
At this point, we believe it does not make sense to just look at risk factors alone as the deciding factor in treatment when the technology exists to easily look directly at the arteries and see how much plaque is actually forming, regardless of the cholesterol level. If you have a low cholesterol level but have a lot of high-risk plaque, that warrants treatment. The converse is also true.
The same can be said of any other risk marker. LDL particle size may have some predictive value, along with other blood tests. But why treat people on the basis of trying to guess if they are making plaque when it is now easy to look at their arteries and definitively answer the question?
Q: What supplements or foods, if any, have been scientifically proven to improve heart health?
A: We are not sure that there are foods that PREVENT cardiovascular disease. The closest we might come to this is omega-3 and vitamin D. There are studies that show that if your diet is very lacking in those items, supplementation may help to lower your cardiovascular risk. However, if you are getting enough of them already, adding more is unlikely to be beneficial.
Q: What is your opinion on the value of statins?
A: There are relatively few classes of medications that have been proven to actually lower cardiovascular risk. Statins are one of them. Overall, taking a statin is likely to prevent at least about a third of heart attacks. (the actual benefit may be higher if the selection of patients who will benefit is more accurate) The statins are generally very well tolerated and it is usually possible to find a specific statin for any given individual that does not cause noticeable side effects. There is some anecdotal evidence that statins may also help to lower cancer and dementia risks, possibly because of anti-inflammatory effects from these medications.
Q: Do we need to undergo a CT Scan periodically strictly due to the family history risk of Cardiac conditions? If yes how often?
A: By age 40, 50% of men are developing detectable plaque. For women that happens at about age 55. So even in the absence of a risk factor like family history, we would recommend screening for the presence of plaque around those ages. How often to repeat the screening is a very debated topic. However, it will typically take plaque about 10-20 years to progress from the earliest point of being detectable to being high risk and a zero calcium score is associated with a very low mortality rate over the subsequent 5 years. So if your initial scan is clear, repeating it in 5 years may be reasonable.
Q: How often are scans recommended (for preventative approach)? Is there any concern regarding exposure to radiation?
A: The radiation doses of cardiac imaging approach those of mammography at this point, a test which is often recommended on an annual basis. While it always makes sense to minimize radiation exposure as much as possible, the risks of missing the leading cause of death are highly likely to outweigh the risks associated with small exposures during cardiac imaging.
It should also be noted that both nuclear stress tests and cardiac catheterizations involve radiation exposure at much higher doses.
Q: If there is plaque in your arteries, can this be remediated by lifestyle changes?
A: Lifestyle changes help. And with mild disease still associated with low risk, that is likely to be the initial recommendation. Bear in mind that medications will undoubtedly further lower risk. So in those people with extensive disease, lifestyle changes are very important and helpful but it would also be unwise to not take advantage of the additional benefits available with pharmacologic treatments.
Q: If you have had positive findings on cardiovascular imaging but are symptom free, how often should you have follow up imaging?
A: This likely depends on the severity of the findings. If you have very mild plaque, we would usually recommend rescanning in 4-5 years to determine if treatment has been effective or more aggressive therapy is needed. If you have more extensive plaque, there may be a benefit in re-evaluating the treatment in 1-3 year intervals. However, at this point there have not been large scale research studies on this issue.
Q: How many mSv with one scan?
A: It depends a bit on body size and a LOT on the equipment being used and the skills of the radiology technician. Advances in technology are rapidly driving doses down so state of the art equipment is very advantageous. We upgrade our scanners continually. At our centers, coronary calcium scan will typically be around .5-1.0 mSv. A Cardiac CT Angiography will range from 0.5 to about 7 mSv depending on technical factors.
Q: How accurate are stress tests on gauging arterial blocking or other negative factors that could lead to a heart attack?
A: A stress test is mainly intended to detect obstruction in a coronary artery. You will generally have to have more than a 70% narrowing of an artery for there to be enough limitation of blood flow for it to show up on a stress test. At that point, the next conversation is “stent vs bypass”. It is really only detecting late stage disease, years after the point where you were already at high heart attack risk. Heart attacks mainly happen in arteries with less than 50% narrowing because it is acute plaque rupture on a non-obstructing lesion that causes heart attacks. So stress test will miss those. Heart scans will detect the total amount of plaque that is present, even at the earliest stages. That is a much better predictor of both current and future cardiovascular risk.
Q: Is there anything you can do to lower your LIPA Protien?
A: Lp(a) is very difficult to lower. There is some evidence that statins and newer medication such as psk9 inhibitors may have some effects. In general, the approach to elevated Lp(a) is to try to minimize any other risk factors and aggressively treat any plaque that may be present to help lower risk, rather than to try to get the Lp(a) itself down.
Q: Please comment on NMR and CRP tests for screening purposes?
A: Blood tests may give some indication of risk. But they will always still be just statistical predictors of the likelihood of plaque being present rather than direct indicators of the actual presence of plaque.
We prefer to use them in the other direction. For example, if you have plaque present and you also have an elevated C-reactive protein your risk is higher than if your C-reactive protein is normal. So more aggressive treatment may be warranted. The same is true of the lipid profile as determined by NMR- anything we can identify that will be a point of possible intervention in someone with high risk plaque is helpful.
Q: How can you have calcification, but never had high LDL?
A: Because LDL only gives a weak probability estimate of whether you are making plaque. Think of it as being the same thing as how much does your salt intake predict your blood pressure. We frequently see people with very high LDL and perfectly clear arteries and we see people with low LDL who have extensive plaque.
Q: How many aspirin do you take if you think you are having heart attack?
A: The general recommendation would be to take one adult tablet- 325 mg. However, always bear in mind that if you think you are having a heart attack, taking an aspirin is what you do after you have called 911 and are waiting for the ambulance to get there. Never delay emergency treatment hoping that an aspirin will save you.
Q: What are the major differences between men and women in heart disease? My mother died from a heart attack in 1982 and did not have the typical signs of a heart attack.
A: There are two major differences-
- Women generally develop heart attack risk about 15 years later than men. So the amount of plaque in an average male at age 40 is about the amount of plaque in an average female at age 55.
- Men tend to develop coronary artery disease first and then the plaque is found more peripherally. Women tend to develop it more peripherally first so it is a bit more likely to show up in the carotid arteries even before the coronaries. This correlates with men having a higher heart attack risk and women having a higher stroke risk. However, for any given individual, the pattern can be different.
Unfortunately, for about 1 out of every 3 people who are developing plaque, their first symptom will be sudden death. “Typical” heart attack symptoms may not precede the event.
Q: Does congestive heart failure cause heart attacks?
A: More likely to be the other way around. Heart attacks kill heart muscle, impairing pumping. So heart attacks are one of the causes of heart failure (but by no means the only way that heart failure can occur)
Q: Is it possible for someone to have a heart attack without having coronary heart disease?
A: Possible, but not common. Spasm of a coronary artery might block blood flow. (Some drugs, legal and recreational, can also do this) Certain clotting disorders may cause clots to form in arteries even in the absence of plaque. However, the vast majority of heart attacks are due to plaque.
Q: Is CoQ-10 useful and worth taking?
A: Co-Q has some anti-oxidant properties and may have some benefits on that basis. Taking statins can interfere with production of Co-Q within your cells and this may have a role in some side effects such as muscle aches. It is generally recommended that patients taking high potency statins take Co Q supplements to avoid becoming deficient.
Q: Why are CT Scans instead of MRI’s ordered for patients needing heart imaging services?
A: MRI’s have some disadvantages. Calcium does not show up very well on MRI, so it is difficult for MRI to accurately pick up early plaque. MRI scans also take extended periods of time to do and require extensive physical precautions. Consequently, they tend to be more expensive. The claustrophobic aspect of the scanner is also a barrier. The bottom line is that the research in cardiac imaging has extensively validated CT scans as highly accurate for detecting plaque and stratifying risk. MRI has uses in cardiac evaluation but plaque detection is not its strength.
Q: Are you using EBT scanners?
A: EBT scanners were a major advance around the turn of the century. They are no longer manufactured and very few remain in service. Multi-slice CT scanners (64 slice or higher) are the standard today and offer more flexibility and better image resolution.
Q: Do statins cause or accelerate neurological issues?
A: There are numerous anecdotal reports of memory effects from statins. Several well done studies have been unable to reproduce those effects. It does not appear that statins impair memory.
Q: I am confused about reversing a calcium score. I have seen a video with evidence that it can be done. Is this possible?
A: Plaque reversal may be achievable. It is not easy and often requires both aggressive pharmacologic treatment combined with very restrictive dietary and other lifestyle changes. For those with mild disease and low risk, this may be more of a burden than is warranted. For those with very aggressive plaque, those kinds of treatments may be advisable. We are currently offering aggressive treatment combined with serial imaging to try to monitor plaque progression or reversal in order to titrate the intensity of treatment to each individual patient.
Q: What is your position on Vascepa as a means to reduce the probability of heart disease? If the recent studies are accurate how does it contribute to lowering heart disease?
A: Vascepa is an omega 3. A recent study appeared to indicate that overall there was little benefit to omega 3 supplementation to reduce cardiovascular risk- except in one group. If you have a very low omega 3 intake then adding supplementation lowers cardiovascular risk by about 28%. If you already have a high intake, then the additional benefit is likely to be small.
In the REDUCE-IT trial, Vascepa was associated with about a 25% decrease in cardiovascular risk in patient who had high triglycerides and were on a statin. Bear in mind, having high triglycerides and being on a statin selects out a different category of risk than the general population. So whether there is as much benefit for the general population is not known.
If you are on a high dose statin and are still having plaque progression, particularly if you have elevated triglycerides or insulin resistance, adding an EPA supplement such as Vascepa may be helpful.
Q: Can you have a Doctor at Princeton Longevity Center as a Primary Care Provider?
A: Yes – in both our NYC and DC offices we offer Direct Primary Care as an elective option to your Comprehensive Exam.
Q: Is the cardio testing you’re describing part of the basic PLC physical or is this an incremental module?
A: The 2-D Coronary Artery Calcium Score is a standard part of every PLC Comprehensive Exam. The 3-D Cardiac CT Angiography is an elective option and may be added to your exam depending on age, risk factors and calcium score.