The New Heart Tests: Which Ones Should You Have?

The New Heart Tests: Which Ones Should You Have?
Experts explain the pros and cons of coronary calcium scores, carotid artery ultrasound, and CT heart scans.
By Charlene Laino
Reviewed by Louise Chang, MD

We've all heard the stories: someone seemingly healthy, with normal cholesterol levels and no obvious risk factors, drops dead of a heart attack. How can this happen?

Morteza Naghavi, MD, says it's because traditional risk factors may not tell you what you really need to know: whether your arteries are diseased.

"Why are cholesterol, smoking, family history so lousy? Because they're just risk factors," says Naghavi, chairman of the Society for Heart Attack Prevention and Eradication (SHAPE) and director of American Heart Technologies in Houston.

"They don't speak to whether the arteries are diseased. So we need to directly visualize the artery. Is there plaque and is the artery dilating properly? You can have a diseased artery regardless of how may risk factors you have."

That disconnect has led more doctors to recommend that patients undergo high-tech heart tests that offer detailed images of the blood vessels as a means of lowering heart disease risks. The three tests -- calcium coronary scores, carotid artery ultrasound, and CT heart scans (CT angiography) -- "are all good at determining early atherosclerosis, or hardening of the arteries," says American Heart Association (AHA) past president Robert Bonow, MD, head of cardiology at Northwestern University's Feinberg School of Medicine in Chicago. "They can help to identify people early on that need aggressive risk factor modification."

But as with anything, these tests have their merits and drawbacks. So how can you tell if these tests are for you? To find out, WebMD spoke with three leading heart health experts: Naghavi, Bonow, and Todd C. Villines, MD, co-director of cardiac CT at Walter Reed Army Medical Center in Washington, D.C.
1. Coronary Calcium Scores

What Are Coronary Calcium Scores?

Calcium is one component of plaque that can build up inside the coronary arteries that supply oxygen-rich blood to heart muscle. Measuring it can help determine the level of plaque buildup that leads to narrowing of the heart arteries, the hallmark of coronary artery disease.

During the test, you lie in a hollow CT scanner. X-ray beams create multiple images of the heart; a computer measures the amount and density of calcium deposits in the artery walls and provides a calcium score. The score can range from 0 to more than 400, and any score over 100 is associated with an increased risk of heart disease.

"Studies have consistently shown that the higher your calcium score, the higher your risk of heart attack or other coronary artery disease event," Villines says. One of the most recent studies, published last year in the New England Journal of Medicine, showed that the coronary calcium score predicted heart events -- heart attack, death from coronary heart disease, or chest pain (angina) -- among men and women of all races. In that study, people with a coronary calcium score of 101-300 were more than seven times as likely to experience a heart event than someone with no evidence of coronary calcium; people with higher scores were at even greater risk.
Who Should Get Coronary Calcium Scores?

People at intermediate risk of heart disease based on traditional risk factors. This includes men over 50 with at least one added risk factor and women over 60 with at least two added risk factors, such as high blood pressure or high cholesterol, according to Villines. In these individuals, the need to commence medications to control these risk factors may not be clear.

For people at intermediate risk, a high calcium score would likely lead to more aggressive lifestyle changes, such as aspirin therapy, and even high-dose statin drugs to control cholesterol, Bonow says.

On the other hand, if you're at high risk to begin with (because you have diabetes or because you have heart or vascular disease), you should already be on aggressive therapy, so measuring the calcium score wouldn't change anything, Bonow explains. And people at low risk are unlikely to have calcium buildup; even if they do, their overall risk of a cardiac event is usually still low, he says.

One exception may be low-risk women, Villines says. "Data from the Multi-Ethnic Study of Atherosclerosis trial showed that women at low risk and a high calcium score faced the same risk of heart attack or dying of heart disease as people at high risk. So even though it's not integrated into the guidelines, I would consider this test in women aged 45 to 65 with at least one risk factor -- or even with no risk factors when there is a strong family history. It might change management."

Naghavi believes that all men ages 45 to 75 and women ages 55 to 75 should undergo screening with either the coronary calcium scan or carotid artery ultrasound -- regardless of whether they have other risk factors. People may have low cholesterol levels or other low risk factors and still have heart problems, he says. "We need to go beyond traditional risk factors."

Bonow, Villines, and many other doctors disagree, saying that further study is needed to show that widespread screening will truly help. "Testing everyone would lead to a lot of costs and detection of minor abnormalities that mean nothing but can cause needless anxiety and further testing," Bonow says.

Advantages of Coronary Calcium Scores

Villines notes that the only study directly comparing coronary calcium scores to carotid artery ultrasound showed that calcium scores are better at predicting risk of future heart problems. Adds Bonow, "Of the two tests, coronary calcium is probably the better studied. Calcium in the blood vessels is clearly a marker of atherosclerosis, and it can be quantified."

"The test is painless and quick," he adds.

Disadvantages of Coronary Calcium Scores

Because calcium deposition is not the first thing that happens during plaque buildup, "a negative test doesn't mean you don't have [any] atherosclerosis," so a low or absent calcium score may make you feel safe even if you're at risk, Bonow says.
Furthermore, as we age, the chance that some plaque has deposited is significant and it is common for older individuals to display calcification in their arteries. So a positive test doesn't necessarily place you at risk: In one study, low amounts of calcium were detected in two-thirds of the participants who did not experience coronary events. The key may be your relative score -- how you compare to your peers. You may be at increased risk only if your score is significantly higher than expected based upon your age and gender.

Also, the test does involve some exposure to radiation, although "at very low doses," Bonow says. A new AHA advisory says CT scans should be used judiciously to minimize exposure to ionizing radiation, but that medically appropriate examinations should not be avoided.

How Much Do Coronary Calcium Scores Cost?

The test typically costs $200 to $500. As with most screening tests, Medicare and other insurers usually do not pick up the tab.
2. Carotid Artery Ultrasound

What Is Carotid Artery Ultrasound?

This test uses ultrasound and sophisticated software to quantify the thickening of the inner walls of the carotid arteries that supply blood to the brain, a sign of early atherosclerosis. "Studies in over 50,000 patients have shown that if you're in the 75th percentile or higher for your age group, you have a higher risk of coronary heart disease and stroke," Villines says. Being in the 75th percentile means that 75% of your peers had less artery thickening than you.

Who Should Get Carotid Artery Ultrasound?

As with coronary calcium scores, carotid artery ultrasound should be reserved for people at intermediate risk of heart disease based on traditional risk factors, according to Bonow and Villines. Naghavi says SHAPE "recommends carotid artery ultrasound or coronary calcium scores as a first line of screening for men over 45 and women over 55. However, of the two tests, I'd lean toward calcium scores."

Advantages of Carotid Artery Ultrasound

This is a painless noninvasive test that can be performed easily in the doctor's office and does not expose the patient to radiation.

Disadvantages of Carotid Artery Ultrasound

Unlike coronary calcium scores, carotid artery ultrasound "does not inform you directly about the heart," as you are looking at the arteries in the neck, Naghavi says.

Also, the accuracy of the test is very dependent on the skill and expertise of the technologist performing the study, "so you need a trained operator who knows all the current protocols. Be sure to ask if your institution follows the most current guidelines," Villines advises.

How Much Does Carotid Artery Ultrasound Cost?

The test typically costs $200 to $500. As with most screening tests, Medicare and other insurers usually do not pick up the tab.
3. CT Heart Scans

What Is a CT Heart Scan?

During CT heart scans (also know as CT angiography), patients receive a contrast dye through an IV. X-rays are passed through the body and are picked up by detectors in the scanner. Special software uses the information gathered during the scan to create 3D images of the coronary arteries on a computer screen.

CT angiography scans give doctors a detailed look at the coronary arteries, which supply blood to heart muscle, without cardiac catheterization.

Who Should Get CT Heart Scans?

While contrary calcium scores and carotid artery scans are used to evaluate people without symptoms, CT angiography is typically reserved for intermediate-risk people with symptoms such as chest pain or shortness of breath that could be due to coronary heart disease, Villines says.

CT heart scans can also be useful if a patient is at low risk for heart disease and has "mildly abnormal" results on an exercise stress test. "Right now, these patients are referred for catheterization, but the CT scan could help avoid that," he says.

Advantages of CT Heart Scans

The technique is quick, producing pictures within five to 10 seconds, compared with 30 to 45 minutes for cardiac catheterization, the "gold standard" for evaluating blood vessel obstructions. It's noninvasive, with less risk and discomfort than catheterization, which often requires sedatives and sometimes a night in the hospital.

Disadvantages of CT Heart Scans

It fails to produce good images in people with a lot of calcium deposits in their arteries, Bonow says. It should not be used in people with chronic kidney disease or severely obese patients, Villines says.

There are also concerns about cancer risks. According to a new study, CT angiography has the potential to expose patients to high doses of radiation, and methods available to reduce radiation dose are not frequently used. A recent study reported that the average radiation exposure from a CT angiogram evaluation is equivalent to 600 chest X-rays.

Villines says that over the past two years, Walter Reed doctors have been able to reduce radiation during CT angiography by 50% to 70% through the use of radiation-sparing techniques. Patients should ask if such methods will be used before having the procedure, he advises.

How much do CT Heart Scans cost?

The CT scan, including the doctors' fee, costs about $1,000. Medicare and other insurers are still evaluating whether to pay for the scans.

In summary, there are several tests which can be used to determine whether or not you have diseased arteries. The results of such tests could influence the type of preventive treatments which are recommended. However, no test is perfect and regardless of test results, optimizing lifestyle choices still remains a cornerstone of heart disease prevention.

When it comes to your heart health, there are no hard and fast rules, our experts say. Talk to your doctor if you have any concerns.

22- Long Live Tricks

22 Live-Long Tricks

By Nancy Rones

It only takes a few minutes a day to dramatically improve your health. And with our list of fun and easy good-for-you habits, you'll want to get started right away.

Yeah, yeah — you know that exercising and eating right should be at the top of your daily to-do list. But let's face it: Some days there's barely enough time to sprint from the car to the pizza parlor to grab a pie to go. We're in no way suggesting you abandon those bigger long-term health goals, but we would like to help you by giving you these 22 simple, science-backed steps that you can take today— and every day — to live a longer, healthier, happier life. And don't let the small nature of these lifestyle tweaks fool you: They're proven to have a major impact on your health.
Buy a bouquet.

Looking at flowers can put you in a brighter mood, research from Rutgers suggests. In three different studies, receiving flowers was shown to have both immediate and long-term positive effects on emotional outlook.
Go overboard on sunscreen.

Skin cancer is the most common form of cancer in this country, but it is largely preventable. While you definitely want to use a broad-spectrum sunscreen (which blocks both UVA and UVB rays) with an SPF of 15 or higher, slathering on enough sunscreen is actually the most important factor for determining how effectively a lotion works, according to a study published in The Lancet. If you're spending a full day on the beach, aim to go through a whole small 3- to 5-oz tube. In winter months when UV rays are weaker, applying an SPF moisturizer to your face and other exposed skin in the morning or before you head outdoors is probably enough. But know that there's no hard evidence that sunscreen protects against malignant melanoma, which is the deadliest form of skin cancer, so your best protection is to minimize direct sun exposure and wear protective clothing in addition to lubing up.
Have oatmeal for breakfast.

Why? For starters, it may help you shed unwanted pounds: In one study, participants who had oatmeal for breakfast ate 30 percent fewer calories at lunch compared to those who had cornflakes. Oats are complex carbs, so they digest slowly and keep blood sugar steady, which fends off hunger and may help control type 2 diabetes. Oatmeal also acts like a sponge during digestion by soaking up excess cholesterol for faster excretion, which can lower risk of heart disease, says Dee Sandquist, R.D., an American Dietetic Association spokesperson.
Play some head games.

Keeping your mind stimulated boosts memory and brainpower and slashes your risk of developing dementia nearly in half, according to a study conducted at the University of New South Wales in Australia. Look for fun ways to challenge your brain: Try to memorize the phone numbers programmed into your mobile phone and make calls without using speed dial; brush your teeth or try using chopsticks with your nondominant hand; mentally tally the total cost of your groceries as you put each item in the shopping cart; or start a monthly trivia game night with friends.
Turn the tube off during dinner.

You already know that watching television at mealtime can lead to mindless eating and subsequent weight gain. Now, a study in the Journal of the American Dietetic Association suggests that families glued to the TV at dinnertime eat fewer fruits and veggies during the meal. To protect your family's health— and their waistlines — move the TV out of the kitchen and put it near the treadmill instead.
Cook with herbs and spices.

Flavoring recipes with fresh herbs and spices rather than cooking with the old standbys — salt, butter, and sugar — can cut sodium, fat, and calories and improve a food's overall health benefits, says Suzanna Zick, N.D., a naturopathic physician at the University of Michigan. "Many herbs such as thyme and oregano are similar to green, leafy vegetables in that they're high in vitamins and minerals," says Zick. Seasonings such as saffron and basil are believed to contain cancer fighters, and "warming" or spicy herbs such as nutmeg and black pepper may also help lower blood pressure.
Treat yourself to dark chocolate.

For years, experts have touted chocolate's ability to help fight cancer and protect your heart. The latest good news: Enjoying about 30 calories of dark chocolate a day (one or two dark chocolate Hershey's Kisses) can help lower your blood pressure enough to reduce your risk of dying from heart disease by 5 percent and of stroke by 8 percent, according to a study in the Journal of the American Medical Association.
Switch to whole-wheat bread and brown rice.

Let go of your nostalgia for the refined white stuff you grew up on — it's basically an empty-calorie food that takes your blood sugar for a roller-coaster ride. Whole grains, on the other hand, contain slow-digesting complex carbs that help keep blood sugar levels steady, plus they're high in fiber, which has been shown to decrease your risk of heart disease, diabetes, and some cancers, says Sandquist. Swapping white for whole- wheat bread can also improve regularity and help you feel full faster, so you're less likely to overeat. Aim for three servings of whole grains a day.
Snack on blueberries.

Compared with more than 40 other fruits and vegetables, blueberries pack the greatest antioxidant punch per serving, according to USDA data. Other research also shows that the antioxidants in blueberries may protect vision and improve motor function and short-term memory. Since berries aren't in season right now, grab a bag from the freezer section — frozen berries are just as good for you as fresh ones — and toss a handful into your homemade pancake batter or blend them into smoothies.
Lift with your legs.

Women are more likely than men to suffer back pain because we tend to have weaker back muscles, says Miriam Nelson, Ph.D., author of Strong Women, Strong Backs. When you're heaving heavy items, kneel down to pick them up — don't bend over from the waist — and clench your abs as you stand up to take the strain off your lower back.
Chew, chew, chew.

Taking the time to thoroughly chew and break up your food makes it easier for your body to extract and absorb nutrients, explains Jack A. Di Palma, M.D., director of the gastroenterology division at the University of South Alabama in Mobile. Plus, keeping food in your mouth longer increases production of saliva, which helps neutralize the stomach acids that cause reflux. And because it takes about 20 minutes for the stomach to signal the brain that you're full, the more slowly you eat, the fewer calories you'll likely consume before you're ready to drop your fork.
Toast with wine.

Red or white, take your pick. The latest research suggests that drinking wine of any hue helps protect against cardio-vascular disease, tooth decay, and upper respiratory infections. But there can be too much of a good thing: Downing two or more alcoholic drinks a day has recently been linked with an up to 82 percent greater risk of developing breast cancer.
Stretch after a hot shower.

Increasing your flexibility with regular stretching can prevent muscle soreness, improve posture, and reduce your risk of injury. "It's best to stretch when muscles are warm and more elastic, whether from exercising or simply standing under hot water," says Nelson. She recommends doing the following three post-shower stretches, which target women's tightest zones (hold each stretch for 20 seconds and repeat three times):

For your lower back: Stand 2 to 3 feet away from a chair and hold on to the back. Keeping your abs tight and your back straight, bend forward at the waist as far as you can comfortably go.

For your calves: Place your hands on a wall in front of you, step your right leg back about 2 feet, and gently press your right heel down; repeat with your left leg.

For your shoulders: Stand with your fingers laced behind your head and gently pull your elbows back.
Floss.

Cleaning between your teeth helps get rid of the bacteria-laden plaque that causes gum disease and possibly a plethora of other problems, including heart disease, stroke, and premature births.
When nature calls, go!

Even if you feel too swamped to take a two-minute potty break, don't put it off. "Stagnant urine in the bladder can lead to urinary tract infections in healthy women," says Jacques Ganem, M.D., a urologist in Charlotte, NC. When you do go, don't hover over the seat, even in public restrooms. It may cause you to rush and not fully empty your bladder, plus the seat's not as dirty as you think: Out of 14 different areas in kitchens and bathrooms, the toilet seat was found to be the least contaminated in a study published in the Journal of Applied Microbiology. If you're still feeling squeamish, wipe the seat with toilet paper and line it before you sit (which, by the way, keeps it dry for the next customer so she can sit down!).
Wash your hands before going to the bathroom.

Think of all the germs you touched while pushing that grocery shopping cart or handling toys at your child's preschool, says Ganem. To avoid transferring them to your private parts, he advises washing your hands thoroughly for at least 10 seconds before peeing.
Make time for me-time.

The list of reasons why chronic high stress is bad for us seems never ending: It can lead to depression, high cholesterol, and weight gain, to name a few. "You want to keep everyday stress levels low, so that when something really nerve-racking happens, your body's stress response isn't over the top," says Pam Walker, Ph.D., a Dallas-based clinical psychologist. Find regular outlets for blowing off steam, such as yoga, journaling, or having fun with friends.
Take a daily multivitamin.

It's good health insurance for imperfect diets — which many of us have, says Michael F. Roizen, M.D., author of You: Staying Young. He recommends choosing a multi that contains the following nutrients: vitamin D (800 to 1000 IUs); calcium (600 mg twice a day — you'll need a separate supplement to meet these needs); magnesium (400 mg); and folic acid (400 mcg; 800 mcg if you're pregnant or trying to become pregnant).
Sport UV-blocking shades.

"Sun exposure can have significant long-term effects on your eyes and on the sensitive skin around them," says Elaine Hathaway, M.D., an ophthalmologist in Highland Park, NJ. Some potential risks: cataracts, macular degeneration (the leading cause of blindness in older Americans), and basal cell carcinoma, the most common form of skin cancer. To protect your peepers, look for sunglasses that promise to block 99 to 100 percent of UVA and UVB rays, and wear them year-round since the sun's rays are damaging even on cloudy and winter days.
Sip white tea.

White tea is gearing up to replace green tea as the ultimate health brew. While both beverages contain cancer-fighting antioxidants called polyphenols, the leaves and buds used to make white tea undergo less processing than green tea leaves and as a result retain more antioxidant power. Studies have also found that white tea extract may help fight some common bacterial infections, including strep and staph.
Relax the right way before bed.

Sleep deprivation doesn't just leave us groggy and grumpy — it also puts us at greater risk for obesity, heart problems, depression, and motor vehicle accidents. Unfortunately, more than half of American women get a good night's sleep only a few times a week, according to the National Sleep Foundation's 2007 Sleep In America Poll. One likely reason: Eighty-seven percent of us opt to zone out in front of the tube for an hour before bed rather than turning in early, and watching television stimulates the brain, making it harder to fall and stay asleep. To ensure sound slumber, TiVo your favorite late-night shows for later viewing, and crawl into bed.
Snuggle with your honey.

Hugging your partner is linked with higher levels of oxytocin, a hormone believed to help form sexual and social bonds, plus it lowers your blood pressure, according to research at the University of North Carolina at Chapel Hill. Need another excuse to get close? Research shows that women in strong, committed relationships lead happier, healthier lives.