Should I have a coronary artery scan and which one? Insights from Dr. Simon Binny

Who should get a heart health check?

Everybody should get a heart health check as it helps determine your lifetime risk of artery or vascular related conditions.

Often those who believe they are healthy like athletes, gym junkies and vegetarians can have advanced artery disease but falsely believe they do not need assessment or treatment due to feeling fine and a degree of perceived “immunity”.

Every single adult should have a heart health check and depending on the findings may need to have reassessments over their life.

As heart health checks continue to evolve it will be recommended to perform some risk assessments in childhood.

Why should you get a heart health check?

Your arteries are essential for all organ function in your body and once your arteries have worn out your organs progressively start to fail and with current medicine the damage is irreversible both to the arteries and to the organs they provide.

As your arteries harden your blood pressure will start to increase continually along with it so if you can look after your arteries you can prevent developing hypertension which is often the biggest pill burden in older patients (can be >12 tablets a day).

So earlier detection and simple treatment may significantly reduce pill burden in later life.

Consequences of hypertension and artery aging.

Arterial damage also known as atherosclerosis happens to everyone and the rate of damage is highly variable and is typically unknown to a person or doctor until it is reaching the end stages and there is organ complications.

What are the earlier features to look out for?

Rise in blood pressure readings, but a person can not feel high blood pressure and it is recommended to do multiple readings at home, at rest to detect as blood pressure slowly rises. There is also the option of a wearable 24hr monitor to give detailed readings both day and night.

What are the late consequences of arterial aging?

Termed hypertension mediated organ damage (HMOD) it leads to permanent and progressive:

• Strokes and mini-strokes (Transient Ischaemia Attack), memory loss, cognitive decline and dementia (Vascular)

• Chest pain (Angina), heart attacks, cardiac arrest, heart stenting or bypass

• Progressive kidney disease, dialysis

• Leg pains (Claudication), Toe/Foot/Limb amputation

• Bowel dysfunction

• Visual loss

When should you get a heart health check?

A heart health check can be as simple as a series of blood tests and medical history and should ideally be performed in childhood to assess for any risks that may predict early plaque development.

Childhood- assess for significant “red flags” like elevated cholesterol or lipoprotein a, family history, inflammatory or autoimmune conditions

Teenagers- same as in childhood but with assessment of blood pressure

About 25 years- this is the proposed age that adults are ready to engage with a GP on health risks or in females at the time of pregnancy and can be used to determine the timing for more definitive heart health check at 35/40/45/50 years

What risks should I look for that may lead to faster arterial aging?

Traditional risks:

• Family history of any advanced artery disease and how early it presented (all the HMODs listed before).

• Elevated LDL (or non-HDL) <3 is classified as non-elevated, >4 is considered a threshold to consider treatment.

• Smoker- important to account for the number exposed to over time (Pack years, based on number of years if smoked ~20day, ie 10/day for 10 years is 5 pack years).

• Diabetes- also important to consider years exposed and how well has been controlled.

• Hypertension- Based on the average number your arteries/organs are exposed to day in day out over years. Even small increases add up.

The lesser known risk factors to look out for.

• Inflammatory conditions- Rheumatoid arthritis, Psoriatic arthritis, Inflammatory bowel disease, Gout and any other conditions leading to an elevated high sensitive CRP blood test (HS-CRP). Noting more conditions are being added.

• Autoimmune conditions- Lupus/SLE, Scleroderma, and more being added to the list with time.

• Mental health conditions- Schizophrenia, bipolar and ADHD (likely due to association with lifestyle risks)

• Obesity- primarily is based on fat around the organs (Visceral fat) and best marker is not weight but waist circumference (Men >94cm, Women >88cm)

• Cancer- prostate, breast, leukaemia/lymphoma (more being added) and the exposure to chemotherapy agents or nearby radiotherapy

• Female specific- premature menopause <45, pregnancy induced diabetes (Gestational diabetes), pregnancy induced hypertension(Pre-eclampsia)

• Kidney Disease (GFR <45 a larger concern)

• Elevated Lipoprotein a level

Other considerations

Despite no being linked to faster artery aging certain conditions if present increase the importance of early diagnosis.

Clotting concerns: history of DVT (Deep Vein Thrombosis) or PE (Pulmonary Embolism), clotting disorder (Factor V Leiden, Anti-phospholipid syndrome (APLS), Protein C/S deficiency, Anti-Cardiolipin, Anti-thrombin III deficiency).

Pre-existing organ damage (visual loss, cognitive decline, thickened heart muscle (hypertrophy), kidney damage, feet/toe ulcers/poor healing.

What if I have risk factors listed?

Early measures to slow artery aging to offset the rate of damage

Diet options:

• Reducing cholesterol- reduce saturated fat (egg yolks, red meat, high fat dairy, many cooking oils (use extra virgin olive oil), deep fried food), incorporate the Portfolio diet

• Reducing Blood Pressure- reduce salt and food containing it and increase potassium intake, reduce fats, alcohol, sugar and incorporate the DASH diet

• Reducing Weight/Blood sugar- Reducing sugar and carbohydrates (Ketogenic diet) noting complex carbs with higher fibre and protein content as less problematic. Consider intermittent fasting diets and avoiding large/late evening meals

What about exercise?

Exercise is important to incorporate into any long term heart healthy plan.

Muscle is important, especially after menopause and men over 50 testosterone levels start drop to low levels and with it muscle mass. Muscle is the key driver of your metabolism and calorie burning so as muscle drops calorie intake needs to drop to maintain a healthy waist circumference.

It is recommended in the above ages that people do 3 muscle strength sessions/week to get to muscle fatigue in as many muscle groups as possible.

Simple walking for longer periods has been shown to have diminishing benefits in regards to weight loss and is recommended to add in HITS training with short duration but high intensity, interval exercise, easiest to do with exercise bikes and spin classes.

What about medications, do I really need to use one now?

Medications are the cornerstone of slowing arterial aging and are recommended in those who cannot reduce/eliminate their risk, like inability to drop LDL with diet or a condition that cannot be eliminated like rheumatoid arthritis

Most effective medications to slow artery aging:

• Reduce cholesterol- statins (reduce LDL by up to 58%), ezetimibe (5-40% reduction, quite variable)

• Reduce blood pressure- ACE/ARB (-prils and -sartans), CCB (-pines), diuretics (spironolactone, hydrochlorothiazide, indapamide), each can drop BP by 5-15mmHg, noting healthier arteries respond more.

• Reduce weight- GLP-1 agonists like Ozempic, Wegovy and Mounjaro have TGA approval to reduce cardiovascular complications

• Hormone Replacement Therapy (HRT) used post menopause has been shown to reduce arterial aging and guidelines are shifting into its use and its duration

• Illness specific medications- treating arterial aging conditions listed before will slow arterial aging, eg using immunological agents in rheumatoid arthritis or lowering uric acid (causes Gout) by can dramatically slow artery aging

What is the benefit of earlier intervention?

By slowly artery aging earlier in life with a combination of lifestyle and medications will preserve arteries, prevent long term complications (HMODs) prevent premature cardiovascular death (stroke, heart attack, cardiac arrest)

Importantly for some people has the ability to reduce the number or even the need for medications later in life.

I’m sure you may know older family members with handfuls of medications every day and the majority of those can be prevented

There is an evolving philosophy of using statins weekly in earlier life can preserve artery age so well you prevent the long term complications and then you come off them later in life as you may have the arteries of a 60 year old at the age of 80.

So back to a more definitive heart health check

It involves direct imaging of your arteries with non-invasive testing and be used to provide the age of your arteries and see how fast they have aged.

As artery “plaque” usually grows very slowly, imaging too early can not yet accurately detect those with mildly faster growth and may find those with very advanced rates.

Carotid ultrasound and wall thickness can visualise the early thickening of the arteries as an early stage.

CT coronary angiograms- when carefully analysed with show the burden of plaque build up in the heart arteries and aorta to provide a coronary age and detect high risk plaques that may lead to heart attacks needing stabilisation.

CT Calcium score- a simple and quick CT scan that shows the burden of the later advanced stable and safer plaque within the heart arteries but calcium takes ~10 years to form so significant amounts of plaque can form well before being detected on a calcium score (so may incorrectly stage your arteries and delay treatment for more recent risk factors within the last 10 years). It also cannot identify high risk plaques.

So what is the ideal heart health lifetime plan?

Know all your risk factors from as early as possible:

• Do you have high cholesterol? Which is found in 1:5 children due to genetic reasons

• Do you have a high lipoprotein a level? A newer genetic marker that can causes dramatically fast arterial aging (Can be tested from age 5)

• Treat as many risk factors as well as possible for as long as possible

• Be healthy- exercise, eat well, knowing this often needs to change later in life

• Consider early medications use to slow/prevent arterial aging, consider it an investment in your health

• Decide on the timing to have a definitive assessment of your heart arteries typically ~45 in males and ~50 in females but earlier if more risk factors present

• Acknowledge the fact that feeling well or being fit does mean your arteries are in good shape and this is a lifetime journey and you cannot reverse damage or quickly make up for prior mis-spent youth