To scan, or not to scan
7/9/2001If you're playing the odds, bet on heart disease to kill you.
While other diseases often get more attention, diseases of the heart are the No. 1 cause of death in the United States, leading to about one-third of all deaths.
That's why there is growing support among some physicians for the use of CT (computed tomography) machines as screening tools for heart disease. CT machines (their images are sometimes referred to as “CAT” scans) have been around for more than 25 years and are widely used for everything from examining broken bones to looking at internal bleeding.
New, advanced CT machines are so powerful they can do a heart scan in seconds. Supporters of the technology say that within minutes the scans can alert physicians if a patient has early signs of heart disease.
These scans detect the calcium present in fatty build-up in heart arteries that over time could block an artery and cause heart disease or a heart attack. These blockages often go undetected for decades. As a result, half of all heart attacks occur in people without any symptoms, and that first heart attack often is fatal.
If CT technology works as well as some physicians claim, it could have an enormous impact on public health. For example, it's generally accepted that all women starting at age 40 should receive an annual mammogram to look for early signs of breast cancer. Yet heart disease kills nine times as many American women each year as breast cancer. Why not scan all women - and men - for heart disease?
Because CT technology for heart scans is unproven and the results are potentially misleading.
At least that's the contention of a large number of physicians, physician groups, and health insurance officials.
“There's no data to support that it's effective,” Dr. Charles M. Cutler says of heart scans.
He said while CTs can pick up calcium, there haven't been any definitive long-term studies that have proven that detecting high calcium levels and subsequent intervention result in any improvement to patient health.
Dr. Cutler is chief medical officer for the American Association of Health Plans, a trade group representing about 1,000 of the nation's managed-care plans that together cover about 150 million Americans. Dr. Cutler said he's not aware of any insurance company that covers heart scans for people without symptoms of heart disease.
The latest “consensus statement” from the American College of Cardiology and the American Heart Association appears to back up Dr. Cutler's caution. Last year the two groups issued a joint statement stating that while some forms of CT scanning might have the potential to detect early heart disease, there isn't enough proof yet to endorse it for widespread use.
Radiology is the medical specialty that is most involved with interpreting diagnostic scans such as the CT. The American College of Radiology, the main professional organization representing the country's radiologists, does not endorse heart scanning. The only scans the college endorses are mammograms and some types for colon cancer .
“I think there is probably going to be good research data showing they're going to be useful,” said Dr. E. Stephen Amis, Jr., of the college.
Dr. Amis said there is some concern that if scans became widespread they would expose a large number of patients to unnecessary levels of radiation, but he thinks the risk is negligible.
Of greater concern is the chance that patients and doctors could misinterpret results of the scans and schedule risky and unnecessary follow-up tests, or assume a “good” result gives patients license to eat in an unhealthy manner, he said.
Also of concern is the potential impact on the nation's health-care costs if insurance companies are pressured to cover unproven technology such as expensive scans.
What bothers Dr. Amis more than heart scans is that some entrepreneurs are now touting “lung scans” to detect early signs of lung cancer, the most common cause of cancer death in the United States. In addition, some are even offering “full body scans” to detect - well, almost anything potentially dangerous in the body.
“The one that bothers me most is this total body scan for the worried well. There isn't any proof at all that this is anything other than a gimmick,” he said.
Lung scans and heart scans may be promising, he said, but until enough proof emerges, he said physicians and the public should be skeptical and cautious about the widespread use of CT scanning for heart disease or lung cancer.
Dr. Jeff Maludy, a Toledo cardiologist, understands people's skepticism and concern, but he disagrees with physicians who dismiss the technology.
“This technique is scientifically sound,” he said. “There are limitations, but that's true of any test. Why belittle this test when others aren't perfect?”
A decade ago physicians were skeptical of statins, drugs which lower cholesterol, he said. But now, physicians widely believe that statins are effective.
And, as Dr. Maludy, who has become an investor in the technology, noted, other screening tests for heart disease, such as stress tests, aren't 100 percent effective either.
Dr. Maludy became convinced of the potential of heart scans after Charles D. Moreno visited him. Mr. Moreno is an X-ray technologist at St. Charles Mercy Hospital. Last year he began researching heart scans as a potential investment opportunity and got one to see how they worked. Fit and trim with no history of heart disease, the 48-year-old Mr. Moreno discovered he had a high “score” on the scan; a subsequent visit to Dr. Maludy confirmed he had early heart disease.
Mr. Moreno's experience convinced him and Dr. Maludy that heart scans had potential, so the two, along with several other investors, plan to open Heartscore of Ohio in the Toledo area by this September. The outpatient facility will offer heart scans and lung scans for $395, and full-body scans for $795.
Heartscore's eventual entry into the Toledo market is just one sign that heart scanning, lung scanning, and even full-body scanning could become common in northwest Ohio and southeast Michigan.
Consulting Radiologists permitted a reporter and photographer to observe a heart scan last month. John Lark, 53, of Maumee, said he was mostly just curious about the technology. He has had high cholesterol levels in the past, but no heart problems and no family history of heart disease. After a friend of his from Consulting Radiologists told him about the heart scan, he decided to try it.
A technician hooked up a heart monitor to his chest. The monitor permits the scanning machine to time its scans so that it “captures” images of the heart between beats to provide the sharpest images. On the other side of a window in an adjoining room, Kim Mangan, diagnostics supervisor for Consulting Radiologists, punched a few buttons, and within 20 seconds the scan was done.
Five minutes after his scan, Mr. Lark was sitting next to Ms. Mangan in a room nearby as she looked over the images from the scan. She peered at the screen, looking for the telltale signs of pink, which would indicate calcium deposits that could be associated with fatty buildup in Mr. Lark's coronary arteries. Her computer analyzed all the images and then comes up with a “score.” The closer the score is to zero, the better. Mr. Lark's score is 14.4, which is quite good, Ms. Mangan told him.
Mr. Lark smiles and then jokes, “This lets me know if I need to be chauffeured home,” he said.
“Don't take this as a license to go out and misbehave,” Ms. Mangan warned him.
While his low score is good news, there may be fatty deposits the heart scan can't pick up, she said.
Ms. Mangan tells Mr. Lark that his results will also be sent to his primary-care physician and that he should discuss the results with him.
Dr. Richard Siders, chairman of radiology at St. Vincent Mercy Medical Center and a member of Consulting Radiologists, said heart scans “are not a substitute for coronary angiograms or stress tests; all it is, is an indicator.” In other words, a high cardiac score may indicate follow-up tests are needed, but no patient or doctor should rely on the test alone, he said.
Heart scanning is relatively rare throughout Ohio, but Cleveland Clinic radiologist Mark Baker said he expects the practice to grow rapidly.
“Clearly, people are doing it because there's a market for this,” he said.
Dr. Baker and his colleagues at the Cleveland Clinic have “mixed feelings” about full-body scans, heart scans, and lung scans.
“If I scan you and you have calcium, it doesn't mean that much. You may or may not have heart disease,” he said.
But while he and his colleagues are skeptical, the Cleveland Clinic has been offering heart and lung scans for about eight months, and full-body scans for about two months.
Dr. Baker said if the scans are going to be offered, he and his colleagues feel they should be offered in a setting like the clinic, where patients can be counseled and followed up.
“I'm not pulling the wool over anyone's eyes,” he said. “I use a similar analogy that people don't need to go around driving a Mercedes, but they do. It's easy to take a holier than thou approach, but everyone in medicine ends up doing things that may not be medically indicated.”
The key, he said, is making sure patients understand the limitations of the technology and what the results may mean.
It may take a few years for the majority of physicians to accept the use of heart scans, lung scans, and full-body scans, but even skeptics say the day is coming when scans will become a routine diagnostic tool.
“We're getting closer and closer to Star Trek,” said Dr. Siders. “You'll put them [patients] in the scanner and read it out; we're almost to that point.”
Dr. Amis is more cautious.
“Yes, maybe 20 or 30 years down the road,” he said. “The technology will be there, sort of like `Beam me up, Scotty' on Star Trek, that's not so far-fetched. But we're not there yet.”