Oct 22 - Status.

With the assistance of my primary care physician, who recognized my agitation and anxiety at the lack of action and to whom I had presented what I think was a convincing case to investigate further (even though my cardiologist did not think it was warranted), worked to get referrals for tests based on the CAC screening and a history of high blood pressure, cholesterol and poor LDL/triglyceride findings. I now have data from advanced lipids panel (Cardio IQ), Arterial Duplex Doppler (Lower Extremities), Carotid Doppler Ultrasound, Aorta Ultrasound, Transthoracic Echocardiogram, Stress Test with Echocardiogram, a second CAC, and a CT Angiogram. My intent was to obtain data from every related, non-invasive test that could provide information related to my high CAC score (1352 in 2019).

The reason I went through my PCP for this was that the cardiologist I consulted with initially sent me for a stress test (without echo) and upon finding it rather normal said to come back in 3-5 years. After waiting three years, the cardiologist about six months ago said nothing else was needed at this time - wait for another stress test in a year or two.

After obtaining the data, I returned to my cardiologist. His notes summarize our discussion - "Patient returns after he had a recent plethora of noninvasive tests done by his PCP. He tells me he feels fine … From a physical standpoint he feels fine. His test showed no ischemia, but for unknown reasons a coronary CTA was done. This demonstrated several calcified lesions which could be "greater than 50%". However, he remains asymptomatic. He tells me he could have walked longer on the stress test. His stress echo showed no wall motion abnormalities or EKG changes. Returns today to discuss the findings and whether not he should have catheterization. He tells me his blood pressure is normally in the 120s. He is not having any arrhythmias.” (ed - It is actually 115-120/68-75 in most cases). We discussed how CTA is unable to completely (effectively) determine blockages with high calcium present due to calcium induced blooming - this is known, but does not, per my reading, completely invalidate the utility of CTA. The cardiologist who initially read the CTA noted blockages that “could be >50%,” and “may be >50%” in the LAD.

My cardiologist further noted in the area related to the original and subsequent increase of CAC score from 1352 to 2388 - “We discussed his coronary CTA at length. He tells me he wanted "all the data" and preferred to have a coronary CTA. As I have explained, and a heavily calcified coronary tree, a coronary CTA is not accurate due to the artifact created by the calcium. The only accurate way to discern the severity of his stenoses would be catheterization. However, his stress test is reassuring with good functional capacity with no EKG changes and no wall motion abnormalities. He does not have any valvular disease. As I have explained, coronary calcification is a marker for risk and he is treating all of his risk factors aggressively. His lipids are well controlled and his blood pressure is normally well controlled. He admits he is apprehensive today. After lengthy discussion, we have agreed to continue clinical follow-up. As I have told him if he develops any fatigue, dyspnea, chest pain, etc. his next step would be cardiac catheterization. He should not have a coronary CTA in the future be calcification precludes the accurate assessment of stenosis due to artifact. I will see him again in 6 months.”

So, armed with more information, some of it not so good but predictable - CAC increase from 1352 to 2388 in three years, and confirmation of several calcium build ups in various parts of my heart, I am faced with whether or not to be catheterized. When I asked the cardiologist, his response was solid - not required unless you are experiencing some physical trait associated - shortness of breath or pain.

One side comment - the cardiologist was obviously miffed I had undertaken the testing regime - which is used by so many in this circumstance - when he had not recommended any further action or investigation. This was off-putting and sounded petulant. Was I off base in this regard?