Updated November 30, 2017 12:56:30
The afterlife of above Australian Ironman Dean Mercer at age 47 abashed the antic world. How could a acutely fit and advantageous man die of cardiac arrest at such a adolescent age?
Interviewed about Mercer’s afterlife on ABC Radio, Sydney cardiologist Dr Ross Walker said that accustomed bloom checks for claret burden and cholesterol were not the best predictors of affection attacks.
Dr Walker instead adapted bodies afraid about their affection bloom should be ability a browse for coronary calcium.
Also accustomed as coronary avenue calcium (CAC) scoring, the analysis is one that Dr Walker pioneered in Australia in the backward 1990s in affiliation with the Sydney Adventist Hospital.
“I anticipate all males at 50 and all females at 60 should acquire a coronary calcium score,” Dr Walker told The Apple Today.
“It’s the best predictive analysis for affection ache risk.”
He continued: “Your cholesterol is not the best predictive test; your claret burden is not the best predictive analysis — this coronary calcium annual is.
“It’s the best way to see if you’re activity to bead asleep of a affection attack.”
Is this coronary calcium annual absolutely the best indicator of affection disease, and is it a all-important analysis for earlier all Australians?
RMIT ABC Fact Check investigates.
There is added to the adventure than Dr Walker’s affirmation suggests.
Studies conducted primarily in the US acquire apparent that coronary calcium scans are able to analyze affection ache in patients, with the consistent calcium “scores” accepting been begin to associate with approaching cardiovascular events.
The Cardiac Association of Australia and New Zealand describes the analysis as a “robust” way to appraisal approaching accident of cardiac events.
By contrast, the sub-committee of the Australian Bloom Ministers’ Advisory Council amenable for new and arising technologies cautions that calcium scoring for admiration affection ache “is of ambiguous analytic annual or utility”.
The sub-committee aloft apropos about the radiation dosage complex (the agnate of 50 x-rays per scan) as able-bodied as the appulse on after tests and treatments.
Cardiologists contacted by Fact Check agreed the analysis was bigger at admiration affection attacks than acceptable claret burden or cholesterol checks, but were afraid to aback the analysis as acerb as Dr Walker.
When it comes to mandating the analysis for men over 50 and women over 60, cardiologists acicular to guidelines appear by the Cardiac Association of Australia and New Zealand suggesting that alone bodies of a assertive age and at average accident of affection disease, or with a able ancestors history of affection disease, abide a calcium scan.
According to the Affection Foundation, coronary affection ache is Australia’s distinct bigger killer, accounting for 12 per cent of deaths.
The Foundation defines coronary affection ache as the absorption of the arteries arch to the affection due to a anatomy up of plaque, blubbery actual that clings to the avenue walls.
This, in turn, can abate claret breeze to the heart, and is the arch basal annual of cardiac arrest.
Professor Gemma Figtree, of the University of Sydney, told Fact Check that the action of applique developing in the arteries arch to the heart, accustomed as atherosclerosis, “most about begins years afore a affection attack”.
She said that the action is accelerated by accident factors such as “high cholesterol, smoking, aerial claret burden and diabetes”.
Professor Figtree, a cardiologist who sits on the Affection Foundation’s Analytic Issues Committee, explained that a coronary calcium annual is acquired by demography a computed tomography (CT) browse of the heart.
The browse measures the bulk of calcium in the arteries to the heart, which accumulates with the applique over time and is a arrow to the attendance of affection disease.
The resultant CAC annual is acclimated both to assort patients into groups based on their accident of a affection advance in the consecutive 10 years, and for evaluating analysis options for anniversary patient.
The Cardiac Association of Australia and New Zealand publishes the afterward analysis guidelines for doctors back because a patient’s calcium score:
Statins advised reasonable
Reclassify as aerial risk
Statins advised reasonable
Statin recommended, to accomplish ambition LDL <2.0 mmol/L
Consider anatomic assessment.
SOURCE: 2017 CSANZ Calcium Scoring Position Statement
Dr Walker claimed that claret burden and cholesterol were not the best predictors of accident of affection disease.
A 2014 abstraction in the peer-reviewed annual of the American Affection Association, Circulation: Cardiovascular Imaging, states: “Although accident factors acquire authentic to be advantageous ameliorative targets, they are poor predictors of risk.”
The abstraction explains that, traditionally, doctors acquire acclimated a analysis alleged the Framingham Accident Annual to categorise patients according to their accident of affection disease.
In Australia, doctors use a apparatus developed by the National Vascular Ache Blockage Alliance alleged the Australian complete cardiovascular ache accident calculator, based on the Framingham Accident Score, to appraise a patient’s accident of affection disease.
While there are slight differences amid the outcomes of the two, both measures booty into annual the aforementioned factors.
The Framingham Accident Annual takes into annual age and , as able-bodied as accident factors such as smoking, claret pressure, cholesterol and diabetes, to aftermath a 10-year cardiovascular accident anticipation for anniversary patient.
However, the Framingham Accident Annual about fails to adumbrate cardiovascular events: the Circulation abstraction begin 75 per cent of adolescent bodies adversity from a authentic blazon of coronary affection ache were accounted to be at low accident (under this system) the day afore their cardiovascular event.
The analysis suggests that, while acceptable accident array can be acclimated as a starting point for categorising patients’ accident of affection disease, they are not complete in anecdotic affection disease.
Dr John Younger, a adviser cardiologist with the Queensland Cardiovascular Accumulation and administrator of cardiac CT casework at St Andrew’s War Memorial Hospital, abundant on the limitations of acceptable accident factors as predictors of coronary affection disease.
“The accustomed accident appraisal would aloof accede your accustomed values, and ability say you are at low risk, but it is aboveboard to anticipate that the accomplished 20 years ability not acquire had some appulse on your accident of [a cardiovascular] event,” Dr Younger told Fact Check.
Dr Christian Hamilton-Craig, who chairs the Cardiac Association of Australia and New Zealand Working Accumulation on CAC Scoring, and advance columnist of the society’s position account on calcium scoring, told Fact Check: “The accuracy abaft Dr Walker’s statements is valid.”
He said the calcium annual was “the best predictive test”, abacus that it was abundant bigger at anecdotic the absorption of arteries than added affection checks offered to patients.
Dr Younger additionally said that CAC array were the best augur of coronary affection disease.
“Calcium scoring can be accumulated with accustomed accident factors, such as age, gender, claret pressure, smoking, diabetes and cholesterol levels, to accommodate a actual authentic accident anticipation of consecutive events,” Dr Younger said.
He said that coronary calcium array provided “a arbitrary of how your activity and affairs to date acquire afflicted your coronary arteries” and “seem to be a actual authentic augur of risk”.
The University of Sydney’s Dr Figtree said the annual was a accessible and evidence-based analysis that could advance accommodating administration in a way that bargain the amount of cardiovascular events.
“[The test] is actual accessible in stratifying risk, and allowance physicians ambition analysis decidedly in patients with average risk, such as those with moderately aerial cholesterol and a ancestors history of coronary affection disease,” Dr Figtree said.
However, Professor Stephen Nicholls, of the University of Adelaide and the South Australian Bloom & Medical Analysis Institute, who is an investigator in a analytic balloon of CAC scoring, told Fact Check that Dr Walker had oversimplified the account of calcium scores.
“Predicting the accident of affection attacks is not easy,” Dr Nicholls said.
“There are acceptable to be added causes of affection ache that we apperceive beneath about and that tests are not accessible for. In added words, no analysis is perfect.”
While accordant that calcium scoring had been apparent in some bodies to advance accident prediction, Dr Nicholls apprenticed attention in announcement its boundless use.
“There is additionally no abstracts at all that shows that accepting a calcium annual leads to a change in analysis and change in outcome. That’s why we charge added analytic trials in the space.”
Much of the affirmation apropos the account of coronary calcium testing is fatigued from the Multi-Ethnic Abstraction of Atherosclerosis — a large-scale, abiding abstraction of the characteristics of affection ache — and accessory studies.
One such study, appear in the American Affection Journal, begin that coronary calcium array were a acceptable augur of affection ache and cardiovascular events.
The study, which focused on bodies with no affection of affection disease, begin that those with a coronary calcium annual of one to 10 were three times added acceptable to acquire a cardiovascular accident than those with a annual of zero.
Further to this, the 2014 American Affection Association abstraction appear in Circulation assured that coronary calcium scoring was “at the present time, above to any aggregate of accident factors” in agreement of actuality an authentic accident anticipation tool.
Dr Younger told Fact Check that some earlier studies had begin alone one-third of affection advance patients would acquire been begin to be “high risk” by acceptable calculators such as the Framingham Accident Score, admitting 95 per cent of affection advance patients will acquire affirmation of coronary calcium, as articular by a CAC score.
The Cardiac Association of Australia and New Zealand’s 2017 position account on calcium scoring says there acquire been “a cardinal of ample calibration -to-be studies appear in the abstract that acquire authentic the anxiety amount of CAC in asymptomatic patients, abnormally in the sub-group at average cardiovascular accident profile”.
The account concludes: “Coronary Avenue Calcium scoring is a able-bodied and reproducible way of audition coronary atherosclerosis and to appraisal approaching accident of cardiac events. It has incremental annual above acceptable accident anticipation accoutrement and biomarkers.”
A chase of the Affection Foundation website finds no references to coronary calcium scoring.
In a statement, the Affection Foundation told Fact Check that “it is not accessible for the foundation to awning every affair on its website”.
“Calcium array are not consistently definitive, and the estimation of the array by a healthcare able about varies,” the account said.
The foundation said it believed doctors should actuate the charge for CAC testing on an alone base and common its advocacy that anybody over the age of 45 (or 35 for Aboriginal and Torres Strait Islanders) ask their GP for approved affection bloom checks.
Governments acquire additionally been alert of acknowledging the calcium scan.
The Bloom Policy Advisory Board on Technology (HealthPACT), a sub-committee of the Australian Bloom Ministers’ Advisory Council, adjourned the use of coronary calcium scoring in 2015.
The board bootless to acclaim the accustomed use of CAC scoring, citation apropos about the radiation dosage complex (the agnate of 50 x-rays per scan) as able-bodied as the appulse on after tests and treatments.
Its admonition to the ministers was that the analysis “is of ambiguous analytic annual or utility” and “therefore, HealthPACT does not abutment the use of CT calcium scoring in analytic convenance at this time for screening asymptomatic patients”.
However, its address said there was affirmation that CT calcium scoring could accurately adumbrate cardiovascular contest in individuals not assuming affection of affection ache and the scanning “has been apparent to accomplish bigger than acceptable accident agency assessment, although the consequence of that aberration in analytic agreement is not clear”.
“It should be acclaimed that the use of CT calcium scoring for admiration Coronary Avenue Ache accident is a broadly debated breadth in which a deluge of appraisal is available, some of which is based on affirmation and some which is not,” the board said.
The analysis is additionally not covered by Medicare, so the amount of a coronary calcium annual comes as an abroad amount to the patient.
In a statement, a backer for the Federal Administration of Bloom told Fact Check that the analysis was not currently listed on the Medical Allowances Scheme, and that Medicare allowances were claimable alone for “relevant analytic services”.
“A clinically accordant account is one which is about accustomed by the accordant profession as all-important for the adapted analysis of the patient,” the administration told Fact Check.
Applications for accessible allotment for new medical casework are fabricated to the Medical Casework Advisory Committee.
Dr Hamilton-Craig told Fact Check that for an appliance to be fabricated to the committee, it bare to appear from a aiguille body, such as the Cardiac Society.
“At this point in time, there has not been acceptable bread-and-er abstracts to abutment an appliance for agreement in Australia,” Dr Hamilton-Craig said.
The National Bloom and Medical Analysis Foundation has allocated $2.6 actor to a randomised analytic balloon of coronary calcium for accident appraisal and blockage in bodies with a able ancestors history of coronary avenue disease.
A arbitrary of the trial, active for bristles years from 2015, describes calcium scoring as “a able brand of subclinical risk” which “has been apparent in empiric studies to accommodate anxiety advice that is incremental to the analytic appraisal of [heart disease] risk”.
Its aims accommodate assessing the cost-effectiveness of antitoxin action based on calcium scoring.
While Dr Walker recommends coronary calcium scoring for all men and women of a assertive age, added cardiologists alone acclaim it for a specific accumulation of bodies at average accident of affection disease.
Professor Nicholls said that the browse should not be acclimated for patients diagnosed with affection ache as they should already be actuality “treated aggressively”.
People at low accident do not charge the annual either.
The Cardiac Association of Australia and New Zealand’s 2017 position account on calcium scoring sets out ambit for the use of the test.
The association recommends the analysis for bodies at average accident of affection disease, for those at low accident but with a ancestors history, and those at aerial accident but who are afraid to acquire treatment.
Dr Hamilton-Craig told Fact Check that calcium scoring was not a screening analysis for all bodies of a assertive age, but for the recommended accumulation the analysis could advance to bigger treatment.
“Coronary calcium scoring leads to an adapted access in prescriptions for cholesterol medications and aspirin, and leads to greater accommodating adherence to medications,” he said.
Topics: health, heart-disease, australia
First acquaint October 10, 2017 06:38:15
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