To Screen Or Not To Screen
Why Not Is The Question For Millions Of People At Risk From Cardiovascular Disease
by Shawn Miller

Despite reports about great strides made in scientific research and medicine that are sure to extend life and improve the quality of living, we continue to be issued regular reminders about our vulnerable susceptibility to the world’s most lethal diseases — no matter what our age. In June of 2002, the death of 33-year-old St. Louis Cardinals pitcher Darryl Kile from an apparent heart attack stunned the sports world. This seemingly healthy athlete had no significant health problems and, in fact, underwent a routine EKG and blood tests only months before his sudden death.

A little over one year later and another disturbing wake up call arrived in the form of sit-com actor John Ritter, who died abruptly at age 54 — old enough to have gained wisdom and peace with self, but still shockingly too young to die — from an aortic aneurysm. That it was Ritter, a person so accessible in his celebrity he has seemed like a good friend to hundreds of thousands of fans, makes the loss not only universally tragic, but alarming. That it happened to him makes it seem more likely it could happen to anyone at any time.

Just days after this shocking loss, Robert Palmer, a musician who has publicly rejected the raucous lifestyle normally associated with his rock star status, died suddenly of an apparent heart attack also at the age of 54. Palmer’s manager, Nick Carter, issued a statement saying Palmer had no history of heart problems and had had a complete check up two weeks before his death and was issued a “clean bill of health.”

America’s Number One Killer
While the specifics of these cases differ, there are some fundamental common threads — the main being death as the first symptom of any problem. The fact is, more than half of all men and women who die each year from coronary artery disease (CAD), the cause of Kile’s and Palmer’s deaths and the leading cause of death in the U.S., exhibited no prior symptoms. An aortic aneurysm can be equally asymptomatic with an even higher fatality rate if left undetected.

Like a balloon that has lost elasticity from too much stretching and pulling, an aneurysm, the bulging or dilation of an artery, is the result of weakening in arterial walls. When the wall stretches to tearing, as it did with Ritter, it is referred to as a dissecting aneurysm. Without detection, aneurysms can grow so large they eventually rupture. Once this has occurred, there is only a 20 percent chance of survival.

Outside of trauma resulting from injury to the chest area, primary risk factors for an aortic aneurysm, like CAD, are elevated cholesterol, smoking, diabetes, and hypertension (high blood pressure). Unlike CAD, which tends to affect both men and women at essentially equal rates, aortic aneurysms are most often seen in men between the ages of 40 and 70. While aneurysm in arteries of the heart is rare — statistics indicate 2 in 10,000 people are affected — the more common aortic aneurysm — abdominal — is among the top ten causes of death in the U.S.

Like CAD, aneurysm is a leading contributor to death. Like CAD, an aneurysm, when detected in its early stages, is treatable, sudden death is avoidable. But also like CAD, it is not routinely screened for. Most are found incidentally, happened upon in the midst of assessing other health issues. Dr. Matthew Budoff, assistant professor of medicine at Harbor-UCLA Medical Center says, “For diseases like prostate and breast cancer, we have routine screening. But for diseases of the heart — the number one cause of death in both men and women— we have not implemented any screening test to identify cases early.”

Which begs the question: Why are we urged to undergo regular mammograms, pap smears, prostate tests, and colonoscopies, but not any such regular, proactive test for the heart?

Obstacles In The Path Of Routine Heart Screening
Organizations like the American Heart Association have made great strides in educating the public on the signs — shortness of breath, upper body or chest pains — that can indicate a cardiac event like a heart attack or dissecting aortic aneurysm. But where there seems to be a deficit of information is in the realm of methods for detecting disease before progression to stages where symptoms are experienced, critical to circumventing sudden death episodes. Says Budhoff, “The problem begins with the onset of whatever the precursor is, such as atherosclerosis, not with the episode; so by the time cardiologists get involved, it’s often too late.”

This juxtaposition is carried over to — or perhaps even derived from — the insurance industry. While patients benefit most the earlier heart abnormalities are detected, most insurance companies won’t cover screening unless deemed medically necessary — meaning disease has progressed to symptomatic, and too often deadly, stages when it is more difficult to avoid complications without major surgery. So for now, as in so many aspects of the HMO-driven medical environment, responsibility lies in the hands of patients to research available medical options and discuss any preventative alternatives with their physicians — and often pay out of pocket for those that have yet to be deemed necessary enough to warrant mainstream coverage.

Who is the ideal candidate for routine screening for the early detection of heart abnormalities? In general, for men and women over the age of 40 with at least one risk factor: heredity, high cholesterol, smoking, diabetes, or high blood pressure. While there are those in this category who may avoid broaching the subject of screening with a physician for fear of visions of long needles and exposure to dangerous chemicals, there are a variety of noninvasive, simple, cost effective methods available. Some are more effective than others, but all are worth discussing with a physician to determine candidacy.

Assessing The State Of The Heart
Perhaps part of the reason for the lack of asymptomatic heart screening lies in the limited capacity for conclusive insight that is a downside to many preliminary, non-surgical, traditional procedures and technologies. A blood pressure check and blood tests for the assessment of cholesterol levels are both routine components of an annual physical. But while abnormal results in either of these tests can indicate at least a predisposition to heart-related health problems, neither can determine unequivocally either the absence or presence of disease. In fact, research has demonstrated that these tests are only 50 percent accurate in predicting future coronary events.

Typically, in the case of elevated cholesterol or blood pressure levels, a physician will subsequently order one of the following conventional methods for providing further insight into patient health:

+ Electrocardiography (EKG): Records the heart’s electrical activity and is useful for determining normalcy of the heart’s rhythm (arrhythmia can indicate risk for heart disease or sudden cardiac death) as well as reveal evidence of a prior heart attack. Like an echocardiogram, it gives no insight into whether arterial blockages exist or to what extent. Normal EKG results cannot rule out the existence of disease and this is not a useful method for detecting aneurysm.

+ Exercise Stress Testing: This test (also not useful in detecting aneurysm) in which blood pressure and heart rate are monitored while patients exercise — usually on a treadmill — has been used to measure the effects of stress on the heart. Studies have concluded this test is useful for diagnosing heart disease. However, it is possible, particularly in its earliest stages, to have heart disease and pass a stress test, since it takes a 60 percent or higher occlusion (blockage) to detect problems using this method — 70 percent of heart attacks occur in individuals that have an occlusion of 40 percent, much less than the occlusion sensitivity of 60 percent. It is also not uncommon for a stress test to yield false positive results, rendering the patient subject to a battery of further, potentially more invasive procedures unnecessarily.

+ Echocardiogram: An ultrasound test to measure thickness of heart walls, abnormal valves, or areas of decreased heart motion, the procedure is most useful for identifying structural abnormalities in the heart. Large aneurysms are detectable using this technique, but it has a limited ability to detect atherosclerosis, an underlying factor in both CAD and some aneurysms.

The Latest Innovations
So clearly, while conventional procedures can be critical in aiding diagnosis, all are limited in ability to provide conclusive insight, requiring further, more invasive, sometimes even surgical procedures to completely rule out or more clearly define disease. The latest diagnostic tools however, may help bring heart screening into the mainstream, routine status of tests like an annual mammogram — and with initial normal results, would be required far less frequently.

+ Electron Beam Tomography: Computed tomography (CT) scans have been used for over a decade to produce images of internal organs that help physicians diagnose presence and extent of disease throughout the body. What’s most significant about electron beam tomography — also called “EBT,” or “ultra-fast” CT — is that this type of scanner operates at speeds so fast that, for the first time ever physicians can now capture diagnostic images by virtually “freezing” the beating heart.

The EBT heart scan measures blockages at an early level not detectable by standard physiological testing. The imaging process is completely non-invasive with about as much radiation exposure emitted as in a set of dental x-rays. An EBT heart scan will allow physicians to not only determine the presence of coronary calcium — a sign of atherosclerosis — but also quantify how much and pinpoint where it is located. The cardiac risk percentile of the patient is then ascertained by means of comparing their age and sex to the total amount of coronary calcium, otherwise known as the “calcium score.” Research has proven that the accuracy of this score to predict an individual’s risk of future cardiac events is significantly higher than traditional risk factor assessment. Unlike the previous tests mentioned, the risk of false negatives is nonexistent. In fact, a zero score can be used to rule out heart disease entirely and, in such cases, tests need only to be repeated every five years.

Until this latest generation technology was cleared by the FDA, the only way for a physician to get the same level of conclusive insight into matters of the heart was through more invasive — needles and chemicals — procedures. An EBT heart scan is taken with the individual fully clothed, and lying on a narrow, gurney-type table. The most uncomfortable aspect of this test is holding your breath and keeping still for about 30 seconds.

An added benefit to this last type of screening is that it is not limited to the heart in terms of diagnostic capability, but can be used to pinpoint location or even propensity for disease throughout the body. This capability is key, says Jim Ehrlich, M.D., medical director of Colorado Heart and Body Imaging, “The body scan’s main utility is a complete vascular exam, looking for aneurysms, plaque, etc. We have found several enlargements of the aorta in the thorax and aneurysms in the abdomen.”

The fact that the capability to provide cost-effective, non-invasive, precise, and routine screening of the heart has been around for more than ten years in EBT underscores the question: Why not screen?

Throughout this past year there has been a barrag of announcements by both public and private research centers about the discoveries of genetic markers for heart disease. These discoveries will lead to further diagnostic and preventative screening tests that will be available in the near future. So clearly, breakthroughs in medicine will continue at the current brisk pace. The question is whether the current health system in the U.S. will allow for the average consumer to benefit from these advances.

Lowering The Bar For Heart Disease Impact
So far though, despite the promise of advanced medical technology and research to offer a preventative approach to identifying heart disease and life-threatening abnormalities, such methods have yet to be incorporated into standard practice. It seems we find ourselves once again in a situation where medical technology has far outpaced the bureaucracy of the insurance industry.

Dr. Robert Brunst, medical director for InnerVision Wellness Imaging, home of the latest generation EBT scanner — one of less than 30 in the world — in Carlsbad, California, is concerned that this gap between medical technology and insurance coverage won’t be bridged without further tragedy or legal maneuvering. “In our current HMO environment, medicine has become more commercial and profit driven. Although there is substantial data supporting the conventional use of screening technology, it may very well require a series of high profile unfortunate and sudden cardiac outcomes or the fear of widespread litigation before insurance companies will consider reimbursement,” he explains.

Budoff agrees and says that the case for routine screening, particularly EBT screening, is strong and that one good thing to come from the untimely death of people like Ritter and Palmer could be a heightened awareness of this need, “Body scanning would have almost definitely identified calcified plaque in [Ritter’s] aorta and an area of enlargement, so John Ritter would most likely have been identified as high risk. Whether that would have led to an alternative ending, we will never know, but clearly there is great room for improvement.”

It’s true we will never know if early detection would have changed the course of Darryl Kile’s, John Ritter’s, or Robert Palmer’s fate, but the parallels in pathology and outcome between these types of sudden death episodes — along with the hundreds of thousands of Americans that die each year from similar or identical disorders — so powerful in their public impact, underscore the need for routine screening of the heart. Because we do know that when detected early, there are several options available to halt and potentially reverse the progression of disease. And the earlier discovered, the milder and more lifestyle friendly any necessary treatment will be.

Solutions to the challenges posed to medical professionals when attempting to identify otherwise clinically silent diseases exist. Yet the question remains — why are some of these advanced methods of heart screening not routine, so that all the progress being made in science and medicine can be utilized to its fullest extent to save thousands of lives each year?