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Little-used scan can find hidden heart disease

Common stress tests can miss problems, cardiologists say. But not all agree that new technique is ready for wider use.

October 11, 2004|Valerie Reitman | Times Staff Writer

The former president has chest pains. A catheter threaded through his heart finds all three major arteries and a tributary up to 90% blocked. Surgeons buzz through his chest with an electric saw, stop his heart for 73 minutes and use veins from his leg and elsewhere to bypass the blockages.

Bill Clinton is saved. But some cardiologists say the event was far from a medical triumph. As soon as word got out about the extent of previously undetected clogs in Clinton's arteries, some of the nation's top cardiologists began trading barbed e-mails and phone calls, decrying the event as the ultimate failure in preventive medicine, even as "unconscionable."

"The bottom line is, Bill Clinton's walking into the hospital with chest pains is a shocking event in a country where we have plenty of tools to prevent that," says Dr. Morteza Naghavi, a Houston researcher who founded the Assn. for the Eradication of Heart Attack, an influential group of cardiologists that advocates an overhaul of how patients are assessed for heart disease.

As it is now, about 88% of those who have heart attacks would have been labeled low to moderate risk by their doctors on the previous day, according to a recent study published in the Journal of the American College of Cardiology.

Clinton's experience demonstrates that even a former president with access to the best medical care available can have undiagnosed heart disease. Doctors like Naghavi advocate aggressive use of preventive screening, such as blood marker tests and noninvasive scans. In particular, some cardiologists are promoting wider use of a noninvasive diagnostic test known as the coronary calcium scan.

But other physicians say some of these tests have not proved their value, and they cite the expense of widespread screening programs in a time of rising medical costs.

About 1.5 million Americans this year will not be as lucky as Clinton was. They won't get a warning sign -- allowing time to get to a hospital -- before they suffer a heart attack. About half of those will die.

Clinton appears to have never had the simple $250-to-$400 diagnostic scan that the eradication association and others advocate, although Walter Reed Army Medical Center, near the White House, has been using such tests in middle-aged Army personnel for years, after finding that traditional treadmill stress tests failed to identify many future heart attack victims.

The scan, known as an electron beam computed tomograph, or EBCT, probably would have detected the extensive plaque that lined Clinton's coronary arteries, some cardiologists said. Aggressive interventions, such as stents that open the blockages, could have been taken long before emergency bypass surgery was necessary. Even if the measures couldn't have averted open heart surgery, doctors would have been prepared, rather than surprised, to find such threatening problems.

Some physicians are skeptical of the scans, however. "There's cost and there's radiation, and we don't know how much information it adds beyond traditional indications," says Dr. Lori Mosca, director of preventive cardiology at New York-Presbyterian Hospital.

She notes that the National Institutes of Health are sponsoring national trials ending in 2008 that may show whether the test actually changed the fates of those who were determined to be at high risk.

Many cardiologists have complained that the scan isn't recommended to more Americans now. That is changing slowly as the evidence supporting the benefits of the test becomes more convincing and more medical organizations endorse its use. Earlier this year, three studies published in leading medical journals, including the Journal of the American Medical Assn., found the scans to be of benefit in detecting heart attack risk.

Dr. Scott Grundy, a University of Texas Southwestern researcher who drafted guidelines for the use of statin drugs for the National Cholesterol Education Program, says he believes the scans are as important as cholesterol tests in determing heart attack risk.

Groups such as Naghavi's recommend that men older than 45 and women older than 55 should have the scan, regardless of whether they have risk factors such as diabetes, sedentary lifestyle, obesity, smoking or kidney disease.

The American Heart Assn. is considering a less radical proposal, suggesting that cardiologists scan only people in those age groups who have traditional risk factors. About 40% of Americans in that age group have some or all of those risk factors, putting them in what is known as the "intermediate risk" category.

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