Cardiac screening

Cardiovascular disease remains a major killer of humans today. When we talk about longevity, it will be irrelevant to talk about all the new novel medications, peptides, and fancy longevity hacks if there is cardiovascular disease developing under the radar.

One of the very first things to be discussed during our longevity visits is cardiovascular risk. Unfortunately, the guidelines look at a few risk factors and ignore plenty of others. Poor sleep, high stress, chronic inflammation, autoimmune disease, diet habits, VO₂ max, baseline HRV, and many others are all cardiovascular predictors, yet in today’s world, our main focus is on cholesterol, diabetes, and hypertension, which is not wrong, but incomplete.

Below, I summarize different forms of cardiac screening for coronary artery disease.

Coronary Calcium Score:

Current guidelines recommend a calcium score for people with intermediate risk for coronary artery disease. This has many caveats. One, how do we determine risk, and is this determination universal and covers all sorts of risk factors? And second, the calcium score will miss soft or low-density plaque, the more dangerous plaque, and most importantly: how do we know that people with low risk do not have cardiovascular disease? Risk and reality are two different things, and this is the beauty of precision medicine.

A calcium score detects the extent of calcifications within the coronary artery structure, giving an indirect idea of plaque burden, but it does not quantify any degree of blockage if present. This is my least favorite screening method, but it has its uses.

CCTA

In contrast to the calcium score, a CCTA (coronary CT angiogram) is a very informative test that shows the extent of plaque if present and will capture soft and low-density plaque, allowing us to understand the risk accurately for cardiovascular disease.

The presence of an iodine dye will allow the radiologist to see each blood vessel clearly and determine if there is any form of plaque and the extent of the blockage if present.

This will allow us to be proactive, years, if not decades, to curb the disease and prevent progression and even reverse some of the changes with appropriate medical therapy, nutrition, and cellular interventions with peptides and such.

CCTA with Advanced Plaque Analysis (Cleerly)

Taking it to the next level, certain companies have taken the CCTA to a different level of plaque analysis with detailed measurement of sizes and composition, with advanced techniques for visualization to monitor subtle changes that happen within the coronary arteries.

This method is expensive but very valuable, especially if we establish the presence of coronary artery disease, as it is easy for comparison and detection of progression or regression. This test is a good starting point for individuals with known cardiac risk factors.

FFR-CT

This method excels at detecting flow restriction within arteries. This method is not the go-to for early detection; this is to quantify if a plaque is causing any significant flow restriction that needs more intense intervention.

Cari-Heart

This is an emerging technology using additional imaging features and AI technology to detect inflammation, which is a key driver for coronary artery disease. It uses multiple data points to determine overall risk, not just by plaque analysis or vascular blood flow metrics.

This is not an ideal screening method per se; this is a method of cardiac risk assessment for individuals with a high likelihood of coronary artery disease, or with established coronary artery disease.

Stress Tests:

EKG stress tests are only informative if the cardiovascular disease is severe enough to cause significant symptoms or flow limitations. It does not provide any sort of direct visualization of the heart.

On the other hand, nuclear stress tests provide direct visualization of the heart muscle and can detect significant flow limitations by visualization, not indirectly through EKGs. It does not detect any early cardiovascular disease.

These two types of stress tests are not good options for cardiovascular screening, as they will miss any mild to moderate plaques or stenosis and can give a sense of false reassurance.

These are diagnostic tests to be used when there is high suspicion of active significant plaque causing flow limitations.

PET Cardiac CT:

This is a functional method that is much more accurate in detecting cardiac disease than regular or nuclear stress tests. This is a great method of detecting cardiovascular disease in microscopic blood vessels that cannot be seen on any of the modalities above.

Early detection of cardiovascular disease is not about rushing someone to the hospital to do an angiogram or save your heart imminently; it is for better insight into how to prevent progression of cardiac disease so we can curb it where it is now and prevent a heart attack a decade from today. Each of the above tests have their own uses and limitations, and it is important to treat everyone individually depending on their risk and determine the best method for cardiac screening if indicated.