Is Popular Heart Scan Sound or Scam?

Carrie Farella, RN, MA

Published on October 9, 2001
© 2001 Nursing Spectrum

THE ADS ARE EVERYWHERE. A test that promises to pinpoint problems and diagnose disease in 20 minutes? Is it real? Can it save lives? Frank Ward, a sheet metal and piping contractor from Blue Island, IL, says it saved his.

“It’s a miracle,” says Ward, who had an electronic beam computerized tomography (EBCT) scan at a local Heart Check America center four years ago. “I did it to get my buddy in there. He was overweight and a heavy smoker. Another friend joined us, and the three of us went together.” Ward’s friends sailed through the 25-minute test with flying colors. He didn’t. “I had no risk factors, but when I got my result, I was shocked.”

His friends’ results — scores that indicate calcified plaque in vital coronary arteries — were low: One friend had a value of 1, the other 17. But Ward’s result was sky-high: 392. Further testing led to an angiogram and immediate balloon angioplasty. “Afterward, I was told my blockage was called a ‘widow-maker,’” says Ward. “I could have dropped dead without warning.”

Hunt for a Hidden Killer

Coronary disease is the nation’s number one killer; nearly 30% of patients don’t survive a first strike. While some patients seem like sitting ducks for the disease, others — like Ward — seem billboards for good health: fit, trim, physically active nonsmokers and nondrinkers.

Bob Jackway, a financial planner from Rosemont, IL, was 39 and in excellent health when asthma began to curtail his daily racquet ball regimen. “I never had asthma before, but quarterly bouts of it turned into monthly episodes,” he says. “Soon, I couldn’t walk or carry my briefcase.”

Pumped up on steroids, Jackway lived on his inhaler. Soon, he was hospitalized every few weeks — but for asthma: Traditional ECG and treadmill test results were all normal. His wife urged him to get an EBCT scan. “I thought it was the biggest waste of time and money, then I got my results.” He had more calcified plaque in his ascending coronary artery than 87% of most people. He was a walking time bomb.

An angiogram proved the EBCT results were right. A significant blockage in Jackway’s ascending coronary artery was relieved with balloon angioplasty. “In the recovery room, I realized I could breathe again.” Today, he’s back at racquet ball and only takes a daily puff on his inhaler. “I would have died without that scan.”

These are strong words from seemingly average people. But are they flukes? EBCT supporters don’t think so. In fact, patients like Ward and Jackway are the population clinicians target, hoping to screen patients for problems long before a chest pain is ever felt.

“This technology is not a test,” says Julie Hoff, RN, PhD, clinical coordinator at the University of Illinois. “It’s a screening tool that allows us to find individuals who are at the highest risk of a cardiac episode.” And they’re far from rare.

“There are so many 30- and 40-year-old people who have subclinical cardiac disease at some level,” says Bruce Friedman, MBA, president of Heart Check America, Los Angeles. “This technology is cutting-edge and has helped open the field of preventive cardiology.”

To prove its merit, Hoff and colleagues followed 8,000 scanned patients between 1993 and 1998. The data, not yet published, is intriguing. “We had a 60% response rate,” says Hoff. “Those with scores in the highest quartile were most likely to report a vascular event, such as having a heart attack, revascularization procedure, or even death.”

“Does this test save lives? Yes,” says Karol Stirneman, RN, BSN, nurse coordinator of UIC Physician Group Cardiovascular Associates, Arlington Heights, IL. “We recently had four patients who had bypass graft surgery before injury to their heart muscle. This test screened them early, and it’s exciting to be able to get them treated before the damage sets in.”

Real or Rip-Off?

EBCT scanners are developing quite a fan club — the high-tech tool is popping up faster than you can spell hyperlipidemia.

Not a magical mystery machine, EBCT is an outgrowth of computed tomography (CT) technology. It “freezes” the beating heart by imaging at speeds approaching 0.1 second. Traditional CT scanners are 10 to 20 times slower. The scanner takes images of vessels without contrast dye and detects minute amounts of calcified plaque in major coronary arteries. EBCT doesn’t detect blood flow, but it checks anatomy, revealing early lesions or buildup of plaque.

Believed to be the most sensitive, noninvasive method available to detect the presence and extent of atherosclerosis, EBCT is not a substitute for an angiogram. It does not measure the amount of narrowing in the coronary arteries — what angiography was designed to do. Some centers now offer whole body scans, imaging colon and lungs, although the bulk of the business is heading off heart disease.

And business is booming. According to a report by the Advanced Market Research for Telemedicine Healthcare, EBCT manufacturer Imatron (just purchased by General Electric) reported brisk sales of the technology. Nine orders in the first fiscal quarter brought in $19.3 million in revenue.

Not everyone is a convert, though. “My physician said my EBCT results were worthless,” says Jackway. “He said he didn’t even know how to read my value. He dismissed it and was angry when I refused to let it go.”

Jackway’s MD isn’t alone. Many healthcare providers are only now learning the scan’s potential. Others have their own reasons for giving it the cold shoulder.

“Unfortunately, it’s still not embraced by all cardiologists,” says Friedman. “I tend to think some are feeling threatened, but EBCT isn’t intended to replace cardiac catheterization or stress tests. It just helps people get to those mainstream tests faster.” He says some physicians see the technology as cutting into their slice of the healthcare pie. “Some are afraid they’ll lose money, especially when they’ve purchased their own treadmill.” For others, he says, it just takes time to get comfortable with the new technology.

“It takes physicians years to digest the information they’re presented with,” says Stirneman. “With more than 400 different journals reporting information, it’s hard to keep up on everything. Some don’t understand, others don’t like to refer patients for a test they’re not comfortable with, and still others just do the same thing over and over.”

“In today’s world, it’s difficult to keep up with changes in technology,” says Hoff. “No physician would prevent patients from doing something beneficial. But to not keep up with the information is a disservice to the patient, too. It’s just ignorance.”

Research Merry-Go-Round

The American Heart Association (AHA) says that while the test may point to coronary calcium values, it’s unsure whether scanning should be done on everyone everywhere. The American College of Cardiology (ACC) and the AHA together reviewed the literature on EBCT and found the test may help determine whether a patient who appears to be at intermediate risk is actually at high risk of coronary artery disease.

The joint panel didn’t recommend the test as the sole method for diagnosing obstructive coronary artery disease in asymptomatic people without multiple risk factors, citing the high percentage of false positives and the expense of additional tests that usually follow. Panel members did, however, support the test for asymptomatic patients if it’s performed as part of a full medical assessment.¹ The ACC later supported EBCT as a “filter” for coronary artery scanning in symptomatic patients.²

Results from the study, conducted at Walter Reed Army Medical Center in Washington, found EBCT could identify patients who appeared to be healthy but in fact were at risk for coronary artery disease that hadn’t been detected otherwise.²

“We don’t state that EBCT isn’t useful,” says Robert O’Rourke, MD, cochair of the AHA/ACC team. “What we would like to see [is] additional studies to determine when the procedure is useful and when it’s not.”

The EBCT camp boasts research to the contrary. A 1999 study published in Mayo Clinical Proceedings found that while calcium values revealed through EBCT may need fine-tuning before guidelines are set, the test is definitely useful: “EBCT identifies subclinical coronary plaque and therefore high-risk asymptomatic patients who are candidates for aggressive preventive therapies such as drugs, even for average to mildly increased cholesterol levels.”³

A 2000 study of 1,238 patients found EBCT scanning predicted coronary death and nonfatal MI and the need for revascularization procedures. It also found EBCT scanning of coronary arteries can’t detect a lesion at risk, only a person at risk, independent of standard coronary disease risk factors.⁴

In yet another study of 299 patients, researchers found EBCT scanning assisted in determining atherosclerosis, helping clinicians manage the disease before it progressed.⁵

While EBCT continues to be marketed directly to the public, opponents question the industry’s motives: Are marketers boosting the bottom line by promoting unnecessary use? Those hoping to err on the side of caution put their trust in a study being conducted by the National Institutes of Health that will provide definitive answers when completed in 2005. In the meantime, don’t expect the hoopla to die down.

“I think this technology will [someday] become as standard as mammography,” says Hoff. “But first, it needs to be more accessible and affordable.” And healthcare providers may need more time to understand its role as a screening tool — not as a substitute for traditional tests or angiography. Supporters see it as filling a badly needed void.

“We all know patients who’ve passed a treadmill test or scored low on a cholesterol test and had a heart attack,” says Friedman. “Those tests aren’t worthless — they’re just not enough. We’ve got survivors who can prove it.”

What Is It?

Electron-beam CT (EBCT) is a faster form of x-ray imaging technology. It has been used in the recent past to evaluate bypass graft patency and intra- and congenital cardiac lesions and to quantify cardiac health.

But it has other uses, too. EBCT can measure calcium deposits in coronary arteries and may help predict heart attacks or the need for angioplasty.

EBCT is not a substitute for cardiac catheterization. EBCT values of coronary calcium offer no value to patients who’ve already had a heart attack or have undergone coronary bypass surgery or angioplasty.

Carrie Farella, RN, MA, is a corporate writer for Nursing Spectrum.

References
1. O’Rourke R, Brundage B, Froelicher V, et al. American College of Cardiology/American Heart Association expert consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circ. 2000: 102:126-140.

2. A brief discussion of full-body (fast CT) scanning. Advanced Market Research for Telemedicine Health Care website. Available at: www.feed-back.com/apr01ezine.htm. Accessed September 26, 2001.

3. Rumberger J, Brundage B, Rader D, Kondos G. EBCT coronary calcium scanning: a review and guidelines for use in asymptomatic persons. Mayo Clin Proc. 1999;74:243-252.

4. Arad Y, Spadaro L, Goodman K, Newstein D, Guerci A. Prediction of coronary events with EBCT. J Am Coll Cardiol. 2000;36(4):1253-1260.

5. Budoff M, Lane K, Bakhsheshi H, et al. Rates of progression of coronary calcium by EBCT. Am J Cardiol. 2000; 86:8-11.

This article originally appeared online at http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=5117