By Phil Davis
The blood in Lyn Garrison's coronary arteries flows around tiny
calcium-rich bumps -- an early sign that disease is slowly choking
her heart.
While not good, the news is a wake-up call, not a death
sentence.
There is still time to stop smoking, to lose weight and to cut
back on the low-density lipoprotein (LDL) cholesterol that feeds
the blockages.
``I'll be changing a lot of my habits, for sure,'' said
Garrison, 54, a Simi Valley resident who works in the radiology
department at Cedars-Sinai Medical Center. ``Being in the medical
field, I know I should be eating low-fat foods and not smoking,
and, of course, I do the opposite. But I think this will do it
because you always think, `Not me.'''
This cardiac wake-up call comes courtesy of a controversial
machine called the Electron Beam Computed Tomography scanner, also
known as the ``ultrafast'' CT. The $2 million machine snaps
electronic images of calcium buildup inside the body faster than
other imaging equipment, which makes it useful in scanning the
heart. Calcium deposits are a sign of atherosclerosis, the buildup
of plaque in arteries that can lead to heart attack or stroke.
The machine is currently at the center of a heated debate: Is
the ability to pick up extremely early traces of heart disease
medically useful, or is the ultrafast CT just an overpriced scare
tactic with no real diagnostic value?
Supporters say the scanner is the best way to detect heart
disease in its earliest, most curable stage. It can provide vivid,
if not frightening, proof that a patient had better change his or
her ways before the disease spreads.
``It's the difference between having risk factors for a disease
and having a disease,'' said Dr. Daniel Berman, chief of cardiac
imaging at Cedars-Sinai Medical Center. ``Tell a smoker that
smoking causes lung cancer and they say, `Yeah, but most smokers
don't get lung cancer.' Show them they have lung cancer in their
chest X-ray, they stop smoking right away.
``The same thing happens with coronary disease,'' Berman
continued. ``It goes in one ear and out the other when you tell
people they have high cholesterol and they really should reduce it.
Show them plaque in their coronary arteries and they go on
medication and change their diet. It really does alter
lifestyles.''
Critics say the ultrafast CT essentially proves what doctors
already know, that a person of a certain age with specific medical
problems is at increased risk of heart disease. They say the
marketing of ultrafast CTs -- which allows patients to schedule the
scan without a referral from their physician -- encourages
unneccesary, expensive medical testing. They also worry a clean
scan will encourage patients to continue the bad habits that put
them at risk.
Dr. Robert Detrano, a cardiologist at Harbor-UCLA Medical Center
and author of a 1996 American Journal of Cardiology study that
questioned the value of the ultrafast CT, said the scan does seem
to frighten some patients enough to ``at least say they're going to
change.'' But he was disappointed with the machine.
``We haven't found that it predicts heart attacks very well,''
Detrano said. ``We see a lot of people with heart attacks who don't
have calcium.''
His biggest problem with the procedure was the cost. He and some
colleagues abandoned a more comprehensive study to measure the
effectiveness of the ultrafast CT in stopping people from smoking
because the procedure cost too much. The researchers determined the
money was better spent counseling smokers or paying for medications
to directly combat the problem.
Cedars-Sinai charges $395 for the scan, a cholesterol screening
and consultation with a cardiologist. Anyone can take it, but
Berman said it is most useful for men ages 35-55 and women ages
45-65 who have at least two heart disease risk factors. The risk
factors are: high LDL cholesterol levels, diabetes, high blood
pressure, smoking, obesity or a family history of early heart
disease.
``The majority of the patients have abnormalities in their
scan,'' Berman said. ``When they have no abnormality, we're careful
to make sure they don't say, `Oh, I can go out and start smoking
and having cheeseburgers.' We'll also be following that with
research.''
Berman hopes to end any debate with the most comprehensive study
of the ultrafast CT to date. In the coming months, he and his
colleagues will be screening 10,000 Cedars-Sinai employees for
heart disease risk factors. Those at highest risk of heart trouble
will be broken into two groups: Both groups will be counseled and
treated to ward off heart disease, but one group will also get an
ultrafast CT. Researchers will follow the patients for five years
to see if the scan has any impact on the way they care for their
heart.
Will the patients be scared straight? No one can say for sure.
In other fields, the philosophy hasn't worked well.
``Scaring people is usually counterproductive,'' said Dr. Frank
Grossman, a dentist in Glendale who often uses high-tech images of
teeth to teach patients about gum disease and tooth decay. ``I
think educating them without scaring them is a better approach.''
Grossman believes many of his patients leave the office with
good intentions, but then slip back into old habits.
The same could be said of heart disease. Despite the fact that
diseases of the heart kill nearly 1 million Americans each year,
most people ignore the well-publicized risks. There is a wealth of
information that high LDL cholesterol, smoking, obesity and a host
of other lifestyle choices have a profound impact on whether a
person will develop heart disease, the nation's No. 1 killer of
both men and women.
According to the American Heart Association, roughly half of the
14 million Americans who have some form of coronary artery disease
will find out about it only after they have a heart attack or
irreversible damage.
For example, a treadmill stress test, another way to detect
blocked arteries, is only effective after the blockage is more than
50 percent, Berman said.
He said the ultrafast CT can catch heart disease before the
material obstructs any blood flow, giving physicians the ability to
head off future problems.
``It's not just about making a diagnosis of something we can't
treat. This is a disease that can be stopped,'' he said. ``It
doesn't really matter if (the plaque) you've already got in there
goes away. If you stop the progression of the disease, there's no
reason you shouldn't be healthy, live to be 100 and have something
else get you.''
But in the end, no matter what researchers say, the bottom line
comes down to money for both hospitals and patients.
Detrano said the roughly 50 American centers that have an
ultrafast CT are pushing calcium scanning to pay for the machines
that can't do much else.
``If you buy one of these machines for $2 million, you're stuck
with it,'' he said. ``It's not very good for scanning the abdomen,
the head, the knees or the spine, so you're stuck with scanning the
heart or screening for calcium. It's the only way you can make it
pay for itself, and that's why all these people are doing it.''
And since most insurers don't cover the ultrafast CT scan,
prospective patients also have to make a bottom-line assessment.
``It depends on how much money you've got in your pocket,''
Detrano said. ``If you've got a lot of money to be scared with,
then it's fine. But I don't know if it's worth it for most people.
That's the issue here.''
