Oct. 4, 2024 – A hidden killer – plaque buildup in arteries – is being pushed to center stage by new research that could change how doctors assess patients’ risk of a deadly heart attack or stroke.
The new study found that people with hidden plaque built up in the arteries – a condition called atherosclerosis – were much more likely to die during the 12-year study period than those whose arteries were clear. Researchers tracked 5,700 people and, in a subgroup, found that an increase in plaque buildup raised that risk more, regardless of people’s risk factors or other health conditions.
What does that mean if you know your cholesterol level, blood pressure, and family history – but don’t know the condition of your arteries? Your doctor may be more likely to consider a scan of the blood vessels feeding your heart and brain.
“Our data all along, and in everything that we have published, is saying that imaging has more power than risk factors, but if you put both together, this is the most powerful tool,” said lead study author Valentin Fuster, MD, PhD, director of Mount Sinai Fuster Heart Hospital in New York. “The future, in my opinion, is that we will do 3D ultrasound.”
“Seeing is Knowing” was the title of a commentary that came with the new study, published this month in the Journal of the American College of Cardiology.
“The power of patients seeing their own atherosclerosis is important,” said David Maron, MD, who co-wrote the commentary. “It’s incredibly effective in helping people change their behavior and agreeing to take medication for controlling cholesterol or blood pressure.”
The Fight Against a Hidden Killer
About half of people in the U.S. are believed to have hidden plaque but no symptoms. Atherosclerosis can start early in life and speed up in midlife. It’s a source of the leading cause of death in the world, but most people who have it aren’t aware until they experience life-threatening symptoms like a heart attack or chest pain called angina.
“That’s why we are seeing so many heart failures, because I think we are too slow and too late in the game,” said cardiologist Quynh Truong, MD, MPH, a professor of medicine and radiology at Weill Cornell Medicine in New York City. She was not involved in the study.
Public health officials and health care providers alike have struggled to compel widespread prevention efforts among younger people.
But as the new study shows, monitoring plaque buildup over time may help predict the risk of early death – above and beyond the usual risk factors.
These latest findings are a midway point in a series of research studies on the risk of death from hidden plaque buildup, which scientists call subclinical atherosclerosis. The collection of research aims to document how imaging technology may be used to help diagnose atherosclerosis earlier in life, when it is more treatable and before health dangers like a heart attack are imminent.
The average age of people in the study was 69 years old, and people without symptoms of atherosclerosis were selected. Fuster said a companion study is already underway following younger people (ages 30 to 49 years old) that will build on the findings.
How Checkups May Change
Currently, health care providers find your risk of atherosclerosis using things like like cholesterol and blood pressure levels, smoking status, and age. For people in the low-risk group, imaging is rarely recommended, even though they may have a single borderline risk factor such as somewhat higher cholesterol.
“What’s interesting about this study is that they even looked at these patients with low risk scores. They are so low-risk that they don’t need to be on medication,” said Truong.
Doctors can detect atherosclerosis using a coronary calcium scan, a CT scan that looks for calcium deposits in heart arteries and costs around $100. Ultrasounds can be more accurate at diagnosing atherosclerosis in younger people, but they are costly, not covered by insurance, and not widely available, Maron said.
Within a few years, though, people may be able to scan themselves with a portable 3D ultrasound device that sends results to their smartphone, said Fuster. Until then, the new study suggests that more CT scanning could prevent some deaths.
“When people have no symptoms and they don’t feel sick, sometimes it’s a hard sell to do anything that will change the way they live,” said Maron, president-elect of the American Society for Preventive Cardiology and chief of the Stanford Prevention Research Center.
“What I do is I try to persuade on the basis of evidence … along with an image of their disease,” he said. “Usually the image is enough.”
Who Needs a Scan?
Truong said that a patient willing to take a very small dose of a cholesterol-lowering medicine called a statin and can get their LDL cholesterol level under 100 mg/dL, or ideally under 70 mg/dL, probably doesn’t need imaging.
“But if you have a patient who is not willing to be on medication, that’s when you need to start talking about, ‘Let’s see if you have already developed some disease,’” said Truong, who specializes in cardiac CT imaging.
Typically, Maron recommends calcium scans to most men over the age of 40 and women over age 50. Sometimes he will recommend scanning earlier, such as for people with a strong family history or poorly controlled cholesterol, blood pressure, or blood sugar.
Managing Your Hidden Heart Threats
For people concerned about hidden risks, Maron recommends focusing on what are known as Life’s Essential 8: diet, physical activity, no smoking, healthy sleep, weight management, plus maintaining healthy levels of cholesterol, blood pressure, and blood sugar.
“Even LDL cholesterol, blood pressure, and blood sugar are ‘hidden’ if they are not measured,” Maron said. “So, to begin with, go with Life’s Essential 8. Then I think that everyone should have a one-time measurement of Lp(a),” which is a less well-known type of cholesterol that can also impact the risk of problems with your heart and blood vessels.
The American College of Cardiology offers an online calculator that estimates a person’s atherosclerosis risk and presents potential advice that could be discussed with a health care provider about managing risk factors.
“There are millions of people walking around right now who have coronary disease or carotid disease, and they don’t know it,” Maron said. “And if they knew it, they would take action because they don’t want to have symptoms, they don’t want to die from atherosclerosis.”
