Beating the Odds : New Test Saves Anaheim Man With Family History of Coronary-Artery Problems

Kenneth Smith of Anaheim felt fine. He ate sensibly, watched his cholesterol, exercised regularly, went in for regular medical checkups. His body showed no symptoms of the potentially fatal deposits in his coronary arteries, not even when he ran a treadmill test while hooked up to a heart monitor.

But Smith, a 58-year-old engineer, was all too aware of a frightening statistic: In approximately one-third of all cases, the first “symptom” of coronary artery disease is sudden death.

“My brother died at 47, while they were running an angiogram on him,” Smith says. “That was about 20 years ago. And then a year ago in October, another brother, 48 years old, who was in great shape--he climbed Mt. Whitney, jogged, went sky-diving--was out jogging one evening and dropped dead. Later, they found out his coronary arteries were about 90% blocked.”

Smith’s mother died at 50 when he was a teen-ager, “but all I heard about that was she had an enlarged heart. After my brother died last year, I went and got copies of the death certificates for all the people in my family. In every case, coronary artery disease was listed as either the main or a contributing cause,” he says.

So when he heard about a new test that could detect the disease much earlier, Smith asked his health maintenance organization whether it would cover the test. When the HMO said no, Smith wrote out a check for $375 for the test.

Known as coronary artery scanning, the test uses ultra-fast computerized tomography--a more sophisticated version of the CAT scan commonly used to detect head injuries and other problems--to locate calcium deposits in the coronary arteries.

While Smith lay still and held his breath, the high-speed X-ray scanning device at Advanced Healthcare Resources Inc. in Brea took freeze-frame images of his heart every one-twentieth of a second. Then the computer processed the images to reconstruct a three-dimensional moving picture of his beating heart.

The whole process took about 10 minutes, after which cardiovascular radiologist Dr. Harvey Eisenberg broke the bad news: Smith had large deposits of calcium in several coronary arteries. The calcium, Eisenberg explained, was an indication of atherosclerosis.

Since the 1950s, doctors have known that calcium and atherosclerosis had a direct correlation, Eisenberg says. But since there was no imaging equipment to detect the calcium, that information had no practical application.

Smith took the coronary artery scan results back to his HMO, where doctors had him repeat the treadmill test, this time using radioactive thallium to make the test more sensitive. But that test also revealed nothing unusual.

The HMO doctors said they could not take the scan results into account “because it was a new technology,” Smith says. Without that, he had no indication of any heart problems. So on his own, he went to UCI Medical Center, where Dr. Jonathan Tobis, who heads the cardiology department, ordered an angiogram in an attempt to find the blockages.

“That was on the morning of Sept. 6,” Smith says. “That afternoon, they performed quadruple bypass surgery.”

Since four of his coronary arteries, which supply blood to the heart muscles, were partially blocked with atherosclerosis, the doctors took blood vessels from other parts of his body and used them to create new, unobstructed paths for the blood to flow. Smith’s HMO has since agreed to pay for the operation, but not for the scan that led to it.

An increasing number of insurance companies are beginning to pay for coronary artery scans, Eisenberg says, while others are still reviewing the data.

So far, the procedure has been written up in several medical journals, including Lancet in England and the American Journal of Cardiology. Doctors from Japan and Miami presented another study about its accuracy at the American Heart Assn. convention in Anaheim last month.

Eisenberg, an associate professor of cardiology at Harvard University and former professor of cardiovascular radiology at UCLA, has worked with doctors in Chicago, Philadelphia and Miami as well as UC Irvine on ultra-fast imaging technology. He also developed the software for the system used at the imaging center in Brea.

Eisenberg says the most important aspect of coronary artery screening is that it can detect coronary artery disease in its early stages, when lifestyle changes such as diet and exercise, possibly combined with medication, can control and even reverse the disease. In Smith’s case, his doctors told him, the disease was so far advanced that he needed immediate corrective action.

Other forms of testing cannot usually detect blockages less than 70%, he said, because smaller deposits do not interfere with the flow of blood. Yet smaller blockages often can cause heart attacks, erupting suddenly and blocking the arteries with blood clots.

According to the research, coronary artery scanning is considered 100% sensitive for disease in two and three blood vessels. That compares with about 60% sensitivity for the standard treadmill, increased to 80% with radioactive thallium, and about 90% for positron emission tomography (PET) scanning. Angiography, according to the study presented last month in Anaheim, is slightly less likely to identify disease than coronary artery scanning. It is also invasive, using a catheter to allow dye to be injected into the coronary arteries. In some cases, such as that of Smith’s brother, the test itself can be fatal.

Coronary artery scanning, on the other hand, requires no dyes, needles or radioactive isotopes, and is completely non-invasive. Aside from the slight radiation risk inherent in all X-ray procedures, the only side effect of scanning is one Eisenberg encountered after he underwent the test himself.

“Sometimes when people find out they have no disease, they go out and gain 10 or 15 pounds to celebrate,” Eisenberg says.

Smith’s case is not unusual, Eisenberg says. “About once a week we have someone walk in with no symptoms, and we find life-threatening disease.”

But in other cases, the opposite happens. Some patients who have shown signs of blockages in other tests come in for a scan and nothing is found.

“A negative test has extremely high accuracy,” Eisenberg says.

Coronary artery scanning is recommended primarily for patients between 35 and 62 years of age, Eisenberg says, because atherosclerosis in that age group is most likely to cause heart attacks or even death. In older patients, who are more likely to have atherosclerosis, the heart is also more likely to have developed cross-circulations to alleviate the pressure on blockages.

Smith, meanwhile, says he’s feeling fine now, although he does get a bit winded when he exerts himself. He’s scheduled for a follow-up treadmill test this week, after which he’ll return to work if the results are normal.

“I’ll be going back right before the holiday break, so that will give me some more time to recuperate,” he says.