March 3, 2000 (San Diego) — The reassuring voice on the car radio tells the listener that doctors know that calcium in the arteries is a sign of heart disease and now the listener can find out if he or she has calcium by simply getting a fast, noninvasive test that will visualize his or her arteries. Call now for an appointment and rest easy, says the voice. Those commercials have a lot of heart disease experts losing sleep.
The scanning device in question is called an electron beam CT, or EBCT, and is being advertised directly to consumers, often as ‘ultra-fast CT,’ as a new way to detect heart disease
But despite its ability to detect heart disease, physicians are divided about using EBCT. On one side, proponents say EBCT is ushering in a brand-new era in heart disease prevention, while the other side says it is overused and overmarketed by operations that use the device for profit. The two camps presented persuasive arguments for their respective positions at the American Heart Association’s (AHA) meeting here, but no minds were changed.
Although EBCT is not a new technology — Robert Detrano, MD, professor of medicine at Harbor-UCLA Medical Center in Los Angeles, says it has been available for 20 years — only in recent years has it become controversial.
In some areas of the country, such as Los Angeles and Chicago, EBCT is heavily marketed in television and radio ads as a quick and easy way to find out if one has heart disease. The slick advertisements urge the public to have the test — at about $500 a scan — to ease worry, claiming that it will either confirm clogged heart vessels by detecting calcium in the arteries or give a clean bill of health because it detected no calcium. That, says Detrano, is worrisome because “again and again, I have seen people with negative scans come back in a year or two with [a heart attack].”
Detrano and Lewis Kuller, MD, professor of public health at the University of Pittsburgh, squared off for an afternoon debate at the meeting and then continued the debate at a press conference. Kuller says EBCT has the potential to remake the field of heart disease prevention so that the goal will not be preventing heart attacks, but preventing the disease that causing heart attacks: atherosclerosis, or hardening of the arteries.
Kuller says that one of the arguments put forth by those opposed to widespread use of EBCT is cost. “I remember 20 years ago people were saying that women wouldn’t have mammography because it cost $300,” says Kuller. “I disagreed with them and I said, ‘It doesn’t have to cost $300; if we do enough of these exams it can cost $50.’ That’s exactly what happened. EBCT can be done for $25 or $50 if we do enough of them.”
Detrano, who has published several EBCT studies, wants to wait. Specifically he wants to wait for the results of a National Institutes of Health study before making any recommendations about the use of EBCT for screening. Detrano tells WebMD the “results should be available in five years.”
Part of the dispute revolves around how to interpret EBCT findings. The EBCT locates calcium in the arteries, but the question becomes how much calcium is a sign of heart disease. The EBCT is scored from ‘0,’ for a negative finding or no calcium, up to scores in the thousands. For example, Detrano says that if a patient told him that he or she had an EBCT score of 500, “I would tell that person that he or she has atherosclerosis, but what if the score is 200 or 150?”
One group of researchers feels they have determined a way to interpret EBCT findings. A team from the Cooper Institute in Dallas, for example, presented a study that found that EBCT was a more accurate predictor of heart disease than were traditional risk factors such as diabetes, high blood pressure, obesity, and family history. Ming Wei, MD, an investigator at Cooper, tells WebMD those persons with an EBCT score of 400 or more had a nearly 76-fold increase in risk for heart disease. He added that a score of 1 to 99 was associated with a threefold increase.
The controversy has not gone unnoticed by physicians who treat heart disease. Rodman Starke, MD, AHA executive vice president for science and medicine, tells WebMD there are less than 100 EBCT units now in use in the U.S., and most of them are at medical centers affiliated with universities. He says there has been ongoing discussion and concern about the overuse of EBCT by marketing to the general public.
In order to sort out the issue, the AHA and the American College of Cardiology are preparing a policy statement on the use EBCT, and Starke says the statement will probably be published by midsummer. He says he thinks the statement will support use of the technology for patients who are at moderate risk.
High-risk patients, he said, should be treated aggressively, and low-risk patients can be treated with some mild lifestyle modifications, but “it is the patients in the middle who pose the problem.” These patients may have a single risk factor, and “one has to weigh the decision about whether you really want to intervene in their lives,” says Starke. Basically, EBCT could aid doctors in making treatment plans for these patients.
As an endnote, Stephen Fortmann, MD, professor of medicine at Stanford University School of Medicine, says, “No scan can replace a visit to a physician, and I don’t think any patient should be getting a scan without first consulting his or her physician.” Fortmann moderated the debate between Kuller and Detrano.