James de Lemos, MD, a professor of internal medicine in the division of cardiology at UT Southwestern Medical Center, Dallas. He is the current medical director of the Dallas Heart Study.
Everyone’s familiar with the traditional risk factors for heart disease. There’s elevated cholesterol…high blood pressure…and diabetes.
What you might not realize is that these measures aren’t very effective at predicting who will have a heart attack. More than half of cardiovascular “events,” including heart attacks, occur in patients who would not be considered at high risk based on the usual risk factors. Another shortcoming is that these factors address only one particular type of heart disease (due to atherosclerosis, or plaque buildup in the arteries) even though there are other, equally serious heart threats.
A better approach: A simple, relatively inexpensive panel of tests that can identify your risk for a broader range of heart issues, including death from heart disease, as well as heart attack, stroke, heart failure (an inability of the heart to pump blood efficiently) and atrial fibrillation, or AF (an irregular heartbeat that increases risk not only for heart-related death but also for stroke). The panel of tests can even estimate future risks in patients with none of the usual risk factors.
Why it works: Each of the tests detects abnormal processes that affect the heart. But their real strength lies in their collective value. When the tests are combined, they provide an accurate assessment of your risk of developing heart disease within the next 10 years. These tests improve upon the performance of the Heart Disease Risk Calculator, CVRiskCalculator.com, created by the American College of Cardiology and the American Heart Association. (If you know your blood pressure and cholesterol numbers, you can do this online test yourself.)
If you worry about heart disease (or already have it), you’ve probably been told to keep your cholesterol down, stop smoking, manage your blood pressure, etc. It’s good advice for everyone, but the benefits mainly involve atherosclerotic cardiovascular disease.
Many people have taken this advice, which is why the prevalence of clot-related heart attacks (as well as stroke) has declined in recent years. But there’s been an increase in the rates of heart failure and AF, conditions that are time-consuming and expensive to treat—and are often fatal. The traditional cardiovascular risk factors don’t affect your odds of getting AF or heart failure.
The five-test panel can give a better view of cardiovascular risks than the currently used methods. It’s particularly useful for people who appear to be in good health and don’t have any of the usual risk factors—but who want to ensure that their hearts stay as healthy as possible.
Each of the five tests below reflects a different aspect of heart health. Used individually, the tests are only modestly useful. Their real predictive strength is additive. You might want to do a baseline battery of these tests in your mid-40s and then again on a schedule your doctor suggests. The five heart tests to have…
• A 12-lead EKG. An electrocardiogram (EKG) measures voltage (the electrical activity created by each heartbeat) using electrodes placed on the chest. Someone with an abnormally enlarged heart will show high voltage. An enlarged heart isn’t always dangerous—it often occurs in highly trained athletes in excellent health. But in average adults, an enlarged heart can increase the risk for heart failure, blood clots and cardiac arrest. It can also indicate if someone has had a silent heart attack (one that occurs without noticeable symptoms).
• Coronary calcium scan. This low-radiation CT scan looks for calcium deposits in the arteries—a sign of cholesterol plaque buildup and future heart risk.
• C-reactive protein (CRP) blood test. Elevated CRP (above 3 mg/L) indicates inflammation in your body and can be a marker for increased risk for coronary artery disease.
• NT-proBNP blood test. BNP (B-type natriuretic peptide) is a hormone produced by the heart. It’s a protective hormone, so levels rise when the heart is under stress. Levels higher than 100 pg/mL indicate that there might be stress or strain within the chambers of the heart—a sign that heart failure is developing or getting worse.
• High-sensitivity troponin T blood test. Troponin T is a protein that’s released when the heart muscle is damaged. Hospitals test for it to diagnose heart attacks. The newer, higher-sensitivity test can detect the smallest amounts of damage to the heart muscle caused by high blood pressure, infection or even a heart attack that’s so minor that a patient never experiences symptoms.
With the exception of the high-sensitivity troponin T test (which only recently received FDA approval), none of these tests are new. Cardiologists have used them individually for years. But they’ve only recently been tested together as a tool for predicting cardiovascular risks.
Important recent finding: Researchers looked at nearly 9,000 participants from the Dallas Heart Study and the Multi-Ethnic Study of Atherosclerosis for a study that appeared earlier this year in the journal Circulation. The participants, who were followed for more than 10 years, were screened to be sure they had no cardiovascular disease, and all were given the five-test panel at the beginning of the study.
Results: Patients with one abnormal test result (approximately 30%) were about three to four times more likely to be diagnosed with one of the heart conditions described earlier. The risk was sixfold higher in those with two abnormal tests…12 times higher in those with three abnormal tests…and more than 20 times higher in the 5% with four or five abnormal tests. Even after accounting for traditional risk factors such as high blood pressure and weight, people with high scores had five to six times the risk for future heart incidents than those with scores of zero.
One out of every four deaths in the US is caused by heart disease. Coronary artery disease, commonly linked to smoking, high cholesterol and genetics, is the most prevalent form, but heart failure, AF and other cardiovascular diseases affect millions of Americans.
The five-test panel is the first approach that permits a global view of risk. Previously, there have not been good predictive strategies. Patients who are given the five tests—which will be used along with the traditional tests for cholesterol, blood pressure, etc.—will have the clearest sense of their future risks. Identifying the risk for heart failure is particularly important because this condition will eventually affect about 25% of Americans…it carries the highest cardiovascular mortality rate…and it isn’t predicted by the “standard” risk factors.
For now, we mainly recommend the panel for individuals without obvious risk factors who want to do everything possible to protect their hearts…those with a family history of heart disease…or those interested in the most accurate information about future risk, for example. If you already know you’re at risk, the extra information may not be as useful, since your doctor would recommend the same healthful strategies—weight loss, a healthier diet, lower blood pressure and cholesterol, etc.—in either case.
In the future: The panel could be used to target existing treatments and to encourage at-risk patients to make lifestyle changes. Example: The diabetes drug empagliflozin (Jardiance) can reduce heart failure by 35%, but it’s expensive. The cost could be justified for diabetics who learn that their heart-failure risk is high. Similarly, heart patients with abnormal test results might be more motivated to get serious about weight loss, fitness, healthy eating and other lifestyle changes.
The panel isn’t expensive. You can expect to pay about $50 to $100 for the calcium scan…$25 to $50 for each blood test…and $50 to $100 for an EKG. The entire panel might be offered for about $400. Insurance companies may cover the costs—but check first.