There is a lot we can do to help minimize the chance of having a cardiac event
By Jake Barnes
When we take the oath to become firefighters, we accept the fact that we may get injured or killed doing the job we love. That aspect is seen by the general public as noble and heroic. I believe the public is right; we ARE noble and we ARE heroic. And it’s our duty to put our lives on the line. With that said, some injuries and line of duty deaths may be avoidable.
For the last ten years, data shows that a majority of line of duty deaths are cardiac related. We have, as a group, started to realize that we have some control over whether that will happen to us or not. We can exercise and eat better. We can get regular checkups with our doctors. And we become better partners with those doctors by letting them know what they can look for based on the known health risks related to our career. Recently, these concerns about cardiac care and advocating for my own health lead me to discover a heart test that is not only helpful, but is also cheap and doesn’t require insurance to have it done.
At my regular physical with my doctor, I came armed as usual with information that is relevant and specific to my career. This time, it was a simple question: “Why can’t we know how clogged our cardiac arteries are until after we have had a heart attack?” To my surprise, my doctor informed me that there IS a way to know that, and she seemed surprised I wasn’t already familiar with it.
The Coronary Calcium Scoring Detection test, she explained, is a CT scan specifically of the heart which can detect calcium which can translate into plaque. The presence of plaque may indicate buildup in the arteries, which can lead to cardiac events. Depending on the hospital, the local cost was only $50 to $120 dollars. I was dumfounded that this test existed and I didn’t even know about it.
Even more surprising was how simple it actually was to have the procedure done. I made my appointment at a local hospital that had an imaging office near me. I went in at the appointed time and paid my $50 and waited for a few minutes before being called back. The tech explained the procedure and had me lie on the CT table. I didn’t have to put on a hospital gown or even take off my boots. I just laid on the table and as the X-ray machine did its thing. After ten minutes, the tech came out with the images and explained what my score was immediately. I was in and out in under 30 minutes, fortunately with good news.
I left that imaging office very happy that I had more information about my heart but also very confused about why I had never heard of this simple procedure before. The next day, I went to work and asked every firefighter I came in contact with if they had heard of this test. Nobody had. Zero. Even those with cardiac conditions.
I decided to spread the word to neighboring departments and I have gotten several stories back from several firefighters who told me they found some blockage and were making appointments with a cardiologist to deal with it. In talking to more and more firefighters, it became increasingly obvious that I had stumbled across an unfortunately well-kept secret, one that could save lives. In my desire to get the word out to as many people as possible, reached out to a cardiologist in my area, Dr. Michael Flaherty, and asked him a few questions to help us all understand a little better.
Dr. Michael Flaherty was born in Franklin Indiana. He received his B.A. in Biology and Chemistry at Franklin College and a Master’s degree in Molecular Biology at Purdue University. He then went on to receive his M.D. and his Ph.D. in Physiology & Biophysics at the University of Louisville School of Medicine. He did his residency in Internal Medicine at Boston University School of Medicine and his Cardiology Fellowship back at the University of Louisville School of Medicine. He then went on to do his Interventional Cardiology Fellowship at Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Flaherty is board-certified in Internal Medicine, Cardiology and Interventional Cardiology. He is an expert in cardiology in the fields of complex high-risk non-surgical coronary artery revascularization (coronary artery stenting) and in the treatment of adult structural heart diseases. To say Dr. Flaherty has a passion for heart health might be an understatement.
Coronary Artery Disease can play a large role in a cardiac event, such as an MI. What are the basics of CAD that we need to understand?
“Coronary artery disease (CAD), obstructive plaque build-up in the coronary arteries (the fuel lines to the heart), can lead to chest pain (a.k.a. angina) and/or heart attack and/or sudden cardiac death. Risk factor determination followed by risk factor modification is essential to preventing CAD. There are several risk factors for CAD development but five primary health issues contribute significantly to the development of coronary artery disease: 1) family history of premature CAD in either one’s mother (CAD at < 65 years) or father (CAD < 55 years) is a strong predictor of CAD development; 2) diabetes; 3) smoking (anything); 4) hypertension or high untreated blood pressure; and 5) abnormal cholesterol = high LDL (bad cholesterol) and low HDL (good cholesterol) with high triglycerides (circulating fats). Early detection and treatment are possible to prevent progression.”
Although there are some risk factors we can’t change, there is still a lot we can do to help minimize the chance of having a cardiac event. This is where the coronary calcium scoring test (CCS) test comes into play.
So many of my brother and sister firefighters have not heard of the Calcium Scoring/Screening Test. Can you explain what it is?
“In general, direct imaging of coronary plaque can be done with coronary calcium scoring/detection (CCS). This is an established means for CAD risk stratification that has been utilized primarily for asymptomatic patients who have risk factors for CAD. Alternatively, CCS may be used as an adjunct stress-testing. Individuals such as firefighters are often well-conditioned and ostensibly could “fool” a standard screening treadmill stress test. Therefore, the addition of CCS as a screening modality bolsters the accuracy of other screening tools and better stratifies the risk of CAD in this population. Specifically, CCS utilizes an x-ray machine called a computed tomography (CT) scanner that samples multiple thin sections of the heart in minutes. These scans reveal specks of calcium in the walls of the heart’s arteries called calcifications; which may be an early sign of CAD.”
Having talked to other doctors about this besides Dr. Flaherty, I have come to realize that this test is only another piece of the puzzle and not a definitive test. If you get a score that is considered a bad score then other protocols would be followed depending on you and your doctor. For example, my doctor said if I got a score that showed significant plaque then she would send me to get a stress test to see how my heart is perfusing. If that test showed poor perfusion then my cardiologist would decide the next step. The important thing is being proactive in your heart health. Your doctor would work together with you to decide if any other tests would need to be done.
Dr. Flaherty, how accurate is the CCS?
“The test is used to quantify the amount of coronary calcium present by CT imaging and uses a validated scoring system based on that quantification to determine the overall risk of developing severe coronary artery disease over time. The larger the amount of plaque in the artery wall, and the greater the risk of a heart attack. If one has a “score” of ≥400, the risk of having a plaque in the coronary arteries (the fuel lines to the heart) that is significantly blocking or obstructing flow to the heart is >90%. Conversely, with a “score” of less than 100, the likelihood of having an obstructive plaque in the coronary arteries is <10-13% (i.e., a negative predictive value of 87%).”
In my case, I was in and out very quickly and the technician came out after the test and showed me my results. It was nice not having to wait for days wondering what my score is.
I understand that the CCS is just one piece of the proactive puzzle. What are some other things we, as firefighters, can do to ensure better cardio health?
“One can only affect modifiable risk factors for the development of CAD, namely smoking, cholesterol management, blood pressure, and yes diabetes. 30 min of exercise that results in a sustained increase in your heart rate to 55-85% of the predicted maximum heart rate by age (i.e., 220 – age) is effective in cardiovascular and aerobic conditioning. Exercise, as described above, should be done a minimum of 3 times per week.”
In other words, the Coronary Calcium Scoring Detection test is a great tool for our proactive cardio toolbox. It is important to note that the test and results are not definitive by any means. It is merely a great way to get ahead of the game. Take the test, show your doctor the results, and go from there with their recommendations. A bad CCS score doesn’t mean a heart cath is next, it just means some more detective work may need to be done. Dr. Flaherty suggests a CCS test every two years depending on the index score. The test along with healthy eating and exercise can put the odds in our favor. We should look at our heart health like we do the first cup of firehouse coffee in the morning, an absolute must!
Jake Barnes is the battalion chief of training for the New Albany (IN) Fire Department. A 25-year veteran of the fire service, he began his career as a USAF firefighter and was a firefighter with the Lexington (KY) Fire Department. He has an associate degree in general studies and a bachelor’s degree in fire protection from Eastern Kentucky University.