How prevalent is cardiovascular disease in patients with diabetes?
Almost 1 out of 5 patients with diabetes has cardiovascular disease
What are the mechanisms that lead to cardiovascular disease?
Patients with diabetes often have pro-inflammatory state and other risk factors such as hypertension, dyslipidemia, obesity, history of smoking which all contribute to accelerated atherosclerosis. The duration of diabetes and glycemia control also play an important role.
Can you screen and detect early subclinical cardiovascular disease?
A simple way to detect early cardiovascular disease in asymptomatic patients is performing a CT coronary calcium score.
What is coronary calcium score?
Cholesterol that circulates in the blood can deposit in the coronary arteries, causing an inflammatory state. With time, as the body tries to heal, the areas where cholesterol has deposited become calcified.
When does cholesterol start depositing in the coronary arteries?
The process of atherosclerosis and plaque formation starts very early in life, slowly, starting as young as 20 years!
When does coronary artery calcification start?
It is rare to have coronary calcification before the age of 40. Coronary calcification, however, is not normal and consider pathologic, especially if detected early in life.
Can coronary calcification develop even in someone with normal or low cholesterol?
Yes. Someone might have normal or low cholesterol levels, but can still have significant coronary calcification. One reason is that the bad-cholesterol (LDL) particles can have different sizes; the smaller they are, the more likely they are to “stick” to blood vessels and cause inflammation.
What does it mean to have coronary calcification?
It means that you already have coronary artery disease.
Why is that important?
If you have coronary artery calcification, you have a higher predisposition of having heart attacks or suffering from heart disease. The higher the degree of calcification, the worse things are. On the other hand, if you do not have any calcification, the chance of having future heart attacks or suffering from heart disease is extremely low even if you are diabetic.
Are diabetic patients equivalent to patients with established coronary artery disease?
Not anymore. Patients with diabetes can have very low event rate if their calcium score is zero or very low. This can be accomplished with early detection, adequate diabetes control and new medications.
How can you detect coronary calcification?
The best way is to do a gated CT scan of the heart. It takes less than one minute to be performed and does not require any contrast or injection. On CT, any calcification will look white/bright and can be easily detected. A special software quantifies the total amount on the arteries.
Can we treat coronary calcification?
Unfortunately, there is no magic pill that can dissolve the coronary calcification completely. Vitamin K2 has shown in small studies to have some positive effects. However, if there is coronary calcification, you should start a particular cholesterol lowering medication to stabilize these plaques, prevent progression, and help dissolve cholesterol plaques that have not calcified yet. Also, once detected, your doctor needs to address other factors that could lead to their progression.
Can someone have coronary artery narrowing if the calcium score is zero?
Yes. While the probability of this is low, some plaques might not have calcified yet. You would need to give intravenous contrast while imaging the arteries to detect these non-calcified plaque.
Who should get CT calcium score?
Patients above the age of 40 who have at least one risk factor might benefit from this screening test. Diabetes is considered a risk factor. If you are diabetic above the age of 40, you should consult with your doctor and consider doing CT calcium score.
How do you score it?
Calcium score 0 (very low risk, no calcification); score 1-100 (low risk); 101-399 (intermediate risk); and score ≥400 (high risk). However, it also depends on the age and gender.
My calcium score was greater than 400 but I feel fine, now what?
If the calcium score is greater than 400, there is a high chance of having significant blockages in the artery. The guidelines recommend either stress test with imaging or coronary angiogram. You need to see a cardiologist.
I am having some chest pain, and my calcium score is zero. Now what?
Calcium score should be done for asymptomatic patients for screening and not if you are having chest pain. You could have a non-calcified plaque causing obstruction and chest pain; your calcium score would be zero (while this is rare but can happen and should not be missed). In such situation, the correct test to do is CT cardiac with contrast, stress test or coronary angiogram depending on the case.
