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From The Desk Of Clarence Bass

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I wish we knew why some people develop calcification in the arteries in spite of a wonderful lifestyle like you have, or why some people can completely ignore lifestyle and have a zero calcium score," Dr. Arnie Jensen wrote. "I suspect that you are a Ďhot responder,í" he told me. "I am too; I try to control it."

Coronary Calcium Score and Stress Management (Update below)

I learn more about myself Ė and preventive medicine Ė every time I go to the Cooper Clinic. For example, my aerobic fitness level was measured on the treadmill for the first time at the Cooper Clinic; see "Fit at 50." I first heard about homocysteine there; see article # 17. They measured my inflammation level; see article # 95. The Cooper Clinic also taught me about "calcium scores."

For many years, itís been known that calcification in the coronary arteries is a marker of coronary artery disease. It often occurs early in the disease process before symptoms occur and can be an early warning. Discovery could save your life.

Atherosclerotic plaque, composed of cholesterol, lipids and cellular debris, which forms in the walls of the arteries, often at the site of an injury, gradually becomes calcified. Soft plaque doesnít show up on X-ray, but can be detected and tracked by monitoring calcium formation.

The relationship between soft plaque and calcified plaque isnít direct, but calcification implies narrowing of the artery, without proving it. A large amount of calcium can be present without significantly blocking blood flow; the calcium is often in the wall rather than the channel of the artery and vessels can remodel themselves to bypass the calcified plaque. Still, calcium is an important risk factor. While calcified plaque is generally stable Ė soft plaque is more dangerous Ė it can rupture causing a coronary thrombosis or blood clot that blocks the artery.

Electron-beam computed tomography (EBCT) now makes it possible to measure calcium formation with great accuracy. EBCT is ultra fast, 10 times faster than the standard CT scan, taking pictures at sub-second intervals producing the imaging effect of virtually stopping the heart. With the help of highly sophisticated software, the result is a calcium score which allows physicians to monitor the arteriosclerotic process as well as the response to lifestyle change or drug therapy.

Once the likelihood of disease is established through calcium testing, more powerful imaging tools are necessary to determine the extent and location of coronary artery stenosis (narrowing). Thallium stress testing is one of the most effective non-invasive techniques (more on that later). The gold standard for accurately assessing artery disease is angiography or cardiac catheterization, where a thin plastic tube is threaded into the heart to clarify the extent of blockage.

Go figure

During my last visit to the Cooper Clinic, EBCT detected enough calcium in my left anterior descending (LAD) artery to warrant a thallium stress test to determine if there is any narrowing or damage to the heart.

This was surprising, because my lipid profile is good. "Your total cholesterol of 159 and LDL cholesterol of 78 are perfect," Dr. Arno Jensen wrote in his report. "Your HDL cholesterol is wonderful at 65," he added. "This gives you an excellent ratio of 2.4. My triglycerides, homocysteine and inflammation level are also good. My weight is ideal, my fitness level is quite good, and I donít smoke.

The thallium test is basically an expanded exercise stress test. Like the treadmill test Iíve had many times before, they monitor your blood pressure and ECG pattern while running you to exhaustion. The idea is see if your heart functions properly or if you develop chest pain or other symptoms as the exercise becomes harder. The difference is they insert an IV in your arm before the test starts and then inject a small amount of thallium (a metallic element which shows up on X-ray) into your arteries during the last minute when your heart is under maximum stress. Immediately after the test an X-ray scan is taken and compared with another scan taken while the heart is at rest. The test reveals if there are areas deprived of oxygen due to reduced blood flow. By comparing the images the doctors can pinpoint potential sites of coronary artery blockage.

"Itís all good," Dr. Pippin, the cardiologist, said, reassuringly, as he called me in to view the results on the computer monitor. Pippin said the images "do not indicate obstructive coronary artery disease or left ventricular dysfunction." Dr. Jensen called my thallium test "perfect."

Thatís a relief, of course, but it doesnít mean thereís no concern about the calcium building up in my heart. Obviously, something bad may be going on and we want it to stop. [For results of follow-up testing 27 months later, see Update below.] As explained above, a high calcium score means there is a greater risk. Itís not a sure thing, however. Dr. Jensen tells me that people with zero calcium often have heart attacks and those with scores far higher than mine sometimes do fine. Because I have few other risk factors, my coronary risk profile is still low.

Dr. Pippin observed that my blood pressure was somewhat elevated (153/84 right arm and 148/84 left) before the stress test. This seemed to be a concern, but I didnít understand why. Iíve been there before and knew what was coming: maximum effort, discomfort Ė and exhaustion.

He recommended that I monitor my blood pressure at home. As he suggested, we bought an Omron Automatic Blood Pressure Monitor. It works great: Put the cuff on your arm, push the button and presto, your BP appears in no time flat. Thereís even a print-out that graphs the results and shows the readings with an average. Itís pretty neat, actually.

I took my BP several times a day, under various circumstances, over several weeks. Itís fine. My average reading was 111/65, which is ideal. Apparently, hypertension or continuously elevated resting BP is not my problem.

My blood pressure response before the exercise stress test may provide a clue, however. In his report, Arnie called it a "slight adrenal response." Like me, Jensen is a competitive person and gets psyched up before the treadmill test. "I do the same," he wrote.

Arnie suspects that I am a "hot responder," a person who tends to overreact to trivial events. I believe heís on to something. Iíve always had "white coat" hypertension. Itís also called an "alerting response" and means the temporary elevation in blood pressure at the time of measurement in a doctorís office.

I vividly remember, right after graduating from college, that my BP was sky high when taken during my draft board physical. The examining physician made me go in the back and lie down for a while before taking it again. A boyhood friend of mine was there for the same physical. Iím sure he wasnít any happier about the prospect of being drafted than I was, but his BP was fine. I immediately went to my fatherís medical office and had my pressure taken again. It was perfect, 120 over 80. I realized then that the my blood pressure response was at times "over the top." But I never knew it might be a problem. My father was definitely a hot reactor. I believe my sister is as well.

White coat hypertension potentially harmful

The impact of stress on health has been known for centuries, but until recently physicians have not been willing to give it a high priority. Thatís probably because stress is hard to measure and people react differently. "For one [person], the event is upsetting and stressful," Joseph C. Piscatella and Barry A. Franklin, Ph.D., write in their excellent book, Take A Load Off Your Heart (Workman Publishing, 2003); "for the other, it is viewed as a new challenge."

According to Piscatella, who had bypass surgery in 1977 and now lectures widely on lifestyle management to physicians and health professionals, and Dr. Franklin, director of the Cardiac Rehabilitation Program and Exercise Laboratories at William Beaumont Hospital, Royal Oak, Michigan, and a professor of exercise science and family medicine at several universities, scientists and physicians long took a "show me" attitude on the idea that stress could make you sick. That view is changing.

Piscatella and Franklin say the negative role of stress is now undisputed. "Researchers estimate that mental stress has either caused or aggravated the symptoms of 50% to 90% of all hospital patients in the United States," they write. "Indeed, stress may be the single greatest contributor to illness in the industrial world."

A bold and broad statement, indeed, and perhaps a bit of an exaggeration, but it appears clear that stress can have a devastating effect.

White coat hypertension, which I demonstrated decades ago during my draft board physical and, recently, before my exercise stress test, has been largely viewed as benign. Iíve never thought of it as a problem, but Iím beginning to wonder.

Dr. I. Michael Prisant, a cardiologist and hypertension specialist at the Medical College of Georgia, says thereís now evidence that someone with white coat hypertension, which he defines as "a persistent raised blood pressure in the doctorís office with a normal ambulatory blood pressure," may react similarly to minor everyday stresses Ė and eventually develop sustained hypertension. That probably explains Dr. Pippinís concerned about my elevated blood pressure before the thallium stress test.

The fact that my father was a hot reactor and developed high blood pressure late in life suggests that I may be predisposed to develop it as well. Piscatella and Franklin say researchers studied young men (18 to 22) who had at least one parent with high blood pressure and a high response to stress themselves. "Ten years later, this group had three times the risk of hypertension, compared with people who had a low response to stress." Happily, the researchers also reported that 10 weeks of stress management training significantly lowered their blood pressure.

The juryís still out on the dangers of white coat hypertension, says Dr. Prisant, and thereís no concrete evidence that drug therapy is indicated for "hot responders." He recommends lifestyle changes to ward off the possibility of damage to the heart and circulatory system.

Home monitoring convinces me that I havenít developed sustained high blood pressure; my exercise habits and excellent diet have probably protected me thus far. I am concerned about developing problems in the future, however. Like Dr. Jensen, Iím motivated to cool my response. Hopefully, this will ward off high blood pressure Ė and perhaps slow or stop the formation of calcium in my coronary arteries as well. [See Update below.]

Maintain a calm mind

Stress is a fact of modern life. It will always be with us. That canít be changed. What we can do is modulate our reaction. We can cool our jets, so to speak. Thatís what Iím trying to do, with some success. My wife says Iím a changed man since coming back from the Cooper Clinic. Realizing that my tendency to overreact could shorten my life has made a big difference. Iím not exactly Caspar Milquetoast, but Iím a lot calmer than before I realized the danger, especially to someone with my family history.

"Stress can have a terrible impact on the heart," Piscatella and Franklin write. Not only does it elevate your blood pressure, according to these authors, it increases cholesterol and homocysteine, constricts arteries, promotes arterial inflammation and increases blood clotting. Thatís enough to get anyoneís attention.

"The secret is not to avoid stress, but to manage it," say the authors of Take A Load Off Your Heart. "The first step is to make a decision to take control, to decide to manage your stress rather have it manage you." Thatís what I did.

Every time I go to the Cooper Clinic, Dr. Jensen asks me about the stress in my life. How much stress do I feel? I always give the same answer: slight to moderate, the normal everyday stresses that everybody experiences. Frankly, I donít consider my life very stressful. I enjoy life. I love my wife and son. I love what I do. Whatís to be stressed about?

My problem is a tendency to overreact to things or events that are controllable or really donít matter much. I simply decided to stop overreacting. It wasnít difficult once I made up my mind to do it. I catch myself when I start to raise my voice, and tell myself to calm down. I take a deep breath. I take a walk. It works.

I did simple things, such as leave the house a few minutes earlier for appointments. I turn off the TV when the sensationalism and negativity start to get to me. I stopped worrying about the stock market; I make the necessary adjustments in my portfolio and go on with my life.

The biggest stress in my life recently has been learning about my calcium score. Thatís a serious concern. I decided to stop worrying and do something about it.

As already mentioned, I took Dr. Pippinís suggestion: Carol and I purchased an automatic blood pressure monitor at Wal-Mart. After a few weeks of taking my blood pressure over the course of the day, it was clear that I donít have sustained hypertension. That was a relief. It made me feel better, less stressed.

I asked my regular doctor, a family friend, to recommend a good local cardiologist and send him Dr Jensenís report and the reports of my calcium score and thallium stress test. I made an appointment and went to see the cardiologist. I found him to be very nice man with a great bedside manner. His interest seemed to grow as he learned more about my background. I liked him a lot. After reviewing my test results and examining me, he told me to keep eating and exercising as I have been, and to work on maintaining a calm mind. Do that, he said, keep my cholesterol low, as it is now, and continue my annual medical evaluations, and my odds of having a heart attack are very low. That was reassuring. My stress level dropped a few more notches.

Finally, I did some research and learned all I could about my condition and wrote this article to share my newfound knowledge. That gave me a sense of control and made me feel more relaxed. Knowledge is power, they say. Itís true. Writing this article was stress management of the first order. [See follow-up report below.]

For those interested in learning more about calcium scores, stress management and all aspects of maintaining a healthy heart, I heartily (pun intended) recommend Take A Load Off Your Heart by Joseph C. Piscatella and Dr. Barry Franklin. For a fascinating look at the role of "hidden" stress in high blood pressure, read Healing Hypertension by Samuel J. Mann, M.D. Youíll find both books at your local bookstore or on Amazon.com.


UPDATE: Reversal of Cardiovascular Disease Likely 

I returned to the Cooper Clinic for follow-up testing 27 months later (April 2005). The results were not conclusive, but they were very encouraging. 

My lipid profile is still excellent (total cholesterol 155, LDL 81, HDL 62, triglycerides 62). My weight is still ideal, and my fitness level is even better than before (two minutes longer on bicycle stress test). A repeat thallium test showed that my heart function is still completely normal; blood is getting to all areas of my heart, under maximum stress and when relaxed. Regarding my exercise thallium test results, Cooper Clinic cardiologist Nina Radford wrote: "Although you have evidence of atherosclerosis in your heart arteries, it is very unlikely to be in the form of any significant blockage that are obstructing blood flow to the heart muscle."

Nevertheless, a repeat EBT scan showed that my coronary calcification is progressing at a "low 16%" annual rate. Fortunately, that may be better than it sounds, when taken with the improvement shown in my carotid arteries (the big arteries on each side of the neck which supply blood to the neck, head and brain).

Although not discussed above, carotid sonography (ultrasound) during the earlier exam showed mild to moderate plaque formation in my left carotid artery, with an estimated stenosis (narrowing) of 42%. Retesting during the latest exam showed that the stenosis is now 37%, an improvement of approximately 12%.

Dr. Lynn McFarlin, who took over my care from Dr. Jensen (see article 128), and Dr. Radford, who supervised my latest thallium stress test, tell me that the increase in my coronary calcium score in combination with reversal of the narrowing in my left carotid suggest overall improvement in the condition of my arteries; at this stage, however, they can't be sure. Dr. Radford's told me that the increased calcium score may be a "finishing out of the process," while the reversal of the stenosis in my left carotid suggests (but does not prove) a reduction of the soft plaque in my arteries. More precisely, the increased calcium may be hardening of soft plaque that was already present at the time of the earlier test, and the improvement in my left carotid may indicate that plaque formation has stopped or even reversed. Significantly, there are no new lesions or areas of calcification.

Stress management, weight control, monitoring blood pressure (as low as 104/56 after exercise), exercise (weights and aerobics) and maintaining an ideal lipid profile seem to be working. To be sure, Dr. McFarlin recommends that I lower my  LDL-cholesterol to 70 or less; the previous goal was <80. To help me achieve this goal, he prescribed Zetia (10mg), a drug which blocks the absorption of cholesterol, along with Lipitor (10mg) which was prescribed earlier. Lipitor is a statin that reduces the production of cholesterol by the liver. 

A look back helps to explain my apparent improvement. In 1998, when calcification was first discovered in my coronary arteries, my total cholesterol was 197 and my LDL was 118 (both normal). Earlier, however, they had been as high as 237 and 139, respectively, which is now considered borderline high. 

I first lowered my LDL (and other lipids) by adding a little "good" fat to my diet (see article 18). More recently, I reduced my LDL to 61 by adding Benecol (see article 132) to the Lipitor I was already taking. As indicated above, the latest test shows that my LDL went back up to 81. 

According to the National Heart, Lung, and Blood Institute, reducing LDL may slow down or even reverse plaque buildup in the arteries. Hopefully, that's what has happened in my case. 

I'll keep doing my part. In a few years, with a bit of luck, we'll have further confirmation that it's working.

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