Nothing is more essential than taking care of your heart. Heart attack risk increases significantly when underlying issues go unchecked and yet many people overlook the importance of understanding their cardiovascular system until it's too late. This is where diagnostic tests that capture images of your heart should enter the picture, revealing artery-blocking plaque before it becomes problematic. Having this kind of information now empowers you to take control of your heart health while there’s plenty of time to do something about it. In fact, most heart attacks should be preventable.

Unlike countless other diseases we can think of, atherosclerosis (i.e. the build-up of plaque in the coronary arteries) takes a long time to develop. Doctors can debate the wisdom of medical or surgical measures to address it – statin drugs, stenting, in cases of advanced disease, coronary bypass surgery. But cardiac imaging tests remind us that we don’t have to let the coronary vessels deteriorate to that point. We can nip atherosclerosis in the bud – and that’s music to your heart’s ears! Here’s a topline on these types of diagnostic tests and whether they’re something you should seriously consider:

Arteries schmarteries, what’s the big deal?

The short answer is, life or (sudden) death! The health of your arteries is vital for your overall wellness and your ‘healthspan.’ They keep you functioning every nano second of the day, transporting oxygen-rich blood and nutrients throughout your body, sending hormones to your cells, carrying off waste products and the list goes on. When that internal highway gets clogged up, a world of trouble follows.

The heart of the matter

The health of your arteries directly impacts heart attack risk. Trouble is, silent issues may exist for years without noticeable symptoms and you presume all is well – until it’s too late. That’s why regular assessments should be on your to-do list, regardless of whether or not it’s on your doc’s. By knowing as much as possible about how healthy your arteries are, you can make more informed lifestyle choices and find the right team to help tailor a personalized fitness and nutrition plan. The game plan -- to help ensure you're doing everything possible to support a strong heart from here on in.

Are you all plaqued up?

Plaques, made up of fat, cholesterol, and other substances, can build up over time. This buildup narrows blood vessels and increases the risk of heart attacks or strokes. Having a window into the plaque accumulation process can be life-changing, whether that takes the form of cleaning up your diet or amping up the amount you move every day, upgrading your sleep habits or re-focusing on stress reduction. The imaging tests help you track your progress and stay motivated on your journey toward better heart health. Being knowledgeable about plaque means you're taking charge.

Kicking the tires, and looking under the hood

To get that window into your innards, specifically your arteries and heart, there are a few different ways to go, but I’ve found the two most useful diagnostic imaging tests are the Coronary Artery Calcium (CAC) score test and the Cleerly Angiogram. Both have their distinct advantages and limitations. Determining which one makes the most sense for your situation depends your personal health needs, risks, and budget. But when it’s time to discuss the options with your doctor, here’s a quick comparison to help guide your conversation:

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1) Coronary Artery Calcium (CAC) Score Test: The CAC score test measures the amount of calcified plaque in the coronary arteries using a specialized CT scan. The scan generates a calcium score that indicates the extent of calcification. With the resulting score, we can estimate the risk of coronary artery disease and the possibility of future adverse heart events.‍

• The test is quick, simple and painless, usually taking about 10-15 minutes, and is quite straightforward to perform. Non-invasive, and without the need for contrast dye, all that’s involved is your lying in a scanner for about 10 minutes while it takes X-ray images of your heart. Following the ‘photo shoot,’ the resulting score is used as an indicator of how low or high your risk is for having a heart attack in the next decade. It’s a ‘big picture’ topline versus an in-depth drill down, helpful in determining how aggressive (or not) treatment needs to be.
• For consideration: Though it’s not an especially expensive test -- typically they run $100 -$300 -- many insurances do not cover it despite its utility so you’ll likely be out-of-pocket. Also, compared to other options, this type of scan doesn’t provide highly detailed 3D images of the arteries, or information on non-calcified plaques, nor does it assess the impact of plaque on blood flow – so it may not be detailed enough for certain types of patients, especially those with multiple cardiac risk factors. 

2) Cleerly Angiogram: A more in-depth way to see what’s going on in your arteries is ‘coronary computed tomography angiography.’ CCTA is a noninvasive 3D imaging test that lets us to look at images from inside the body, enabling your docs to identify plaque and blockages or narrowing (stenosis) of the coronary arteries. One highly regarded leader in the field is the Cleerly angiogram which uses advanced artificial intelligence (AI) and machine learning to analyze images of the heart and arteries.

• With the Cleerly angiogram, contrast dye is typically injected into a vein in the arm, multiple X-ray images are taken and assembled into a detailed internal ‘picture.’ From there, cutting-edge software analyzes the images to determine the types of plaque that may be present, i.e., calcified, non-calcified, or mixed, as well as its location(s), and the overall extent of coronary artery disease (CAD). With this highly detailed view, the risk for heart attack can be more fully assessed, guiding treatment decisions with greater specificity.
• For consideration: The injection of contrast dye may not be recommended for those with kidney issues or allergies to contrast material. Exposure to ionizing radiation, considerably more than with the CAC test, is something you and your doctor may want to take into account as well. It’s also more expensive and less widely available than CAC scoring. 

And the winner is....

Both tests – and ultimately you. They’re both excellent tests but what matters most is which one will best identify what you and your healthcare provider need to know in order to determine the way forward. When you put them side-by-side, here’s how they shake out:

• When it comes to diagnostic detail, the Cleerly angiogram wins by far, as it provides the most detailed and comprehensive assessment of coronary artery disease, including the type and extent of plaques and their potential impact on blood flow. The typical CAC score, however, measures just the calcified plaques, not the soft plaques which are the more dangerous kind because they’re less stable and more prone to rupture. Because of this, the CAC is often thought of as more of a risk assessment tool, which depending on your particular circumstance, may be enough. By contrast, the Cleerly angiogram can flag specific danger spots, for instance, identifying if you’ve got a lot of invisible soft plaque in play that isn’t showing up on a CAC, not unlike being able to find the iceberg ice under the water line.
• The CAC score is less invasive and requires no contrast dye, making it suitable for a broader range of patients, including those with kidney issues. Think of this one as the cheap and cheerful topline option.
• The CAC score test also wins on the affordability and accessibility scale, making it a good choice for initial risk assessment. Though the high-tech Cleerly Angiogram is more advanced and detailed, it can be more difficult to access and considerably more costly – think upwards of $1,500 – and may only be partially covered by insurance, or not at all.
• The CAC score is often used for initial screening and risk stratification in asymptomatic patients. Some doctors may say to a middle-aged person, hey why not?, we might learn something. But my sense is, most would want to look for some evidence of elevated cardiac risk – high Apolipoprotein B (ApoB), a not great Apo B/Apo A ratio (a higher ratio indicates a higher CV risk), high triglycerides, high HbA1C, possibly a lot of visceral or abdominal fat -- before recommending it.
• The Cleerly Angiogram may be more suitable for symptomatic patients or those needing a more detailed evaluation for treatment planning.

Raising happy, healthy arteries

To help tame your heart attack risk, start with a few basic steps – you know, the ones you should already be doing, but may backslide on a bit from time to time. Well, now’s a good time to get back into the groove (test or no test!). Every proactive step you take helps so don’t underestimate the power of small changes when it comes to keeping your arteries as clear as possible and reducing the chances of a heart attack. Here are a few musts to get you started, or restarted on the artery-health path:

1. Start by adopting a well-balanced Mediterranean style diet with a good amount of proteins from healthy sources, plenty of non-starchy veggies and some low sugar fruits.
2. Also include foods high in omega-3 fatty acids, like sardines and mackerel, nuts like walnuts and almonds and other healthy fats – all of which are particularly beneficial for cardiovascular health.
3. Movement, and lots of it, every day, throughout the day. Shoot for about 150 weekly minutes of movement that includes aerobic activity, plus strength training and your arteries will rest easy. All that movement will not only help make you stronger but also make it easier for you to maintain a healthy weight and lower blood pressure to boot.
4. If your heart could talk it would tell you in no uncertain terms: manage your stress bro! To do that, look to practices like yoga and meditation to quickly (and even pleasurably!) take the edge off stress levels and upgrade overall well-being.
5. Pay attention to sleep. Poor sleep or irregular sleep patterns can increase the risk of plaque buildup in your arteries
6. Monitor and manage your blood pressure. High blood pressure can damage artery walls over time, which can lead to plaque buildup.
7. Get a diagnostic cardiac imaging test to learn more about where your heart health stands, and from there, check in with your doc on the regular to monitor your heart’s condition, for instance, your cholesterol levels and blood pressure, all of which are good yardsticks to help steer you toward potentially life-saving lifestyle changes you can make now, before bigger issues arise.