Let's clear up 4 common misconceptions about coronary calcium scores

My 35 years of involvement with CT heart scans that generate coronary calcium scores has provided many important lessons on how to put this measure to use. Unfortunately, many misconceptions surround this technology due to incomplete understanding. 

I therefore provide the rationale and evidence on how to make the most with this important measure. 

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Why Calcium Scoring Matters

William Davis, MD 0:00

Hi everybody, I'm Dr. William Davis. If you don't know who I am, I practiced cardiology for over 30 years. Most of it interventional cardiology, that is opening people's arteries, and then many years of preventive cardiology. And now I do other things like write books, including my best-selling books, Wheat Belly, Undoctored, and some others. Now, I want to clear up some misunderstandings in carneur calcium

How CT Heart Scanning Began

William Davis, MD 0:26

scoring. Now, my involvement with carneartic calcium scoring and CT heart scanning goes back about 35 years. So I was there a long, long time ago. In fact, I learned how to read heart scans from the doctor who actually invented the entire concept, Dr. John Rumberger, a cardiologist and also an engineer, a PhD engineer. And he did something extraordinary. He took the heart arteries of a bunch of people who had died, died of different causes, car accidents, cancer, dementia, and heart disease. And he took those arteries and examined the composition of those arteries with specific attention to the content of calcium. And he discovers something very interesting, and that is 20% of atherosclerotic plaque volume, that's the stuff that accumulates in arteries and causes heart attack. 20% of the volume of atherosclerotic plaque in the caronic arteries was occupied by calcium, regardless of your age, sex, male or female, or cause of death. 20%. So he he reasoned that calcium could therefore be used as a gauge of total atherosclerotic plaque. So this being 35 years ago, I learned how to interpret scans from Dr. John Romberger. I also spent some time with the inventor of the device that was then became the first device to be able to quantify calcium in living people, not in autopsies. That was Dr. Douglas Boyd. He invented what's called electron beam tomography. That was an excellent, very interesting technology. It was super fast. That was the challenge in imaging the heart. The heart is always in motion, has multiple phases of motion, not to mention respiratory motion from breathing, and human motion, because we all fidget, right? And so he invented a device that could obtain cross-sectional images of the very small arteries in the heart. They're only about two to four millimeters in diameter and they're moving. So you need a very rapid imaging device to get confident images. And this electron beam device, because the X-ray beams were focused by magnets, not by physical motion of the device or of the table the patient is lying on, it only required a tenth of a second, 0.1 seconds for each image. It was the first time you could image the coronary arteries accurately, as well as in infants and anybody who couldn't sit still. So that was now that was a great technology, but there was a competitive technology called multidetector CT. And those are big companies, much bigger than the inventor and his small company in South San Francisco. And one of these big companies did not like that they had this competing, excellent technology, so they bought the company and patents, the intellectual property, and then shut it all down. That paved the road for the evolution of what's now the device that's being used for CT heart scanning, multidetector CT imaging. It's an excellent device, it has evolved, it's gotten a lot better, time has gotten better, the amount of time it required to obtain heart images, the accuracy, the reproducibility. It is a good technology, but it came from the odd situation. So I also established the first heart scan center in uh Wisconsin, one of the first in the Midwest, at a time when this was coming almost unknown. And the concept of quantifying calcium as a gauge of carinar athosclerosis was entirely new. And it caused a lot of confusion, a lot of anger. People thought I was trying to make a monopoly of heart disease. Of course, that's ridiculous. The reason I did it, by the way, I got involved, was because my mother, who lived in New Jersey at the time, I was I had just moved to Milwaukee, Wisconsin. They had brought me in to teach some of the docs the new technologies. So it's not new now, but 35 years ago. Uh, not just angioplasty, but stent implantation, laser uh angioplasty, different forms of atherectomia, that's device to drill out arteries, those kinds of things.

The Personal Story Behind The Work

William Davis, MD 4:28

So I was brought to into this, into Wisconsin, but my mom, who lived in New Jersey where I grew up, had a two-vessel carnero angioplasty at a New Jersey hospital. Four months later, she died, sudden cardiac death in her bed, uh died in her sleep. So it made me think, here I am opening people's arteries, aborting heart attacks, those kinds of things, and my mom dies of the disease that I was managing every day in a cath lab in the hospital. So it made me think long and hard. Was there something I could have done for my mom a month ahead of time, six months, a year, five, ten years? Well, the conventional answer would be look at cholesterol, which is a completely idiotic, silly, outdated idea. It's a whole other topic. See my numerous videos on that topic, how you can predict what's gonna happen in somebody, but it's not gonna come from cholesterol. If I said my mom's cholesterol is 240 milligrams, which is people regard that as high, does that tell you she's gonna have a heart attack and die in a month? A year? Ten years? Never? It tells you nothing. It's useless. So, what was the device, what was the method that was available 35 years

What A Calcium Score Measures

William Davis, MD 5:42

ago? And this remains largely true today, and that is a carnary calcium score. Using the methods that Dr. John Rumberger developed, a scoring method developed by Dr. Arthur Agatston, you may recognize that name. He's the guy who got famous for his South Beach diet, though a much bigger accomplishment was the development of a scoring system, and then the work of Dr. Douglas Boyd, and then other people who've refined this technology of CT heart scanning. And so I established, I helped establish the first heart scan uh imaging center in Wisconsin. And we began scanning people left and right. Now, these are people not in the emergency room, having chest pain, having a heart attack. These are people like you and me, riding your bike, going for walks, no symptoms, just going about your life, but you want to know if you have early asymptomatic heart disease. Maybe something like this. Maybe your mom had a heart attack at age 64, and you're 52. You want to know if that's in your future too. So you have a CT heart scan, you get a carniar calcium score. Normal is zero, and abnormal scores can be in the hundreds, even thousands, and the higher the score, the more potential there is for rupture. We'll talk about that. Not blockage, but rupture, and thereby the potential for heart attack, sudden cardiac death, or the development of symptoms. So over the years, I helped review about 10,000 heart scans. So I had a deep understanding and a lot of experience with this. And it's great now that there are more and more of my colleagues talking about it, but I also see not having the history that I've had, they have many misunderstandings, many false impressions of what's going on, what this cardiot calcium score means. So let's address some of the very common misconceptions about cardiomyocalcium scoring. First one, a calcium score only measures hard plaque. If you've gotten to this point in the conversation, you already know that's not what it shows. It is hard itself, of course, but it's an index of total atherosclerotic plaque, just as Dr. Rumberger showed in the autopsy specimens, that calcium is a gauge, an index, a dipstick for the volume of total atherosclerotic plaque. It's kind of like checking the oil in your in your car. If you pull up the dipstick and it's maybe a centimeter down, you don't say I need a centimeter of oil, right? You may know it might mean you need a quart or whatever, a half quart of oil. You know that that little gauge tells you that you're lacking oil. Same thing here, the carnivalcium score, you're not actually concerned about the calcium. You're gonna use it as a gauge of total atherosclerotic plaque volume. So if you had two cubic millimeters of calcium, you know you have 10, right? 20% cubic millimeters of total atherosclerotic plaque volume. Now it's we're gonna convert that to a score to make it easier to use, easier to understand. But calcium score is not a measure of hard plaque, it's a gauge of total atherosclerotic plaque. Think of it like an uh like a metal pipe. If you have rust lying the interior of the pipe, uh a calcium score would be something like this. I looked at the pipe and there's 167 cubic millimeters of rust in the pipe. So it's a volume measure. Now, how high can you go? Very high, right? Because there's lots of room in that pipe. Uh, same thing here. You can get very high scores. But what you're going to get from this calcium score is an index of a volume of atherosclerotic plaque.

Blockage Myth And Plaque Rupture

William Davis, MD 9:20

Another common misconception is that a carno calcium score does not reveal blockage. That's true. In fact, that was a big debate up until about the year 2000, when numerous studies came out showing that carino calcium scores were not all that reliable in telling us whether there was a severe blockage. In other words, if you had a score of 300 or 400, which is high-ish, heart attack risk in the neighborhood 6-7% per year or so. Does that tell you you have a blockage? Well, there's about a 60 to 70% chance you have a blockage somewhere in that artery that has calcium that is enough to cause symptoms. But it became clear that's not the usefulness of a calcium score. So think of it this way: this has only been known for about 30 years. Heart attacks and related events, sudden cardiac death, et cetera, are not caused usually by the progressive accumulation of plaque that suddenly closes the arteries. In other words, you don't go from a 30% blockage, 50%, 75%, and then finally 100%. That's not how heart attacks work. That was thought for many decades, many years to be the case. That's not the case. It's clear that it doesn't take much. It could be a minor plaque that blocks no more than maybe 30% of the diameter of an artery. Not enough to block flow, not enough to pose to cause symptoms like angina, chest pain, or breathlessness, completely asymptomatic. But that 30% plaque, as many other plaques are, are very metabolically active. They have inflammation, for instance, in their walls. They can actually have hemorrhage within the plaque itself. There can be microscopic or capillary hemorrhage. And that so either hemorrhage or rupture or inflammation causes that plaque to rupture, like a little volcano. And when it spews its internal contents, when the internal contents are exposed to blood that is flowing by, it's very, if we say thrombogenic, it's very likely to cause a blood clot. And that's how a 30% blockage can go to a 100% blockage in just minutes by the provocation of formation of a blood clot. So that's so the calcium score is not a good index of percent blockage. It is an excellent index of the volume of total atherosclerotic plaque. And as you would imagine, the greater the volume lining arteries, the greater the volume of atherosclerotic plaque, the greater the likelihood of one of those plaques rupturing. That's what a caronic calcium score does. It's a predictor of caronary plaque rupture, thereby heart attack, and similar terrible events.

Why High Scores Do Not Mean Procedures

William Davis, MD 12:06

Another common misconception is that a high calcium score, say a thousand, means you need more procedures, a heart catheterization, stent implantation, bypass surgery. Now remember, these are people without symptoms, going about their business, not being limited by chest pain or breathlessness. There is no calcium score that obliges you or your doctor to go through more testing, that is a heart catheterization, et cetera. At the very most, at the very most, you might go through a stress test in some form to gauge the safety of exercise, to see if poor flow can be provoked. The most common test, or I should say the best test, would be a stress echocardiogram. It's less expensive than other forms of stress testing. You just walk a treadmill and your heart is imaged before exercise, and then just after you get off the treadmill, during exercise, you see if there are areas of poor contraction, uh, indicating poor blood flow through an artery. There's no radiation, it's relatively inexpensive, nothing's inexpensive in healthcare anymore, but it's less expensive than some of the other tests, like stress nuclear tests, those are much more expensive and they expose you to huge amounts of radiation. So a stress, a stress echocardium or even a plain old stress EKG, where there's no imaging just an EKG, that would be reasonable too. That's the most testing that should be triggered by a high cardiovasculum score in a person with no symptoms. Because it's clear if a person with no symptoms, and let's say they do a stress test and it's normal, flow is normal, but they're still because sadly cardiocasm scores and CT heart scanning are often used as tools to scare you. They say things like, well, you're a walking time bomb with that score of a thousand, or we can't be responsible for your safety if you don't have these tests. This is all ridiculous. These are all tricks, these are all lies to get you into the hospital for more very expensive testing. If you went, for instance, as an asymptomatic person with a high carnal calcium score, through, let's say, stress test and heart catheterization, and then an unnecessary, because there's no issue of uh of uh symptoms or poor blood flow, you go through, say, implantation of three stents or bypass operation. Now we're talking about tens of thousands, typically 50,000 to as much as $200,000 from something that was not necessary because the evidence is clear. These are called revascularization procedures, restoring blood flow procedures, revasculization. Revascular procedures do not provide any benefit to an asymptomatic person, especially if they have normal blood flow. Remember, the risk is plaque rupture, not progressive blockage, not progressive stenosis, we say. So a high score should not trigger, it should trigger preventive efforts, of course, but it should not trigger more and very costly procedures.

Why Statins Do Not Stop Progression

William Davis, MD 15:01

Lastly, another common misconception that comes from many of my colleagues is there's nothing you can do to stop the increase in carneury calcium scores. They say that because there have been about a half dozen or more clinical trials in which statin drugs were used. These are the cholesterol-reducing drugs, and they did not stop the progression of carniar calcium scores. So if you had a score, let's say 400, which is high ish,

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William Davis, MD 15:56

and you did nothing, which is not wise, but you did nothing, a year later your score is about 25% higher, so 500. Another year, 625. So 25%

(Cont.) Why Statins Do Not Stop Progression

William Davis, MD 16:06

per year, and as plaque accumulates, as you would imagine, there's greater risk for rupture, greater potential for rupture. And at some point, you have your heart attack or die or develop symptoms that uh cause you to go through procedures. What if you took high-dose uh statin drug, baby aspirin, beta blocker, and a hypertensive, uh, low-fat, low saturated fat diet exercise program, what my colleagues to this day continue to call optimal medical therapy. How fast will your score go up? 25% per year. We helped publish those data 25 years ago or more, a long time ago. It's been established beyond any doubt, statin drugs do not stop the relentless progression of cardiorcium scores and thereby the increase in atherosclerotic plaque volume. So, for that reason, because most of my colleagues have nothing else in their bag except statin drugs and things like baby asthma, they don't have, they don't have the tools to deal with this. So they say, uh don't don't have another scan. And they actually say this, they actually say this. Don't repeat the scan, wait for that person to have their heart attack, then deal with it. Which, of course, is horrible advice because we know you've heard this before, half of all heart attacks cause death before the person even gets to the hospital. So telling you, well, you're gonna die, don't worry about it. Take your Lipitor. That's ridiculous. There are things you can do. And now, thankfully, some of my colleagues, like Dr. Matthew Boudoff at UCLA, has done extensive, very excellent work using uh

Tools That Can Shrink Plaque

William Davis, MD 17:48

a method on the CT heart scan device called CT carne angiography. I was doing that 20 years ago, but the technology 20 years ago, not so much the technology, but the software, was inadequate to quantify volumes of what's in the arteries in three-dimensional space. Well, now that technology, now that software has advanced and they can do it. And to date, there have been five CT caronary angiographic studies that provide exquisite detail in the composition of arteries, not just calcium, but also the soft elements, that's the stuff that ruptures, fibrous elements, and other things. So they can see in exquisite detail what's in your atherosclotic plaque. And these five trials have all shown that higher doses of omega-3 fatty acids not only reduce cardiovascular events like heart attack, but they also cause regression, a reduction in the volume, especially of the softer elements, the stuff that ruptures. It also has beneficial effects on the fibrous elements. So you can actually reduce the amount of plaque with omega-3 fatty acid. Now, there's more you can do. In those trials, they didn't have the best success in stopping the progression of calcium scores. They did slow it down, they didn't stop it. And that's because they failed to incorporate vitamin D. When vitamin D is incorporated into your program, it's the first time you'll see the calcium scores because vitamin D has a major influence on calcium metabolism. And so when we added vitamin D to my programs, it's the first time we saw calcium scores plummet. A score of 700, for instance, could be 435 or something like that a year later. So vitamin D is a crucial component. Now you can go farther than they did. You can get better results than they got in those five CT carnior angiographic trials. Because we're going to do go even further. We're going to eliminate the trigger

Diet And Missing Nutrients

William Davis, MD 19:39

for the expansion or the growth of carneur atrophloctic plaque, which is small dense LDL particles. So we stop eating the trigger for that abnormality, which is wheat, grains, and sugars, not fat, not saturated fat, not butter, not olive oil, not the fat on your beef or pork. Wheat, grains, and sugars. And that's a whole other conversation, but see my other videos and other conversations elsewhere, like my blog, William DavisMD.com, thousands of conversations, as well as my books, Super Gut, Superbody, Wheat Belly, Undoctored, where I show you why this is so important. Because wheat, grains, and sugars, when ingested, cause the liver to engage in a process called liver denoval lipogenesis that causes the liver to produce V LDL particles, very low density lipoproteins, that are converted to the small dense LVL particles. So it's wheat grain and sugar elimination also has a huge and powerful effect. We also introduce nutrients lacking because of the way we conduct our lives. For instance, the water you drink, you must filter. You have no choice. Because water in a river, lake, or stream has sewage, uh, farm runoff, herbicides, pesticides. You must filter your water, right? And now microplastics as well. So when you filter your water, you remove all magnesium. So we have to supplement magnesium. We've talked about vitamin D. Most of us live indoors. We wear clothing, we go outdoors. You may live in a northern climate like I do, where it's cold or dark half a year. You can't get vitamin D. So we take vitamin D. Iodine, because most people live inland, they don't live on the ocean where all the iodine is located. And now put those four nutrients together: vitamin D, omega-3 fatty acids, magnesium, iodine, and they act synergistically to reduce insulin resistance and inflammation. That's important because that drives uh expansion and rupture of carnero aphosquartic plaque and it amps up, it amplifies liver denova lipogenesis, their production of VLDL and small dense LDL particles. Lastly, we address the microbiome because if you have coronary disease, it's virtually certain you have SIBO, small intestinal bacterial overgrowth. That

Microbiome SIBO Yogurt And Next Steps

William Davis, MD 21:53

is the invasion of the 24 feet of small intestine with fecal microbes, E. coli, citrobacter, campylobacter, salmonella, cracea, uh, pseudomonas, into the small bowel. Small bowel is not well equipped to deal with that. So trillions of fecal microbes invading the small intestine. They only live for a few hours. When they die, they shed a component of their cell walls called lipopolysaccharide endotoxin that enters the bloodstream. And that's called endotoxemia, a major trigger for both expansion of carnivore atherosloc plaque and plaque rupture. So we deal with that also. There are a number of ways to deal with it. The way I do it is to make a yogurt, it's not yogurt, yogurt-like fermented dairy product using three microbes. Three microbes chosen for their unique capacity, most microbes can't do this, chosen for their unique capacity to colonize the small intestine and colon and produce bacteriocinse. These are natural peptide antibiotics effective in killing those invading fecal species. We call them protobacteria, gram-negative protobacteria. And that reduces endotoxemia. And see my blog, see my other YouTube videos on how to make what I call SIBO yogurt. But it's just three microbes that we ferment for a prolonged period to get as many count, as high count as we can in the hundreds of billions per species. And the species are Lactobacillus rotori, lactobacillus gastri, and the most recent recipe I've changed to substitute the Bacillus coagulans with Bacillus subtlis. You can co-ferment all three, or even better, individually ferment them and then consume a quarter or a half cup per day of each. And that has so far been proven to be very effective in normalizing uh hydrogen gas measurement. That's how we detect SIBO. It's one of the options you have. You don't have to do that, but it's one of the ways to document whether you have SIBO or not. Use timing of the release of hydrogen gas with uh the air device, A-I-R-E, or formal testing in the laboratory. Now, you might say, well, do you have any formal proof of this? No. I'm still developing the funding to do that clinical trial. But now here's something to bear in mind. If I said to you that the solution for SIBO, and thereby endotoxemia as a carnival risk factor, is surgical removal of the small intestine, you need to say, well, you better have really good proof of that, right? Before anybody considers that. But what if I told you the solution is something that looks and smells like yogurt that you make in your kitchen inexpensively, and you have it with some blueberries and chia seeds. How confident do you have to be? Not very confident, right? And what if that concoction, those things, SIBO yogurt, also provides huge other benefits outside of reducing endotoxemia? So you don't have to be absolutely confident because the solution might be so accessible, so inexpensive, so benign, and so beneficial in other ways. Anyway, so I hope that clears up some of the uncertainties about cariocalcium scoring. Uh, if you post your questions below, I don't answer questions individually, but I will do in future, do a live broadcast where I select some of the questions that come up most frequently and then address them in a live broadcast.