As a journalist covering the medical field, Thomas M. Burton has written many articles about strokes, but he never considered himself to be at risk for one. After all, he didn’t smoke, worked out almost every day and ate a healthy diet. “Most doctors would have put me in the asymptomatic, or less-risky, category,” he reported in The Wall Street Journal. Actually, Burton, 68, did have an odd symptom. Five years ago, he noticed that after a long run, his right leg sometimes shook. A few months ago, this started happening frequently, and his right arm also shook after exercise.
Suspecting that the culprit might be a pinched nerve, he underwent a battery of tests. An ultrasound scan of his neck revealed that one of his carotid arteries was 99% blocked. He was told without immediate surgery to unclog the artery, he’d be at extreme risk for a major stroke. “I feel lucky to have gotten a test that may have saved my life,” he wrote in an article that has sparked confusion and controversy about the best way to screen people for hidden heart attack and stroke risk. Here are the key facts you need to know to protect your arterial wellness.
Should healthy people be screened for plaque in their neck arteries?
Eighty percent of strokes — and 70% of fatal heart attacks — occur in people who had no previous symptoms. Yet these catastrophes are potentially preventable with early detection and treatment, highlighting the potentially lifesaving value of the comprehensive, personalized evaluation the BaleDoneen Method offers. To directly check each patient for hidden signs of arterial disease, we use leading-edge lab and vascular imaging tests, include a painless, FDA-approved ultrasound exam of the neck called carotid intima-media thickness or cIMT.
The cIMT test measures the thickness of the two inner layers — called the intima and the media — of the carotid arteries, the major arteries of the neck, which carry oxygenated blood from the heart to the brain. Most importantly, cIMT can detect cholesterol plaque growing in the wall of the artery, which is also known as atherosclerosis. If plaque deposits become inflamed, they can rupture explosively, like a volcano, leading to the formation of a blood clot that causes a heart attack or a stroke. As Burton’s story highlights, even seemingly healthy people may be harboring silent, deadly plaque in their arteries.
While checking the neck may seem like a surprising way to tell if you might be headed for a stroke or heart attack, the carotid arteries, which lie near the surface of the skin on both sides of your neck, offer an easily accessible “window” into your arterial health — without any exposure to X-rays. CIMT is safe, painless, widely available and takes only 15 minutes to perform. Many studies have shown that cIMT can dramatically improve ten-year predictions of risk for heart attack and stroke, as compared with only looking at the patient’s risk factors.
Should I get the carotid duplex ultrasound scan recommended in The Wall Street Journal?
The U.S. Preventive Services Task Force — a group of public health doctors who issue evidence-based guidelines for medical providers — recommends against use of this scan, carotid duplex ultrasound, as a screening test for people with no symptoms of carotid artery disease, as does the BaleDoneen Method. Yet most people over age 50 have gotten unsolicited letters in the mail touting this test as “a simple, potentially lifesaving screening to access your risk for stroke.” Typically these ads are sent by direct-to-the-consumer marketers, such as Life Line Screening, and urge older adults to buy a package of ultrasound tests to check for several vascular diseases.
For people with symptoms of reduced blood flow through the carotid arteries, carotid duplex ultrasound is a safe, painless and potentially lifesaving diagnostic test to indirectly check for signs of arterial blockage. Medical providers typically use this test to evaluate blood flow in people who have had mini-strokes (transient ischemic attacks), which typically cause brief periods in which the person loses vision in one eye, experiences weakness or numbness in one leg or arm, or has difficulty speaking.
The test appears to have been appropriately ordered in Burton’s case, given his symptoms and findings from a MRI suggesting that he may have suffered brain injuries from multiple “silent strokes.” However, his article goes on to argue that the diagnostic test that detected his severely blocked artery should also be used as a screening tool, despite the USTSPF guidelines to the contrary. A recent study found no evidence that this type of screening is beneficial to symptom-free patients — and could even harm them, since an abnormal result could lead to invasive tests, such as an angiogram, that may not be necessary.
Who should get cIMT testing?
BaleDoneen Method cofounder Dr. Amy Doneen recently served on a Society of Atherosclerosis Imaging (SAIP) expert committee that developed guidelines for appropriate use of cIMT, including these:
- Screening people whose ten-year risk for coronary heart disease (CHD) is moderate (6% to 20%).
- Screening people age 30 or older who have metabolic syndrome, a cluster of risk factors that triple risk for heart attack and stroke, and quintuples it for type 2 diabetes.
- Screening people with diabetes or a family history of early CHD.
- Screening people with two or more of the following risk factors: low HDL (good) cholesterol, high LDL (bad) cholesterol, diabetes, age (being over 45 for a man or over 55 for a woman), and a family history of early CHD.
What do the results of this test mean?
Along with checking for plaque, this test also calculates how “old” your arteries are. Having arteries that are more than eight years “older” than your chronological age is a sign of trouble, since it’s evidence that you are headed for atherosclerosis in the future, while the presence of plaque means you already have it. If cIMT testing reveals that you have plaque in your neck arteries, you are not only at risk for a stroke, but also a heart attack.
Should you breathe a sigh of relief if no plaque is found? Unfortunately, as is true of all medical tests, a normal finding isn’t conclusive proof that you don’t have cardiovascular disease, since this test, while highly accurate, only checks one of many arterial beds. Therefore the BaleDoneen Method recommends that people with normal cIMT results also be checked with coronary artery calcium score, which uses a different imaging method to check directly for plaque. Discuss your cardiovascular risks and the best ways to reduce them with your healthcare provider. Also check out our top ten prevention tips for women, most of which are also helpful for men.