Dear Dr. Roach: I’m 60. Pretty much 100 percent of the people I know, both older and younger, who have had stents installed, had a heart attack FIRST, before getting stents. Why must you have had a heart attack before this procedure is performed? Why almost die before this can be addressed? One buddy had a stress test on Tuesday and a heart attack the following Saturday, and needed four stents before being released to go home. What reliable test can be performed upfront to potentially prevent the heart attack? At what approximate cost, since insurance probably will not cover this?


Dear W.A.: Doctors do try to identify blockages in the arteries before there’s a heart attack, but there are several reasons we aren’t always successful.

There is no perfectly reliable test. All tests have false positives (the test says you have blockages, but you don’t) and false negatives (says you’re fine, but do have blockages). The possible exception is a coronary angiogram, which is too invasive a test to do on people experiencing symptoms, unless they are at extraordinarily high risk.

Most (but not all) people with a heart attack have had warning signs ahead of time. These often are missed or ignored. The signs include the familiar chest ache or discomfort on exertion, but also can be less typical: indigestion, arm pain, stomachache or backache, shortness of breath, sweatiness. Women are more likely to have atypical symptoms, but men can, as well. These symptoms are not definitive for heart blockages, but should be discussed with one’s doctor, and in people at risk for heart disease, further investigation can be done. A stress test is a very common test. I’m not sure if your buddy had a positive stress test that wasn’t acted upon in time, or if he was one of the unlucky few whose stress test was normal yet he still had blockages.

Another test many cardiologists order in appropriate people is the coronary calcium score, or its related, more-invasive CT angiogram. The coronary calcium score looks for calcium in the blood vessels of the heart. If it is positive, then blockages are a lot more likely; but if it’s negative, the risk of a heart attack in the next few years is very small. The CT angiogram adds dye and more radiation, with their associated risks, but it’s nearly as good as a cardiac angiogram, something that is done via a catheterization of the heart (which means a tube needs to be inserted into the vessels of the heart).

These tests are worth considering for people who are at moderate to high risk of coronary disease. In people without symptoms, insurance in the U.S. often refuses to pay. The costs typically are between $100 and $400 in the U.S. for a calcium score, and $500 or more for a CT angiogram. I want to emphasize that these tests are appropriate to consider only in people at above-average risk for heart attack.

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