What about executive physical examinations?
are they effective?
Popular with corporate executives, "Executive Physical" programs can give a false sense of security. Performing screening health physicals has no effect on overall mortality or on cardiovascular mortality (1). Stress tests, often employed to assess cardiovascular risk, are woefully inadequate (2,3,4). Although easy to use, risk calculators can also give a false sense of security, as they miss too many people who have high risk (5).
Ask about their track record
Ask your executive physical program to provide their CV event statistics. How many of their executives have had events? How many have survived 5 years after a heart attack? Compare their statistics to our track record.
do you have artery disease? look at the arteries
A heart calcium scan, with the proper equipment and technique, is much more sensitive than risk calculators (6).
There are two good non-invasive ways to assess how much plaque is in the arteries: CT calcium scores and ultrasound. The problem with CT scans is that they are currently being done by many hospitals with older sub-standard equipment. When the CT detection ring moves around the patient's chest too slowly, because the coronary arteries are in motion with every heart beat, pictures of the arteries can be blurred by "motion artifact." So these slower CT heart scans are not as sensitive in detecting calcium as the Electron Beam CT (EBCT) with no moving parts, which captures images at the speed of light. These old out-dated CT machines are (like stress tests and executive physicals) often giving high-risk patients a false sense of security by the telling them their arteries are OK, when their actual calcium scores are much higher.
After screening mammograms locate calcified lesions in the breast, ultrasound technology is employed to get a better picture of the actual breast tissue. In the same way, we use ultrasound technology to get a close-up picture of plaque in the peripheral arteries after calcium has been identified by screening CT heart scans. Combining the CT information from the heart arteries with the ultrasound data from peripheral arteries provides the most thorough and comprehensive non-invasive trending technology available today.
The most important question a doctor can ask is whether plaque is getting worse with therapy, or getting better. When we follow the effects of lifestyle and bio-marker changes on the actual plaque itself, our therapeutic decision-making process has the traction that can only come from the linking together of cause-effect relationships. This is the power of personalized medicine.
- This meta-analysis of 14 randomized trials involving 183,000 adults who had screening health physicals showed no effect on overall mortality, cardiovascular-related mortality, or cancer-related mortality. Several trials showed that screening physicals did result in more diagnoses and in better self-reported health. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345;e7191
- Over 80% of people who have heart attacks would pass their stress test the day before the heart attack. So a stress test can never predict heart attacks. Stress tests are designed to determine whether someone's symptoms are caused by obstructive plaque which would require a surgical procedure or stent. A recent task force paper reviewed the evidence for screening by using EKGs, nuclear stress tests and stress echocardiograms to find coronary disease in low-risk patients with no symptoms. They found no evidence supporting the use of these methods. They failed to address the well-documented evidence for screening by using CT heart calcium scans, but they did recommend using risk calculators. Chou, Cardiac screening with electrocardiography, stress echocardiography or myocardial perfusion imaging: Advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162:438-447
- E. Falk, PK Shah, V Fuster, Coronary Plaque Disruption. Circulation 1995;92:657
- Little WC, Constantinescu M, Applegate RJ, Kutcher MA, Burrows MT, Kahl FR, Santamore WP. Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease? Circulation. 1988;78:1157-1166
- Framingham-based risk calculators tend to miss too many high-risk people. A medical way of saying this is that risk calculators are specific for CV disease but are not very sensitive. Doneen AL, Bale BF, ISA June 15, 2009
- This excellent prospective study of 44,000 patients with no symptoms and no history of coronary disease compares the relative predictive value of risk factors versus heart calcium scores. "Our study findings support a paradigm shift in CVD risk assessment from RF-based (risk factor) approach to detection of sub-clinical atherosclerosis burden as evident by the fact that a significant proportion of those with no RF (risk factors) have a severe amount of coronary atherosclerosis and have a high risk for all-cause mortality. The higher precision of CAC (coronary artery calcium) relative to RFs (risk factors) for identifying at-risk individuals may be because of the fact that CAC is a measure of actual disease that occurs further down the causal pathway than the presence of RFs that are mere surrogates for this process." (parentheses and italics added) Nasir, et al. Interplay of coronary artery calcification and traditional risk factors for the prediction of all-cause mortality in asymptomatic individuals. Circ Cardiovasc Imaging. 2012;5:467-473