If you’ve been following us for any amount of time, you remember the podcast we just released about cardiovascular screenings. It’s gotten a lot of interest, and because we’re so excited about this topic, we’ve decided to look deeper.
Heart disease is the number one killer of humans. If you’re prioritizing longevity in your health journey, there are few things more important than becoming part of that statistic.
That’s why we want to focus on a completely revolutionary piece of technology that’s changing how we evaluate risk, how we stratify it, and how it impacts heart disease outcomes.
Before this technology entered the picture, the standard for cardiovascular risk stratification — how we evaluate and identify heart disease — was based on population health, or what’s best for the population as a whole. That is, are you showing some of the most common signs of heart disease?
There’s a whole range of screening factors that need to be considered when monitoring for heart disease. Do you have diabetes? Do you have high blood pressure or high cholesterol? How about a family history of heart disease or a sedentary lifestyle?
With these population health recommendations, patients are generally put on a path for annual screenings of “classic” tests like high cholesterol, diabetes, and high blood pressure, and “classic” symptoms like chest pain and shortness of breath. These screenings search for indicators that heart disease has advanced to the point where intervention is needed.
While these approaches are certainly better than nothing, they fail to identify those who have heart disease but have yet to show symptoms. A lack of heart disease symptoms does not equate to a lack of heart disease!
What Gaps Has This Approach Left?
Let’s look at the experience of a 55 year old man with a moderate risk profile.
This man is 50 pounds overweight. He has high blood pressure, high cholesterol, and a family history of heart disease. But he still works out vigorously four days a week, with no chest pain or shortness of breath to speak of.
This man might consider himself a bit overweight and a bit short of his ideal health. He’s getting concerned because his dad had a heart attack around this age.
At his annual wellness visit, his doctor orders a stress test, but because this patient exercises regularly with no symptoms, not surprisingly the test comes back negative. He has high blood pressure and his bloodwork shows high cholesterol, but that’s nothing some medication can’t help. He’s also noted to have “borderline” diabetes. The doctor says, “Eat a little less, exercise a little more, take your medications and we’ll reevaluate in a year.”
Three months later, the patient winds up in the ER suffering a heart attack. This is the same man that left his annual checkup with no heart disease diagnosis.
There’s a huge disconnect between the individual symptoms you might be showing and the conditions you actually have. It’s almost a universal experience: you’re fine until you’re not.
What most people don’t understand is that in traditional health care, the only metric used to gauge whether an intervention is needed is a person’s symptoms. The problem with that approach is that symptoms only appear at the end of a disease cycle. In other words, symptoms are a late finding.
In most instances of chest pain and shortness of breath, you won’t notice something’s wrong until you have a blood vessel that’s over 90% blocked. Even if your heart vessels are incredibly blocked and you have profound heart disease, you might not exhibit a single symptom.
We as physicians are asking (and answering) the wrong questions. When we conclude you don’t have symptoms, we’re only confirming you’re likely not at a disease’s end stage.
What we need to ask instead is: how much disease is present? When you’re overweight, 55 years old, have a family history of heart attacks, and you have diabetes and hypertension — it’s unlikely you don’t have heart disease. With those conditions, it’s almost completely impossible you don’t have any atherosclerosis!
Here’s an analogy I like to use: you can get an oil change and tire rotation on your car every 5,000 miles with no check engine light, but just because you get that service regularly doesn’t mean it’s impossible for your check engine light to turn on.
In our current healthcare model, there’s no way to intervene before bad outcomes happen. We’re part of a reactionary system, and it’s a borderline approach we’ve discussed in the past. While many healthcare providers don’t fundamentally believe diseases are binary, most patients are managed as if they either have a condition or they don’t. Most diseases, including heart disease, fall on a spectrum our current approach doesn’t address.
This isn’t due to a lack of trying. Many doctors simply don’t have the tools, time, or permission from insurance companies to dig deeper. If patients need the bulk of their costs covered through health insurance, certain tests may run outside the scope of standard coverage, because health insurance only pays based on population-based recommendations. If a doctor has a feeling they should dig deeper into a patient’s health but has no way to pay for that digging, there’s nothing they can do.
In short, there hasn’t been a better way to screen for heart disease. Until now.
What Is Cleerly, and Why Is It Useful?
A new healthcare technology company named Cleerly has harnessed the power of artificial intelligence to take high-resolution pictures of the coronary arteries. These arteries funnel oxygenated blood to the heart — and they’re also where plaques form and heart attacks happen.
Cleerly extracts from these pictures granular data about the nature and amount of plaque it sees in the coronary arteries. It can measure in grams the cumulative total plaque burden on your heart, and it can give a segmented analysis of each coronary artery and its unique contribution to that plaque burden.
Why Is Plaque So Important?
Plaques, or fatty deposits, can build up in the arteries to cause atherosclerosis. The reason we care about plaques is that they can rupture in unstable situations. When a plaque ruptures, a fragment of the plaque breaks off from the inside lining of the artery and travels with the blood flow downstream into a smaller artery.
If a plaque gets stuck in a smaller artery, it’s like a big boulder in a creek, stopping all downstream flow of oxygenated blood through that channel, killing heart cells that are fed with that blood flow. That’s what creates the chest pain we know as a heart attack — dying heart cells.
What Is Cleerly’s Role In Diagnostics?
Previously, the only way to get an idea of someone’s plaque buildup (and composition) was through a heart catheterization, an invasive procedure in which dye is shot into an artery and pictures are taken of the coronaries.
This new technology from Cleerly is changing the game. Now, we’re not just seeing the quantity and location of plaque buildups — we’re also able to get an idea of its composition without a heart cath procedure.
What Are the Benefits of Detection and Prevention?
Most heart attacks happen because of small, noncalcified or unstable plaques. This is interesting because if you have a big mountain of heart plaque, that’s usually not where the heart attacks come from, especially if that plaque is predominately calcified (or stable plaque), like a hard rock. It’s the smaller buildups that cause <50% blockage, but are completely unstable, that are more prone to rupturing.
Cleerly is incredibly powerful because it can identify the location and composition of the plaques in question — that is, are they calcified or noncalcified, stable or unstable — which can drastically change your treatment plan.
When you do this test as a baseline and find a problem, it also gives you as the patient the power to repeat the test annually and see if the composition of the plaque has changed over time, not just the quantity.
In a lot of ways, this approach can help you avoid heart attacks because you’ll see them coming. If you find an unstable plaque early, you can potentially manage the composition and render it less dangerous, or intervene before an escalating plaque becomes a problem.
What Are Cleerly’s Challenges?
A challenge that comes with any groundbreaking revolutionary technology is that it’s not widely available. For example, we’re in the greater Nashville market, and there’s only one CT scan machine in town that produces the high-quality images required to use this technology. The first challenge is going to be finding a machine that can support Cleerly.
You might say, “Well, why wouldn’t everybody have the best-of-the best equipment now that it’s out there?” It’s because these machines cost millions of dollars. Institutions have to justify the costs of these investments, and not all CT scan machines are created equal.
Ordering the Test
A second factor is that you need to find a cardiologist that knows about the Cleerly test and has the ability to order it. At Brentwood MD, we’re fortunate to have built a relationship with Cleerly, but we only have that relationship because we created it, and finding a cardiologist is another step you’ll need to take.
The last challenge to overcome is Cleerly’s cost. If you’re dependent on insurance to pay for testing and there isn’t a clear narrative that indicates you need this test, you may be forced to pay for the service out of pocket or look into alternative testing.
It can cost several thousand dollars to perform the test, and access to the machine is a real barrier. We’re fortunate to have negotiated very favorable rates for those that don’t use insurance. But if insurance doesn’t pay for it, it’s an investment. Not everybody has the capacity to make that kind of investment.
With all of these barriers in mind, don’t be mad if your cardiologist doesn’t order you a Cleerly test if you don’t have chest pain or shortness of breath. If you don’t have symptoms, it’s unlikely insurance is going to get involved. With that said, I haven’t had a patient who couldn’t get insurance to cover Cleerly if their situation warranted it.
Cleerly: Final Thoughts
We’re extremely passionate about Cleerly. Not only is the technology incredible, but it fits quite well into our mission of proactive health care. If there’s one area of health I’d recommend you put some additional discretionary income into, I can’t think of a better way to get meaningful data on a potentially life-threatening discovery — especially if you have a high-risk profile. Cleerly needs to be at the top of your list.
If you want to know more about Cleerly, visit their website for more information.
Dr. Aaron Wenzel is a concierge physician specializing in the care of fast-moving entrepreneurs, executives, and public figures in the Nashville, TN area. Dr. Wenzel’s diverse life experience and extensive training in family medicine, emergency care, nutrition, and hormone replacement therapies give him the unique platform to provide unmatched care for his patients.