If we're really concerned about cardiovascular safety post-ORAL Surveillance, isn't it time we did something more for rheum patients?
I recently turned 50, and will admit that I’m starting to feel the years.
In the last decade, I’ve been more focussed on taking good care of my health, exercising more regularly, eating less badly and intermittently fasting, and making all sorts of tweaks to sleep better.
But after I hit this milestone birthday, I couldn’t help but feel a little bit of doubt creeping in. My life and income protection insurance premiums dramatically increased (I assume based on actuarial realities) and I started to worry about how many more decades I’d have on this planet. The number unfortunately was now likely to be confined to the number of fingers on one hand.
Then, another wake-up call with five friends and colleagues around me getting rather serious and unexpected diagnoses. All profoundly life changing, without any time to prevent.
I stopped procrastinating. The birthday present from the National Bowel Cancer Screening Program was finally attended to. My major health risk factor is a strong family history of heart disease, and I needed some kind of reassurance. So, I rocked up for a coronary artery calcium score.
I’ll admit, I was a bit nervous. It took three minutes and cost $192. The result was available within two hours. I gather it’s all based on the algorithm and is not reliant on any radiologist’s skill.
I felt very relieved when the results came back. I’m in the lowest risk category and relatively secure for the next decade, at least from myocardial infarction/stroke. I declined the offered increases to my insurances, and I haven’t cut back on the roast pork banh mi or my fried chicken compulsion.
As rheumatologists, we’re well aware of the increased risk of cardiovascular disease in patients with inflammatory rheumatic disease. We all likely engage with this in slightly different ways, with the support from our GP colleagues.
We’ll tell people to quit smoking, hoping some might over many years. We’ll likely leave blood pressure management to GPs. We all measure lipid levels and fasting sugar, and maybe even discuss exercise and nutrition. Some might even address sleep and emotional and mental health, but for most, this is likely a step too far.
So, I’ve started thinking about recommending coronary artery calcium scores to my patients, those who might have risk factors such as their disease, steroid use, excess belly fat or higher risk ethnicity which may result in underestimation of risk by traditional cardiac risk calculators (for lots of detail, see the National Heart Foundation’s position statement).
Some caveats come to mind. A coronary CT score does involve low level radiation exposure, around 1mSv (compared to >20 mSv for PET). It does have out-of-pocket costs, although I was surprised it was only $192 (there’s no Medicare rebate). That’s probably comparable to the gaps patients pay for an initial consult to many rheumatologists and cardiologists.
It may, however, provide my patients with a more tangible measure of their cardiovascular risk. It may reassure both the patient and me. And if the result is not so good, it’s likely to be a better motivator than my nagging for them to make positive changes in their lives.
I haven’t actually ordered any for my patients yet. I’m still mulling it but I’ve definitely asked a number of friends to go for it.
The 2022 EULAR recommendation for cardiovascular risk management in rheumatic and musculoskeletal diseases includes an overarching principle that rheumatologists are responsible for this risk assessment and management in collaboration with the broader health team.
I’m not quite sure how far to go, in the context of my community-based, metro-centred practice without being seen as overstepping my remit. Our GP readers might provide comment.
As for our rheumatologist readers, would you consider adding this relatively simple non-invasive test to our toolkit?
Dr Irwin Lim is the editor of Rheumatology Republic. He is a Sydney-based rheumatologist and director of BJC Health.
