At Central Heart, we regularly see patients who appear healthy by all conventional measures. They’re active, trim, and often feel well — yet some carry hidden cardiovascular risk.
Take Michael, a 54-year-old semi-retired accountant. He wasn’t overweight, exercised occasionally, but was an occasional smoker. His GP referred him because his father had had coronary bypass surgery. Michael himself had no symptoms but a mildly raised cholesterol.
Dr Ford did a cardiac CT angiogram looking for any narrowing of his heart arteries (plaque) and to work out his chance of a heart attack in the next few years. Although there were no blockages, he had the start of narrowing with mild plaque buildup, both soft and hard (calcified plaque), a key artery supplying the heart muscle (Figure). His calcium score was 91, placing him in the top 10 per cent for his age/sex in terms of calcified plaque buildup. International current guidelines suggest that he start drugs to lower his cholesterol and reduce his risk of a heart attack. Dr Ford recommended a statin, regular exercise, that he stop smoking and eat a healthy diet.
Figure: These CT scan images show two different angles of the same heart artery (the LAD) in a 54-year-old man. The red arrow points to a soft plaque causing mild narrowing — this wouldn’t register using a calcium score alone. The white arrow shows a separate calcified plaque, also mild.
Michael decided not to take the statin but to take all the other advice. We provide clear medical advice, but the final decision for any treatment is always yours. Our team supports your choice in a non-judgmental way. It’s important that you feel comfortable with your treatment plan and understand the risks and benefits.
Sudden change — the hidden risk beneath the surface
Unfortunately, about four months later, Michael developed sudden chest pain and was rushed to the hospital, where he was diagnosed with a heart attack. A soft plaque in the LAD had burst and stopped the blood from flowing properly to his heart muscle. Plaques can burst because of inflammation or internal bleeding. Although this is more common if you smoke, have a family history of heart disease or diabetes, it can happen to anyone. Statins stop this inflammation as well as lowering cholesterol. So they work in two ways.
No one can yet predict which plaques will become unstable, and we understand that some people don’t wish to take tablets when they feel well. We support your informed decision.
Michael was treated successfully with a stent and is recovering well. He realises how incredibly lucky he was because not everyone survives a major heart attack. He doesn’t want to take any chances now, is taking tablets regularly and has changed his lifestyle for the better. regularly, has committed to stopping smoking, and understands that having had a heart attack means he’ll always be considered high risk going forward.
The mild narrowing seen on Michael’s original scan would not have been treated with a stent because most mild plaques are stable, heal naturally, and never cause problems. Stenting a mild narrowing in someone without symptoms isn’t just unnecessary and may even do more harm than good.
Cardiac CT helps to detect early plaques and guide treatment before symptoms appear. If we find plaque, it is very important to improve your lifestyle and start taking preventative medications, including statins, to help stabilise artery walls and prevent plaque rupture.
If you have a close relative who has had angina or a heart attack, then it is important to dig deeper.
Understanding risk factors for coronary disease
There are two types of risk factors for coronary artery disease:
Non-modifiable risks: age, gender, and genetics. These are out of our control, but they set the baseline for our risk level.
Modifiable risks: high blood pressure, high cholesterol, diabetes, smoking, obesity, a poor diet, and a sedentary lifestyle. These can be managed and improved.
When these modifiable risk factors are addressed early, we can often prevent or slow down the progression of disease. But to do that effectively, we first need to understand each person’s true risk, and that’s not always obvious from the outside.
Why family history matters
Having a family member who had a heart attack or needed heart surgery before the age of 60 significantly increases your own risk. Even if your cholesterol levels are only slightly raised, your inherited risk may mean you develop plaque at a younger age.
Interestingly, the opposite is also true: some people with poor lifestyle habits may have protective genetics and avoid major heart issues. This is why relying only on cholesterol numbers or blood pressure readings can sometimes be misleading.
For people like Michael — healthy, active, but with a strong family history — it’s important to dig deeper.
Calcium scoring and cardiac CT: Looking Inside the arteries
Calcium scoring is a low-radiation CT scan that measures the amount of calcium in your coronary arteries. Calcium is a marker of long-term plaque build-up, and higher scores suggest a higher risk of future heart events. A score of zero is reassuring, while a score over 100 usually warrants preventive treatment.
However, calcium scoring only detects calcified plaque. Cardiac CT angiography takes it a step further. This test uses contrast dye and advanced imaging to visualise both calcified and soft plaque and gives a clearer picture of whether the arteries are narrowed or blocked.
In Michael’s case, while his calcium score wasn’t over 100, the CT angiogram showed plaque in multiple locations. This meant he had early atherosclerosis, and that was enough to guide a change in his treatment plan.
When to consider preventive treatment
These scans aim to prevent future problems, because if we find plaque even if you have no symptoms, early treatment can reduce the risk of heart attack, stroke and even sudden death.
This might include:
- Lifestyle measures (cardiac rehab): smoking cessation, weight loss, regular moderate exercise, and a heart-healthy diet.
- Cholesterol-lowering therapy: often with statins, especially if there’s plaque or a high calcium score.
- Blood pressure control: aiming for a systolic pressure below 140 mmHg.
- Managing diabetes or pre-diabetes.
Finding plaque justifies starting medications even if your cholesterol levels are borderline. On the other hand, if the scans show no plaque, you may avoid unnecessary tablets.
A personalised approach to prevention
Cardiac imaging means we tailor treatment to you. Instead of talking about what might happen, we can discuss what’s already happening, and this can be a powerful motivator. With the information that Michael had, you may have decided to start a low-dose statin, and your outcome might have been different from his.
Assess your heart health on the Central Coast
You can’t change your genes, but you can change your outcome. If you have a strong family history of heart disease, or you’re unsure about your risk, speak to your GP or cardiologist to find out if a calcium score or CT scan might be appropriate.
Using advanced imaging and diagnostic tools, we can detect problems early, tailor prevention plans, and help you live a heart-healthy life. Speak to our team of cardiologists about risk assessment, calcium scoring, and early intervention options.