Cardiac Calcium Test -- worth it?

[omni550]

extract from post by RS53576GG
https://www.early-retirement.org/forums/f38/where-does-medicare-fall-short-114320-2.html

"The only thing I've had done in the last four years that Medicare wouldn't pay for was a Cardiac Calcium Test that measures the calcium buildup in your heart arteries. It was $104 which I was happy to pay since my cardiac doctor thought it was a good idea. My score came back as nearly zero. Turns out the CCT test doesn't detect plaque and plaque is usually what causes heart artery obstructions. Seven months after having the CCT I needed 3 stents, which gives you an idea of what the CCT was worth. Now I understand why Medicare won't pay for it."


My long-time wonderful doctor retired and now I'm searching for another doc. Meanwhile, I'm being seen by a PA in her old practice. The PA just suggested I get this Calcium Cardiac Test done, paying out-of-pocket, and handed me a form to call a local provider. I dutifully called for an appointment, and the earliest one I could get was Aug 31!

And based on RS53576GG's comment (above) about plaque and NOT calcium usually being the issue, I'm wondering if this test is more of a money-maker than something of diagnostic value.

Have others here taken this test? What was your experience? Useful or not? Positive/negative/neutral?

omni

 

[Morgan22]

I thought heart plaques contained calcium? Therefore the test to detect calcium..

 

[Bamaman]

My wife and my doctors retired. The wife was referred to another doctor who later dropped her as a patient so he could tend to his weight loss practice. You'd thought that they would have referred us to two other doctors in their practice, but I guess most docs would prefer to not even deal with Medicare patients with Supplements.

Most of the family clinics are being manned by nurse practitioners today.

If you've had 3 stents, you should be seeing the cardiologist every few months for a while. I would think he'd be doing periodic heart scans after getting you on a treadmill or chemically dilating your heart chemically.

20+ years ago, my doctor got a combined treadmill/EKG machine. Every yearly physical he'd have the patients get their heart pumping fast and he'd be looking for abnormal EKG activity. Then they'd be referred to a cardiologist for further studies. My doctor headed off problems before they were fatal in all his patients.

One thing I'm saying is that anyone pushing middle age or older needs to take a proactive stance on their healthcare. With so many internal medicine and family practice doctors retiring (and selling their business to hospitals), it's likely that no one is watching your health as closely as in the past.

 

[braumeister]

I have no medical training so my thoughts should be discounted for that reason. But I've done a fair amount of reading on the subject.

Cost is not usually a big deal; the test typically costs in the $100 range. The only real downside is that it's a significant dose of radiation. And it's only recommended for people who are already at high risk for a heart attack.

Usefulness varies by who's interpreting it. Many doctors will say that anything other than zero is problematic, others will be more forgiving of low scores, and some will even discount the test entirely.

But suppose you get the test (assuming you're a high risk individual), and you find out your score.
Is there anything you can do to lower that score? No.
Is there any way to know if the calcium buildup is recent or very old? No.

 

[Sojourner]

I thought heart plaques contained calcium? Therefore the test to detect calcium..

+1

The way my doctor explained it, the more calcium detected (i.e. the higher the score), the more plaque is likely in your cardiac arteries. This gives some indication of your statistical risk for adverse cardiac events. It isn't a perfect correlation, but a zero score is much better than a higher score. My doctor recommend it as a very low risk, low cost way of deciding whether we needed to get more aggressive about treating my moderately-high blood pressure and frequent PVCs.

 

[Peter]

A near-zero CAC score was enough to get my doctor agree to drop statins.

 

[RS53576GG]

Since I'm the one who wrote about the questionable value of a Cardiac Calcium Test I'll babble a little about my experience and what I've learned since then. I had the CCT test and my score was 21. Not zero but nothing to get too excited about. My cardiac doc said anything higher than 100 is something to start being interested in, greater than 400 is genuinely concerning, and 1000 or more is a big deal.

Since my problem was plaque it didn't show up on the CT scan. My calcium buildup was relatively low so it didn't ring any alarm bells.

Later when I talked to several cardiac docs and others I got a better understanding of what's going on. Generally speaking LDL cholesterol leaks through the inner layer of the artery wall and lodges behind it because it can't go any further. The cholesterol particles are very small and somewhat fluid in nature. Over time these particles accumulate and slowly dry out and eventually calcify. These calcium deposits show up in x-rays and other scans. Calcified plaque is not considered to be dangerous because it's solid and doesn't tend to burst through the inner artery wall and rapidly restrict blood flow. The most dangerous plaque is the fluid-small particle type. If it collects and becomes bigger and breaks through the inner artery wall the particles make their way through the blood system and cause strokes and other unpleasant problems. One of the cardiac docs said that this type of event is almost always fatal. Plaque that firms up is less dangerous when it bursts through the inner artery wall because it sticks together and pieces are less likely to break off and cause a stroke. And plaque that has calcified isn't too dangerous because it's a solid.

Sometimes the plaque doesn't burst through the inner artery wall at all. It just pushes the wall into the blood stream and slowly obstructs the blood flow. This is what happened to me.

The problem with a Cardiac Calcium Test is that it only detects plaque that has calcified. The assumption that if you don't have any calcium you don't have any plaque is not 100% correct. It may be an indicator but it's not proof positive that you don't have plaque. (The Voice of Experience has spoken!)

An angiogram is pretty much the gold standard for detecting plaque. It doesn't show plaque either but it shows if any of your arteries are obstructed. The cardiac doc who put in the first stent wrote in his report that my Left Anterior Descending artery was 100% obstructed but this wasn't quite right because a 100% obstructed LAD is usually fatal. I measured the angiogram pictures later and the ID of the obstructed flow passage in the LAD was down to 1/6 of it's unobstructed diameter. If we assume the flow passage is circular the area of a circle is a function of radius squared so the 1/6 diameter means the flow area was 1/36 of what it should have been. That's a 97.2% reduction in flow area.

The left side of the heart where the LAD is located usually has two arteries that supply blood to the big chamber that pumps blood throughout the body. The second artery is the Left Circumflex and it goes around the heart to the back. The LAD goes down along the front of the heart. About 20% of the population has a third artery called the Ramus Intermedius between these two arteries that supplies blood as well. I happen to be one of the lucky 20% who has one.

The report for my first stent procedure said the LAD was 100% obstructed, the Ramus was 90% obstructed and the Left Circumflex was 80% obstructed. The cardiac doc on call put a stent in the LAD and a week later another cardiac doc who specializes in stents put stents in the Ramus and Circumflex. Not an easy procedure. She estimated it had a fatality rate of 10% when she discussed it with me beforehand. It took her and the team 4 hours to put in two stents. The first stent took an hour and fifteen minutes. I was awake the whole time and watched the big monitors that showed what they were doing. It was cool. The music playing in the background was pretty good too. I watched them measure the inside of one of the arteries after it was expanded by a balloon and it was 3.8 mm by 4.2 mm. They used this info to select the proper diameter and length stent. It was a very interesting way to spend an afternoon.

I read up on hearts after all this and came to the conclusion that an angiogram is the only way to really know if you're okay or not. The problem is that catheter procedures have a 1% fatality rate so they won't do an angiogram without the appropriate justification. So the real problem in this from my point of view is that there doesn't seem to be a good way to conclusively prove your arteries aren't obstructed without doing an angiogram and they won't do an angiogram if you don't show signs of having a problem. An EKG can show if any of your heart muscles have been starved of blood and have scar tissue because the profile of the voltage on the plot is slightly different in certain places because the scar tissue has different resistance to the electrical signals that make your heart muscles work. That's probably why they do an EKG right off the bat because this is a good indicator what kind of problem you're having when you walk in the hospital.

Since I wasn't told that plaque isn't easy to detect when I had the usual tests done 6 and 18 months earlier I wasn't paying attention to what my physical situation was. I do a lot of hiking in the hills north of my house and in retrospect I can see signs of a problem that I didn't recognize at the time because I wasn't looking for them. One day I was two miles up my usual hiking trail at a location that is a 900 ft gain in elevation when I suddenly felt very tired. I mean, exhausted. Seriously exhausted. It was early on a July morning and it starting to get hot. I rested a bit but didn't feel any better. I decided to walk back. Normally this would take me 45 minutes but this time it took me 3 hours. I wasn't in a big hurry. Survival was more important than speed. I drove home and laid down and felt a little tingle in my left shoulder. I knew what that meant. A friend drove me to the hospital which was 10 minutes away. 20 minutes after walking through the Emergency Entrance I was laying on an operating room table. Pretty quick service.

I think each of us is our own best advocate for our health. Pay attention to what you are feeling and the little aches and pains that collect as we get older. When I look back on it I had hints that something was wrong but I wasn't looking for them and didn't know what they would feel like if they occurred. For a long time every month or two I felt an occasional twitch in my chest and a very mild pressure over a small region. Nothing painful or bothersome but noticeable. Since I've had the 3 stents put in I've never felt either of these things again. My heart is totally unnoticeable as it beats away. My resting heart rate is 51 beats per minute which is what it was earlier. It gets as high as 136 when I'm exercising. When I'm sleeping it's in the low 40's. My heart's ejection fraction used to be 70%. Immediately after the first stent was put in it was 35%. Now it's 50% and 55% (it's measured in two planes). Anything over 50% is considered a "full recovery" because the normal EF range is 50-70%. There's some scar tissue that resulted from blood starvation but it's not a big deal. I can run, ride bikes, hike and all the other things I've always done.

I'm not a healthcare professional so anything I mention is of dubious value to anyone but myself. Do your own homework and read up on these things. Make your own decisions about what's important for you. Pay attention to what you are feeling. Push yourself physically so you'll be aware of what your limits are and how your body handles this sort of thing.

I've tried to stay physically active. I think this worked to my advantage. When my arteries closed down enough to effect my physical performance when I was hiking up a steep section of the trail there was still enough blood flow to allow me to survive once I stopped pushing myself. I wasn't aware of what was going on but I knew I felt very tired and it would be wise to go slow and steady. If I hadn't been exercising this wouldn't have happened. My arteries would have continued being restricted and I wouldn't have known it. My guess is that if I wasn't physically active I'd have plodded along until one day I walked out to the mailbox and keeled over dead in my driveway because the exertion of walking 100 ft was finally too much for my heart to withstand.

Thought some of you might find this interesting. Your doctors will tell you what they believe is most likely but it's better to design for the worst case. (A lesson from engineering school.) You are your own best advocate for your health.

I'll also say that as we get older it's probably a good idea to live somewhere that has good healthcare nearby. If I lived 50 miles out in the boondocks instead of 5 miles from a decent hospital with a cardiac specialty group I probably wouldn't be writing this now.


Sorry for the extended babble. If my story saves the life of one person sometime in the future it was worth the time to write it.

 

[audreyh1]

I have no medical training so my thoughts should be discounted for that reason. But I've done a fair amount of reading on the subject.

Cost is not usually a big deal; the test typically costs in the $100 range. The only real downside is that it's a significant dose of radiation. And it's only recommended for people who are already at high risk for a heart attack.

Usefulness varies by who's interpreting it. Many doctors will say that anything other than zero is problematic, others will be more forgiving of low scores, and some will even discount the test entirely.

But suppose you get the test (assuming you're a high risk individual), and you find out your score.
Is there anything you can do to lower that score? No.
Is there any way to know if the calcium buildup is recent or very old? No.

My understanding is that the CAC radiation exposure is not high these days, more on the order of a mammogram.

 

[captain3d]

Since I'm the one who wrote about the questionable value of a Cardiac Calcium Test I'll babble a little about my experience and what I've learned since then. I had the CCT test and my score was 21. Not zero but nothing to get too excited about. My cardiac doc said anything higher than 100 is something to start being interested in, greater than 400 is genuinely concerning, and 1000 or more is a big deal.

Since my problem was plaque it didn't show up on the CT scan. My calcium buildup was relatively low so it didn't ring any alarm bells.

Later when I talked to several cardiac docs and others I got a better understanding of what's going on. Generally speaking LDL cholesterol leaks through the inner layer of the artery wall and lodges behind it because it can't go any further. The cholesterol particles are very small and somewhat fluid in nature. Over time these particles accumulate and slowly dry out and eventually calcify. These calcium deposits show up in x-rays and other scans. Calcified plaque is not considered to be dangerous because it's solid and doesn't tend to burst through the inner artery wall and rapidly restrict blood flow. The most dangerous plaque is the fluid-small particle type. If it collects and becomes bigger and breaks through the inner artery wall the particles make their way through the blood system and cause strokes and other unpleasant problems. One of the cardiac docs said that this type of event is almost always fatal. Plaque that firms up is less dangerous when it bursts through the inner artery wall because it sticks together and pieces are less likely to break off and cause a stroke. And plaque that has calcified isn't too dangerous because it's a solid.

Sometimes the plaque doesn't burst through the inner artery wall at all. It just pushes the wall into the blood stream and slowly obstructs the blood flow. This is what happened to me.

The problem with a Cardiac Calcium Test is that it only detects plaque that has calcified. The assumption that if you don't have any calcium you don't have any plaque is not 100% correct. It may be an indicator but it's not proof positive that you don't have plaque. (The Voice of Experience has spoken!)

An angiogram is pretty much the gold standard for detecting plaque. It doesn't show plaque either but it shows if any of your arteries are obstructed. The cardiac doc who put in the first stent wrote in his report that my Left Anterior Descending artery was 100% obstructed but this wasn't quite right because a 100% obstructed LAD is usually fatal. I measured the angiogram pictures later and the ID of the obstructed flow passage in the LAD was down to 1/6 of it's unobstructed diameter. If we assume the flow passage is circular the area of a circle is a function of radius squared so the 1/6 diameter means the flow area was 1/36 of what it should have been. That's a 97.2% reduction in flow area.

The left side of the heart where the LAD is located usually has two arteries that supply blood to the big chamber that pumps blood throughout the body. The second artery is the Left Circumflex and it goes around the heart to the back. The LAD goes down along the front of the heart. About 20% of the population has a third artery called the Ramus Intermedius between these two arteries that supplies blood as well. I happen to be one of the lucky 20% who has one.

The report for my first stent procedure said the LAD was 100% obstructed, the Ramus was 90% obstructed and the Left Circumflex was 80% obstructed. The cardiac doc on call put a stent in the LAD and a week later another cardiac doc who specializes in stents put stents in the Ramus and Circumflex. Not an easy procedure. She estimated it had a fatality rate of 10% when she discussed it with me beforehand. It took her and the team 4 hours to put in two stents. The first stent took an hour and fifteen minutes. I was awake the whole time and watched the big monitors that showed what they were doing. It was cool. The music playing in the background was pretty good too. I watched them measure the inside of one of the arteries after it was expanded by a balloon and it was 3.8 mm by 4.2 mm. They used this info to select the proper diameter and length stent. It was a very interesting way to spend an afternoon.

I read up on hearts after all this and came to the conclusion that an angiogram is the only way to really know if you're okay or not. The problem is that catheter procedures have a 1% fatality rate so they won't do an angiogram without the appropriate justification. So the real problem in this from my point of view is that there doesn't seem to be a good way to conclusively prove your arteries aren't obstructed without doing an angiogram and they won't do an angiogram if you don't show signs of having a problem. An EKG can show if any of your heart muscles have been starved of blood and have scar tissue because the profile of the voltage on the plot is slightly different in certain places because the scar tissue has different resistance to the electrical signals that make your heart muscles work. That's probably why they do an EKG right off the bat because this is a good indicator what kind of problem you're having when you walk in the hospital.

Since I wasn't told that plaque isn't easy to detect when I had the usual tests done 6 and 18 months earlier I wasn't paying attention to what my physical situation was. I do a lot of hiking in the hills north of my house and in retrospect I can see signs of a problem that I didn't recognize at the time because I wasn't looking for them. One day I was two miles up my usual hiking trail at a location that is a 900 ft gain in elevation when I suddenly felt very tired. I mean, exhausted. Seriously exhausted. It was early on a July morning and it starting to get hot. I rested a bit but didn't feel any better. I decided to walk back. Normally this would take me 45 minutes but this time it took me 3 hours. I wasn't in a big hurry. Survival was more important than speed. I drove home and laid down and felt a little tingle in my left shoulder. I knew what that meant. A friend drove me to the hospital which was 10 minutes away. 20 minutes after walking through the Emergency Entrance I was laying on an operating room table. Pretty quick service.

I think each of us is our own best advocate for our health. Pay attention to what you are feeling and the little aches and pains that collect as we get older. When I look back on it I had hints that something was wrong but I wasn't looking for them and didn't know what they would feel like if they occurred. For a long time every month or two I felt an occasional twitch in my chest and a very mild pressure over a small region. Nothing painful or bothersome but noticeable. Since I've had the 3 stents put in I've never felt either of these things again. My heart is totally unnoticeable as it beats away. My resting heart rate is 51 beats per minute which is what it was earlier. It gets as high as 136 when I'm exercising. When I'm sleeping it's in the low 40's. My heart's ejection fraction used to be 70%. Immediately after the first stent was put in it was 35%. Now it's 50% and 55% (it's measured in two planes). Anything over 50% is considered a "full recovery" because the normal EF range is 50-70%. There's some scar tissue that resulted from blood starvation but it's not a big deal. I can run, ride bikes, hike and all the other things I've always done.

I'm not a healthcare professional so anything I mention is of dubious value to anyone but myself. Do your own homework and read up on these things. Make your own decisions about what's important for you. Pay attention to what you are feeling. Push yourself physically so you'll be aware of what your limits are and how your body handles this sort of thing.

I've tried to stay physically active. I think this worked to my advantage. When my arteries closed down enough to effect my physical performance when I was hiking up a steep section of the trail there was still enough blood flow to allow me to survive once I stopped pushing myself. I wasn't aware of what was going on but I knew I felt very tired and it would be wise to go slow and steady. If I hadn't been exercising this wouldn't have happened. My arteries would have continued being restricted and I wouldn't have known it. My guess is that if I wasn't physically active I'd have plodded along until one day I walked out to the mailbox and keeled over dead in my driveway because the exertion of walking 100 ft was finally too much for my heart to withstand.

Thought some of you might find this interesting. Your doctors will tell you what they believe is most likely but it's better to design for the worst case. (A lesson from engineering school.) You are your own best advocate for your health.

I'll also say that as we get older it's probably a good idea to live somewhere that has good healthcare nearby. If I lived 50 miles out in the boondocks instead of 5 miles from a decent hospital with a cardiac specialty group I probably wouldn't be writing this now.


Sorry for the extended babble. If my story saves the life of one person sometime in the future it was worth the time to write it.

Thanks for that

 

[skyking1]

RS53576GG, thanks for sharing your detailed story. Was your first stent an emergent case with an ambulance ride?

I'll also say that as we get older it's probably a good idea to live somewhere that has good healthcare nearby. If I lived 50 miles out in the boondocks instead of 5 miles from a decent hospital with a cardiac specialty group I probably wouldn't be writing this now.

I ask because I've had a trip to the cath lab myself. Mine was vague and not much pain, but enough to go to the ER in the night.

 

[bmcgonig]

Since I'm the one who wrote about the questionable value of a Cardiac Calcium Test I'll babble a little about my experience and what I've learned since then. I had the CCT test and my score was 21. Not zero but nothing to get too excited about. My cardiac doc said anything higher than 100 is something to start being interested in, greater than 400 is genuinely concerning, and 1000 or more is a big deal.

Since my problem was plaque it didn't show up on the CT scan. My calcium buildup was relatively low so it didn't ring any alarm bells.

Later when I talked to several cardiac docs and others I got a better understanding of what's going on. Generally speaking LDL cholesterol leaks through the inner layer of the artery wall and lodges behind it because it can't go any further. The cholesterol particles are very small and somewhat fluid in nature. Over time these particles accumulate and slowly dry out and eventually calcify. These calcium deposits show up in x-rays and other scans. Calcified plaque is not considered to be dangerous because it's solid and doesn't tend to burst through the inner artery wall and rapidly restrict blood flow. The most dangerous plaque is the fluid-small particle type. If it collects and becomes bigger and breaks through the inner artery wall the particles make their way through the blood system and cause strokes and other unpleasant problems. One of the cardiac docs said that this type of event is almost always fatal. Plaque that firms up is less dangerous when it bursts through the inner artery wall because it sticks together and pieces are less likely to break off and cause a stroke. And plaque that has calcified isn't too dangerous because it's a solid.

Sometimes the plaque doesn't burst through the inner artery wall at all. It just pushes the wall into the blood stream and slowly obstructs the blood flow. This is what happened to me.

The problem with a Cardiac Calcium Test is that it only detects plaque that has calcified. The assumption that if you don't have any calcium you don't have any plaque is not 100% correct. It may be an indicator but it's not proof positive that you don't have plaque. (The Voice of Experience has spoken!)

An angiogram is pretty much the gold standard for detecting plaque. It doesn't show plaque either but it shows if any of your arteries are obstructed. The cardiac doc who put in the first stent wrote in his report that my Left Anterior Descending artery was 100% obstructed but this wasn't quite right because a 100% obstructed LAD is usually fatal. I measured the angiogram pictures later and the ID of the obstructed flow passage in the LAD was down to 1/6 of it's unobstructed diameter. If we assume the flow passage is circular the area of a circle is a function of radius squared so the 1/6 diameter means the flow area was 1/36 of what it should have been. That's a 97.2% reduction in flow area.

The left side of the heart where the LAD is located usually has two arteries that supply blood to the big chamber that pumps blood throughout the body. The second artery is the Left Circumflex and it goes around the heart to the back. The LAD goes down along the front of the heart. About 20% of the population has a third artery called the Ramus Intermedius between these two arteries that supplies blood as well. I happen to be one of the lucky 20% who has one.

The report for my first stent procedure said the LAD was 100% obstructed, the Ramus was 90% obstructed and the Left Circumflex was 80% obstructed. The cardiac doc on call put a stent in the LAD and a week later another cardiac doc who specializes in stents put stents in the Ramus and Circumflex. Not an easy procedure. She estimated it had a fatality rate of 10% when she discussed it with me beforehand. It took her and the team 4 hours to put in two stents. The first stent took an hour and fifteen minutes. I was awake the whole time and watched the big monitors that showed what they were doing. It was cool. The music playing in the background was pretty good too. I watched them measure the inside of one of the arteries after it was expanded by a balloon and it was 3.8 mm by 4.2 mm. They used this info to select the proper diameter and length stent. It was a very interesting way to spend an afternoon.

I read up on hearts after all this and came to the conclusion that an angiogram is the only way to really know if you're okay or not. The problem is that catheter procedures have a 1% fatality rate so they won't do an angiogram without the appropriate justification. So the real problem in this from my point of view is that there doesn't seem to be a good way to conclusively prove your arteries aren't obstructed without doing an angiogram and they won't do an angiogram if you don't show signs of having a problem. An EKG can show if any of your heart muscles have been starved of blood and have scar tissue because the profile of the voltage on the plot is slightly different in certain places because the scar tissue has different resistance to the electrical signals that make your heart muscles work. That's probably why they do an EKG right off the bat because this is a good indicator what kind of problem you're having when you walk in the hospital.

Since I wasn't told that plaque isn't easy to detect when I had the usual tests done 6 and 18 months earlier I wasn't paying attention to what my physical situation was. I do a lot of hiking in the hills north of my house and in retrospect I can see signs of a problem that I didn't recognize at the time because I wasn't looking for them. One day I was two miles up my usual hiking trail at a location that is a 900 ft gain in elevation when I suddenly felt very tired. I mean, exhausted. Seriously exhausted. It was early on a July morning and it starting to get hot. I rested a bit but didn't feel any better. I decided to walk back. Normally this would take me 45 minutes but this time it took me 3 hours. I wasn't in a big hurry. Survival was more important than speed. I drove home and laid down and felt a little tingle in my left shoulder. I knew what that meant. A friend drove me to the hospital which was 10 minutes away. 20 minutes after walking through the Emergency Entrance I was laying on an operating room table. Pretty quick service.

I think each of us is our own best advocate for our health. Pay attention to what you are feeling and the little aches and pains that collect as we get older. When I look back on it I had hints that something was wrong but I wasn't looking for them and didn't know what they would feel like if they occurred. For a long time every month or two I felt an occasional twitch in my chest and a very mild pressure over a small region. Nothing painful or bothersome but noticeable. Since I've had the 3 stents put in I've never felt either of these things again. My heart is totally unnoticeable as it beats away. My resting heart rate is 51 beats per minute which is what it was earlier. It gets as high as 136 when I'm exercising. When I'm sleeping it's in the low 40's. My heart's ejection fraction used to be 70%. Immediately after the first stent was put in it was 35%. Now it's 50% and 55% (it's measured in two planes). Anything over 50% is considered a "full recovery" because the normal EF range is 50-70%. There's some scar tissue that resulted from blood starvation but it's not a big deal. I can run, ride bikes, hike and all the other things I've always done.

I'm not a healthcare professional so anything I mention is of dubious value to anyone but myself. Do your own homework and read up on these things. Make your own decisions about what's important for you. Pay attention to what you are feeling. Push yourself physically so you'll be aware of what your limits are and how your body handles this sort of thing.

I've tried to stay physically active. I think this worked to my advantage. When my arteries closed down enough to effect my physical performance when I was hiking up a steep section of the trail there was still enough blood flow to allow me to survive once I stopped pushing myself. I wasn't aware of what was going on but I knew I felt very tired and it would be wise to go slow and steady. If I hadn't been exercising this wouldn't have happened. My arteries would have continued being restricted and I wouldn't have known it. My guess is that if I wasn't physically active I'd have plodded along until one day I walked out to the mailbox and keeled over dead in my driveway because the exertion of walking 100 ft was finally too much for my heart to withstand.

Thought some of you might find this interesting. Your doctors will tell you what they believe is most likely but it's better to design for the worst case. (A lesson from engineering school.) You are your own best advocate for your health.

I'll also say that as we get older it's probably a good idea to live somewhere that has good healthcare nearby. If I lived 50 miles out in the boondocks instead of 5 miles from a decent hospital with a cardiac specialty group I probably wouldn't be writing this now.


Sorry for the extended babble. If my story saves the life of one person sometime in the future it was worth the time to write it.

Excellent “extended babble”.

What about CT Angiogram? Isn’t that something worthwhile and is it useful?

 

[Dash man]

My calcium score was 1,036 six years ago. I was told I had a 95% chance of a cardiac event within five years. Nothing yet!
I see my cardiologist twice per year and just had an echocardiogram last month. My last stress test was good.
He says I’m not dead yet.

 

[RS53576GG]

RS53576GG, thanks for sharing your detailed story. Was your first stent an emergent case with an ambulance ride?


I ask because I've had a trip to the cath lab myself. Mine was vague and not much pain, but enough to go to the ER in the night.

I had to look up "emergent case" because I didn't know what it means. For those who are equally ignorant it means "not immediately life threatening". The problem may not need to be addressed immediately but it should be attended to in two hours or less.

The people in the hospital told me that the max acceptable treatment time to diagnose and start treating someone with my problem is 45 minutes.

They had an open operating room and gathered up the staff pretty quickly. I was feeling more tired and in the back of my mind I was starting to think "this may not end well". Then they started pushing me down the hall and turned down another hall and I saw a door with light streaming out of it. As they pushed me inside I thought "I'm golden. There is no better place in the world for me to be than right here."

They started shaving me in the groin in case they needed to go in that way but they were also looking at my right wrist and that was their preferred route. It's easier to get to the heart from there. Meanwhile while they were shaving me in the groin I tried to think of something funny to say. Unfortunately I couldn't come up with anything that seemed suitable for mixed company. I was very disappointed in myself.

They started hooking me up to an IV and people seemed to be getting ready for action. Knowing that they'd soon be getting down to business I spoke up in a fairly loud voice and said "I appreciate that all of you decided to come to work today." A few moments later the lights went dim and I was semi-asleep. I was awake enough to sense the passage of time but I couldn't see anything, hear anything, feel anything or move. My guess is that they put me out deep enough that if something dramatic went wrong they could quickly open me up and poke around inside.

For the second procedure I was awake the whole time. I could move my head and talk, which I only did one time. About two hours into the procedure they were playing Ozzie Osbourne Crazy Train in the background and I said "You can't go wrong with Ozzie".

I didn't take an ambulance to the hospital. I called a friend who lives nearby. The conversation went like this.

Me: "Hey, can you stop by and take me over to the hospital?"

Him: "Huh? Uh yeah, sure."

Me: "Great. I'll be standing by the front door when you get here."

It took me 5 minutes to gather up some stuff to take with me to the hospital and then I turned off everything in the house and walked out the front door and locked it. I was really tired so I sat down next to the door. A minute later my friend turned down my street and pulled into my circular driveway and drove up to me. I got in and said "Let's go."

The hospital people said I should have called an ambulance because they would start treatment the moment they see me. If I had cardiac arrest they could work on me while we were driving down the road. In retrospect this was probably a good idea but I had the feeling that if I made it 3+ hours walking in the desert I'd probably last long enough to get to the hospital without dying. Eight or ten minutes later I walked in the Emergency Entrance and my life was in good hands.

Sometimes we roll the dice for no good reason...

 

[RS53576GG]

Excellent “extended babble”.

What about CT Angiogram? Isn’t that something worthwhile and is it useful?

My guess is that a really accurate CT scan would show plaque but the settings would have to be for a slower and more detailed scan and there might be a chance for more exposure to radiation or cosmic rays from outer space or whatever else is bad for us. I've been involved with CT scanning metallic objects in aerospace but not on the medical side of things. If we played around with the settings on the scanner we could get some pretty decent results. (Like 0.0002 inch tolerance on the point cloud.) A scan of an aluminum housing the size of a football took 8 hours to get that kind of resolution. This was 5 or 6 years ago. It's probably quicker today.

I imagine the challenge in dealing with a really detailed CT scan on arteries is that someone would need to painstakingly work through all your heart arteries and try to see where plaque is present. This might be worth doing for the President of the United States but for the public on a huge scale it may not be practical.

Just a guess. Maybe someone on the forum knows about this sort of thing.

 

[RS53576GG]

My calcium score was 1,036 six years ago. I was told I had a 95% chance of a cardiac event within five years. Nothing yet!
I see my cardiologist twice per year and just had an echocardiogram last month. My last stress test was good.
He says I’m not dead yet.

If they put you on a statin to minimize or eliminate further plaque build up you could live for a long, long time.

There's a guy on YouTube named Ford Brewer. He's an MD and talks a lot about preventative medicine. I think he has some videos where he discusses CCT and the generally benign behavior of calcified plaque.

Here's a story about my experience with Crestor. When I was in the hospital they started me on 40 mg Crestor every day. After I got out of the hospital and went to some followup visits with various doctors I noticed that my liver enzymes (ALT and AST) were going up. After a few months they were 50% higher than the max acceptable values. I have all my lab reports since 1995 so I plotted my ALT and AST for the last 27 years and showed them to my cardio doc and general doc. Both of them ignored the plot and said Crestor wasn't the problem and there must be something wrong with my liver. I should go see a gastro doc and get looked at.

I made an appointment and then I did some research. Turns out liver enzyme problems are well know for statins but they only happen to 0.1 to 1.0% of the people who are taking them. I saw the gastro doc and he said "Oh yeah, I see this all the time." We had some blood tests done over time and I cut the statin in half to 20 mg and watched the results. After a month he said "Stop taking the statin."

I was switched over to Praluent which is different type of drug for reducing cholesterol. It's more expensive but you take an injection every 15 days rather than a pill every day. It works fine. I feel great. Better than I felt when I was taking Crestor. Noticeably better.

Here's the really important thing that resulted from this. About 11 weeks after stopping Crestor I was out hiking one day and it suddenly struck me that I was thinking more clearly. I wasn't expecting this and certainly wasn't looking for it but it's something I noticed. For the following couple days I paid attention to how my thought processes were working and I was convinced that I was thinking more clearly. I looked into this and the Mayo website says that "mental fuzziness" is a well known side effect of statins. Some people have very noticeable problems while others are less significant.

The scary part about this is that I didn't notice my lack of mental acuity while it was happening. I only noticed it's absence once I stopped taking Crestor. If I hadn't been one of the 1% who have liver enzyme problems from taking a statin I'd have probably been "mentally fuzzy" for the rest of my life and never known it.

That's a frightening prospect.

 

[skyking1]

mine was more of a fishing trip. I had vague pains, my troponin was low @ .027, EKG was a little weird but not much. They all listened carefully for that telltale rasp of the heart rubbing on the pericardium, because that fit my symptoms better. They kept me for observation, an echocardiagram, repeat blood gases and EKG.
About 4 PM my pain went to a solid 7 or so and the next blood gas had my troponin at ~8.7! and my CK-MB was equally bad at ~51.
Now I had problems. The trouble is there was an emergency or two ahead of me and my pain had subsided. I got in the cath lab about 11 PM , and they found one artery that was 20~30% occluded and that was it. No other issues and that was not treatable. They figured it was pericarditis and I did have virus symptoms the week proceeding.

 

[SecondCor521]

Here's the really important thing that resulted from this. About 11 weeks after stopping Crestor I was out hiking one day and it suddenly struck me that I was thinking more clearly. I wasn't expecting this and certainly wasn't looking for it but it's something I noticed. For the following couple days I paid attention to how my thought processes were working and I was convinced that I was thinking more clearly. I looked into this and the Mayo website says that "mental fuzziness" is a well known side effect of statins. Some people have very noticeable problems while others are less significant.

The scary part about this is that I didn't notice my lack of mental acuity while it was happening. I only noticed it's absence once I stopped taking Crestor. If I hadn't been one of the 1% who have liver enzyme problems from taking a statin I'd have probably been "mentally fuzzy" for the rest of my life and never known it.

That's a frightening prospect.

I decided a few years ago to start a health log to track stuff. In my early 50's, there were a lot of things that were going on but they were more chronic and subtle so it was hard to tease out what caused what.

After a while, I was able to start noticing patterns and correlations. Then I started changing things a bit at a time to test things out. Some of the patterns were so subtle that it took a long time and addressing other confounding things first. And many of my health things are multifactorial - either A causes X, Y, and Z, or A, B, and C can cause X.

But after about three years of this, I now have a full page of what works for me and doesn't work for me in terms of sleep, diet, exercise, fatigue, hydration, and infections (which were an issue with me for a while). I can use this page to either avoid problems, or if something is wrong I can usually track it to something that I've forgotten to do.

Will it guarantee me a long healthy life? No. Is it as good as a double blind placebo controlled peer reviewed evidence based medicine? No. But it has helped me be healthier than I have in about two decades.

 

[militaryman]

My calcium score was 1,036 six years ago. I was told I had a 95% chance of a cardiac event within five years. Nothing yet!
I see my cardiologist twice per year and just had an echocardiogram last month. My last stress test was good.
He says I’m not dead yet.

8 years ago my calcium score was a 42 (at the age of 46) I didn't think too much about it then. A few weeks ago I retested at 361. Apparently that is typical for a person that has any score above zero ....to increase 20 to 30 percent a year. Mine was about 30 percent. I'm not overweight and exercise 5 times a week. Blood was all good. No chest pain. Going for a nuclear stress test in a couple weeks to make sure all looks ok. Really the only thing that I can pin it on is diet. I love sweets, sugar sugar sugar and so I stopped sugar and empty carbs as of 10 June. Retested blood after 3 weeks of no sugar and my cholesterol dropped from 189 to 161 and triglycerides were 37 ldl 99 . Not sure what now to do but seems like a drum beat from all sides is to eliminate sugar/breads....empty carbs

 

[Scuba]

Since I'm the one who wrote about the questionable value of a Cardiac Calcium Test I'll babble a little about my experience and what I've learned since then. I had the CCT test and my score was 21. Not zero but nothing to get too excited about. My cardiac doc said anything higher than 100 is something to start being interested in, greater than 400 is genuinely concerning, and 1000 or more is a big deal.

Since my problem was plaque it didn't show up on the CT scan. My calcium buildup was relatively low so it didn't ring any alarm bells.

Later when I talked to several cardiac docs and others I got a better understanding of what's going on. Generally speaking LDL cholesterol leaks through the inner layer of the artery wall and lodges behind it because it can't go any further. The cholesterol particles are very small and somewhat fluid in nature. Over time these particles accumulate and slowly dry out and eventually calcify. These calcium deposits show up in x-rays and other scans. Calcified plaque is not considered to be dangerous because it's solid and doesn't tend to burst through the inner artery wall and rapidly restrict blood flow. The most dangerous plaque is the fluid-small particle type. If it collects and becomes bigger and breaks through the inner artery wall the particles make their way through the blood system and cause strokes and other unpleasant problems. One of the cardiac docs said that this type of event is almost always fatal. Plaque that firms up is less dangerous when it bursts through the inner artery wall because it sticks together and pieces are less likely to break off and cause a stroke. And plaque that has calcified isn't too dangerous because it's a solid.

Sometimes the plaque doesn't burst through the inner artery wall at all. It just pushes the wall into the blood stream and slowly obstructs the blood flow. This is what happened to me.

The problem with a Cardiac Calcium Test is that it only detects plaque that has calcified. The assumption that if you don't have any calcium you don't have any plaque is not 100% correct. It may be an indicator but it's not proof positive that you don't have plaque. (The Voice of Experience has spoken!)

An angiogram is pretty much the gold standard for detecting plaque. It doesn't show plaque either but it shows if any of your arteries are obstructed. The cardiac doc who put in the first stent wrote in his report that my Left Anterior Descending artery was 100% obstructed but this wasn't quite right because a 100% obstructed LAD is usually fatal. I measured the angiogram pictures later and the ID of the obstructed flow passage in the LAD was down to 1/6 of it's unobstructed diameter. If we assume the flow passage is circular the area of a circle is a function of radius squared so the 1/6 diameter means the flow area was 1/36 of what it should have been. That's a 97.2% reduction in flow area.

The left side of the heart where the LAD is located usually has two arteries that supply blood to the big chamber that pumps blood throughout the body. The second artery is the Left Circumflex and it goes around the heart to the back. The LAD goes down along the front of the heart. About 20% of the population has a third artery called the Ramus Intermedius between these two arteries that supplies blood as well. I happen to be one of the lucky 20% who has one.

The report for my first stent procedure said the LAD was 100% obstructed, the Ramus was 90% obstructed and the Left Circumflex was 80% obstructed. The cardiac doc on call put a stent in the LAD and a week later another cardiac doc who specializes in stents put stents in the Ramus and Circumflex. Not an easy procedure. She estimated it had a fatality rate of 10% when she discussed it with me beforehand. It took her and the team 4 hours to put in two stents. The first stent took an hour and fifteen minutes. I was awake the whole time and watched the big monitors that showed what they were doing. It was cool. The music playing in the background was pretty good too. I watched them measure the inside of one of the arteries after it was expanded by a balloon and it was 3.8 mm by 4.2 mm. They used this info to select the proper diameter and length stent. It was a very interesting way to spend an afternoon.

I read up on hearts after all this and came to the conclusion that an angiogram is the only way to really know if you're okay or not. The problem is that catheter procedures have a 1% fatality rate so they won't do an angiogram without the appropriate justification. So the real problem in this from my point of view is that there doesn't seem to be a good way to conclusively prove your arteries aren't obstructed without doing an angiogram and they won't do an angiogram if you don't show signs of having a problem. An EKG can show if any of your heart muscles have been starved of blood and have scar tissue because the profile of the voltage on the plot is slightly different in certain places because the scar tissue has different resistance to the electrical signals that make your heart muscles work. That's probably why they do an EKG right off the bat because this is a good indicator what kind of problem you're having when you walk in the hospital.

Since I wasn't told that plaque isn't easy to detect when I had the usual tests done 6 and 18 months earlier I wasn't paying attention to what my physical situation was. I do a lot of hiking in the hills north of my house and in retrospect I can see signs of a problem that I didn't recognize at the time because I wasn't looking for them. One day I was two miles up my usual hiking trail at a location that is a 900 ft gain in elevation when I suddenly felt very tired. I mean, exhausted. Seriously exhausted. It was early on a July morning and it starting to get hot. I rested a bit but didn't feel any better. I decided to walk back. Normally this would take me 45 minutes but this time it took me 3 hours. I wasn't in a big hurry. Survival was more important than speed. I drove home and laid down and felt a little tingle in my left shoulder. I knew what that meant. A friend drove me to the hospital which was 10 minutes away. 20 minutes after walking through the Emergency Entrance I was laying on an operating room table. Pretty quick service.

I think each of us is our own best advocate for our health. Pay attention to what you are feeling and the little aches and pains that collect as we get older. When I look back on it I had hints that something was wrong but I wasn't looking for them and didn't know what they would feel like if they occurred. For a long time every month or two I felt an occasional twitch in my chest and a very mild pressure over a small region. Nothing painful or bothersome but noticeable. Since I've had the 3 stents put in I've never felt either of these things again. My heart is totally unnoticeable as it beats away. My resting heart rate is 51 beats per minute which is what it was earlier. It gets as high as 136 when I'm exercising. When I'm sleeping it's in the low 40's. My heart's ejection fraction used to be 70%. Immediately after the first stent was put in it was 35%. Now it's 50% and 55% (it's measured in two planes). Anything over 50% is considered a "full recovery" because the normal EF range is 50-70%. There's some scar tissue that resulted from blood starvation but it's not a big deal. I can run, ride bikes, hike and all the other things I've always done.

I'm not a healthcare professional so anything I mention is of dubious value to anyone but myself. Do your own homework and read up on these things. Make your own decisions about what's important for you. Pay attention to what you are feeling. Push yourself physically so you'll be aware of what your limits are and how your body handles this sort of thing.

I've tried to stay physically active. I think this worked to my advantage. When my arteries closed down enough to effect my physical performance when I was hiking up a steep section of the trail there was still enough blood flow to allow me to survive once I stopped pushing myself. I wasn't aware of what was going on but I knew I felt very tired and it would be wise to go slow and steady. If I hadn't been exercising this wouldn't have happened. My arteries would have continued being restricted and I wouldn't have known it. My guess is that if I wasn't physically active I'd have plodded along until one day I walked out to the mailbox and keeled over dead in my driveway because the exertion of walking 100 ft was finally too much for my heart to withstand.

Thought some of you might find this interesting. Your doctors will tell you what they believe is most likely but it's better to design for the worst case. (A lesson from engineering school.) You are your own best advocate for your health.

I'll also say that as we get older it's probably a good idea to live somewhere that has good healthcare nearby. If I lived 50 miles out in the boondocks instead of 5 miles from a decent hospital with a cardiac specialty group I probably wouldn't be writing this now.


Sorry for the extended babble. If my story saves the life of one person sometime in the future it was worth the time to write it.

Thank you for your post. DH had a heart attack followed by emergency quadruple bypass surgery after an angiogram indicated multiple severe blockages. Less than 3 weeks before his heart attack, he had a physical exam including an EKG which was normal. I asked his cardiac surgeon as well as a couple of the cardiac ICU nurses how we could have anticipated this shocking event. They all echoed your point that an angiogram is the gold standard, but due to its invasive nature, no one gets one until there are clear signs of an immediate problem.

Like you, DH said that in hindsight, he had experienced some similar symptoms before, but he thought he just had indigestion and the symptoms had always gone away after taking an antacid. This time they didn’t and when he described his symptoms to me, we agreed a trip to the ER was prudent. Thankfully it took us less than 10 minutes to get there. We should have called 911 and will do that if either of us needs an ER visit in the future.

Excellent point about advocating for our own health, and also really paying attention to what our bodies are telling us. Not sure if a calcium scan would have helped DH or not. His cardiologist seems to prefer echocardiograms as an ongoing monitoring tool.

 

[donheff]

I decided a few years ago to start a health log to track stuff. In my early 50's, there were a lot of things that were going on but they were more chronic and subtle so it was hard to tease out what caused what.

After a while, I was able to start noticing patterns and correlations. Then I started changing things a bit at a time to test things out. Some of the patterns were so subtle that it took a long time and addressing other confounding things first. And many of my health things are multifactorial - either A causes X, Y, and Z, or A, B, and C can cause X.

But after about three years of this, I now have a full page of what works for me and doesn't work for me in terms of sleep, diet, exercise, fatigue, hydration, and infections (which were an issue with me for a while). I can use this page to either avoid problems, or if something is wrong I can usually track it to something that I've forgotten to do.

Will it guarantee me a long healthy life? No. Is it as good as a double blind placebo controlled peer reviewed evidence based medicine? No. But it has helped me be healthier than I have in about two decades.

Two years ago I started doing this to track the effectiveness of various actions I take to control Parkinson's symptoms. It has been very helpful.

 

[oldtrig]

extract from post by RS53576GG
https://www.early-retirement.org/forums/f38/where-does-medicare-fall-short-114320-2.html

"The only thing I've had done in the last four years that Medicare wouldn't pay for was a Cardiac Calcium Test that measures the calcium buildup in your heart arteries. It was $104 which I was happy to pay since my cardiac doctor thought it was a good idea. My score came back as nearly zero. Turns out the CCT test doesn't detect plaque and plaque is usually what causes heart artery obstructions. Seven months after having the CCT I needed 3 stents, which gives you an idea of what the CCT was worth. Now I understand why Medicare won't pay for it."


My long-time wonderful doctor retired and now I'm searching for another doc. Meanwhile, I'm being seen by a PA in her old practice. The PA just suggested I get this Calcium Cardiac Test done, paying out-of-pocket, and handed me a form to call a local provider. I dutifully called for an appointment, and the earliest one I could get was Aug 31!

And based on RS53576GG's comment (above) about plaque and NOT calcium usually being the issue, I'm wondering if this test is more of a money-maker than something of diagnostic value.

Have others here taken this test? What was your experience? Useful or not? Positive/negative/neutral?

omni

I took the test 15 months ago. My total score was 262. They told me I had a good chance of having a heart attract in three to five years. My total cholesterol has never been over 150 and I take no medicine to lower it. I take a low dose of blood pressure medicine and have for twenty years. B/P is always normal in doctors office. I never check it otherwise.



The reason I had the heart scan was I started having heart palpitations all of sudden. Local doc sent me to heart doctor and he suggested I have it done. Nothing was found bad with my heart other that the higher than normal calcium. He told me to come back 6 months. I never did and don't plan on it. No more heart palpitations since. The stress of my wife breaking her hip probably caused it anyway.



I will be 75 next month . I wish I had never had the test. I think its a scam because the doctor told me if I would go to a hospital 50 miles away my insurance would pay. I just paid the local hospital $130 here one mile from my home.

 

[Dash man]

If they put you on a statin to minimize or eliminate further plaque build up you could live for a long, long time.

There's a guy on YouTube named Ford Brewer. He's an MD and talks a lot about preventative medicine. I think he has some videos where he discusses CCT and the generally benign behavior of calcified plaque.

Here's a story about my experience with Crestor. When I was in the hospital they started me on 40 mg Crestor every day. After I got out of the hospital and went to some followup visits with various doctors I noticed that my liver enzymes (ALT and AST) were going up. After a few months they were 50% higher than the max acceptable values. I have all my lab reports since 1995 so I plotted my ALT and AST for the last 27 years and showed them to my cardio doc and general doc. Both of them ignored the plot and said Crestor wasn't the problem and there must be something wrong with my liver. I should go see a gastro doc and get looked at.

I made an appointment and then I did some research. Turns out liver enzyme problems are well know for statins but they only happen to 0.1 to 1.0% of the people who are taking them. I saw the gastro doc and he said "Oh yeah, I see this all the time." We had some blood tests done over time and I cut the statin in half to 20 mg and watched the results. After a month he said "Stop taking the statin."

I was switched over to Praluent which is different type of drug for reducing cholesterol. It's more expensive but you take an injection every 15 days rather than a pill every day. It works fine. I feel great. Better than I felt when I was taking Crestor. Noticeably better.

Here's the really important thing that resulted from this. About 11 weeks after stopping Crestor I was out hiking one day and it suddenly struck me that I was thinking more clearly. I wasn't expecting this and certainly wasn't looking for it but it's something I noticed. For the following couple days I paid attention to how my thought processes were working and I was convinced that I was thinking more clearly. I looked into this and the Mayo website says that "mental fuzziness" is a well known side effect of statins. Some people have very noticeable problems while others are less significant.

The scary part about this is that I didn't notice my lack of mental acuity while it was happening. I only noticed it's absence once I stopped taking Crestor. If I hadn't been one of the 1% who have liver enzyme problems from taking a statin I'd have probably been "mentally fuzzy" for the rest of my life and never known it.

That's a frightening prospect.

Interesting. My cardiologist put me on 40mg of atorvastatin as soon as he saw the calcium score. That may explain the mental fuzziness I sometimes have. I haven’t experienced any other side effects. I thought it was just aging. I’ve had the increased liver enzymes, but they returned to normal after losing ten pounds.
Since I’m doing well according to my cardiologist, I’ll likely keep things as they are. I’d rather be fuzzy than dead.

 

[testing321]

CAC score appears not to have much value:

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2791663

 

[skyking1]

two cardiologists I have seen never mentioned it.

 

[aja8888]

CAC score appears not to have much value:

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2791663

Studies like this are a reason Medicare won't cover it. My cardiologist did not recommend the calcium scan for me during any of my recent visits.

I did have SVT (Super Ventricular Trichardia - accelerated heartbeat) a few years ago, and that was fixed with an ablation procedure, and I underwent a battery of tests to determine SVT. None of the tests (stress, nuclear stress, etc, etc) I took indicated any heart issues beyond the SVT. The calcium scan was not recommended during that evaluation period.

All my recent blood work results are normal in all categories and I take no meds other than one for BHP, which is common in old men like me at almost 79.