The Slidepacks to go with the Chronic Disease University! Number 3 - The Power of the Coronary Artery Calcification Scan and More

1. 2017 Ivor Cummins BE(Chem) CEng
An Engineering Guide to
Chronic Disease Avoidance
From Measuring it - to
Managing it
Ivor Cummins BE(Chem) CEng MIEI PMP®

2. David Bobbett and his Irish Heart Disease Awareness charity
(http://www.IHDA.ie/)

3. If you Don’t Measure It
- it Don’t Get Fixed
PART 1

4. Rule Zero: Always Honor Pareto
20% of the input (Time, Resources,
Effort)
Account for 80% of the Output (Results,
Rewards)

5. Rule Zero: Always Honor Pareto
20% of the Root Causes for the
Issue…
Account for 80% of the Issue Resolution

6. David Bobbett – one of the Saved
* CEO/Owner of H&K International
* Jogging ~4 times per week
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker

7. David Bobbett – one of the Saved
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG

8. David Bobbett – one of the Saved
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG

9. David Bobbett – one of the Saved
* CAC=906 ! Worst 1% for age.
* CAC supersedes all
tests
* ~75% chance of Heart Attack
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG

10. David Bobbett – one of the Saved
* CAC=906 ! Worst 1% for age.
* CAC supersedes all
tests
* ~75% chance of Heart Attack
* Angio shows severe blockages
* No Surgery – lifestyle + meds fix
* David takes 6mths to study
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG

11. David Bobbett – one of the Saved
* CAC=906 ! Worst 1% for age.
* CAC supersedes all
tests
* ~75% chance of Heart Attack
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG
* Angio shows severe blockages
* David takes 6mths to study
* He was diabetic, undiagnosed
* But Heart Disease IS resolvable
* Nutrition is primary ROOT CAUSE
* No Surgery – lifestyle + meds fix

12. David Bobbett – one of the Saved
* CAC=906 ! Worst 1% for age.
* CAC supersedes all
tests
* ~50% chance of Heart Attack
* He was diabetic, undiagnosed
* But Heart Disease IS resolvable * Founded www.IHDA.ie
* Funded The Widowmaker
Movie
* Total Philanthropy
* Resolved his disease
process
* CEO/Owner of H&K International
* Jogging ~4 times per week
* 15 executive medicals…
* All Bloods Good
* Fittest 10% for age
* Described by docs as “bulletproof”
* 52 years old, slim and fit non-smoker
* Treadmill Stress Tests/ECG
* Angio shows severe blockages
* David takes 6mths to study
* Nutrition is primary ROOT CAUSE
* No Surgery – lifestyle + meds fix

13. The Biggest Challenge:
Atherosclerosis

14. Google “Budoff Ivor”
“Progression to Disability and/or Death…
Passage of Time…

15. Google “Budoff Ivor”
Passage of Time…
“Progression to Disability and/or Death…

16. Google “Budoff Ivor”
Passage of Time…
“Progression to Disability and/or Death…

17. Google “Budoff Ivor”
Passage of Time…
HEART
ATTACK!
“Progression to Disability and/or Death…

18. Maybe 10-20
Years...
Passage of Time…
HEART
ATTACK!
“Progression to Disability and/or Death…

19. Passage of Time…
Stabilization
“Progression to Disability and/or Death…

20. CAC: THE MASTER MEASURE
Google “Budoff Ivor”

21. “We Stand on the Shoulder’s of Giants…”
Bruce Brundage
Cardiologist
Former Professor David
Geffan School of Medicine
UCLA
Doug Boyd
Physicist, Inventor of CAC
Technology
Former Professor of Radiology
(Physics) UCSF
Harvey S. Hecht
Cardiologist
Professor Mount Sinai
Medical Centre New York
John A. Rumberger
Cardiologist
Princeton Longevity Centre
Matthew J. Budoff
Cardiologist
Professor of Medicine UCLA
Arthur Agatston
Cardiologist
Associate Professor of
Medicine University of Miami

22. Calcium Score Risk Equivalent 10-Year Event Rate, %
0 Very low 1.4
1 – 100 Low 4.1
101 – 400 Intermediate 15
>400 High 26
>1000 Very high 37
J Am Coll Cardiol Img. 2015;8(5):579-596
Based on 100’s of thousands of subjects
Reproducible and quantifiable
CAC: THE MASTER MEASURE FOR HEART ATTACKS
? ? ?

23. Calcium Score Risk Equivalent 10-Year Event Rate, %
0 Very low 1.4
1 – 100 Low 4.1
101 – 400 Intermediate 15
>400 High 26
>1000 Very high 37
J Am Coll Cardiol Img. 2015;8(5):579-596
Based on 100’s of thousands of subjects
Reproducible and quantifiable
CAC: THE MASTER MEASURE FOR HEART ATTACKS
? ? ?

24. Calcium Score Risk Equivalent
Patients Dead after 12
Years
0 – 10 Very low 0.6%
11 – 100 Low 2.2%
101 – 400 Intermediate 5.5%
401 – 1000 High 7.0%
>1000 Very high 23.1%
J Am Coll Cardiol. 2007 May 8;49(18):1860-70.
25,253 patients followed for 12 years…
CAC: THE MASTER MEASURE FOR DEATH
? ? ?

25. Calcium Score Risk Equivalent
Patients Dead after 12
Years
0 – 10 Very low 0.6%
11 – 100 Low 2.2%
101 – 400 Intermediate 5.5%
401 – 1000 High 7.0%
>1000 Very high 23.1%
J Am Coll Cardiol. 2007 May 8;49(18):1860-70.
25,253 patients followed for 12 years…
CAC: THE MASTER MEASURE FOR DEATH
? ? ?

26. Calcium Score Risk Equivalent
Patients Dead after 12
Years
0 – 10 Very low 0.6%
11 – 100 Low 2.2%
101 – 400 Intermediate 5.5%
401 – 1000 High 7.0%
>1000 Very high 23.1%
J Am Coll Cardiol. 2007 May 8;49(18):1860-70.
25,253 patients followed for 12 years…
CAC: THE MASTER MEASURE FOR DEATH

27. Calcium Score Risk Equivalent
Patients Dead after 12
Years
0 – 10 Very low 0.6%
11 – 100 Low 2.2%
101 – 400 Intermediate 5.5%
401 – 1000 High 7.0%
>1000 Very high 23.1%
J Am Coll Cardiol. 2007 May 8;49(18):1860-70.
25,253 patients followed for 12 years…
CAC: THE MASTER MEASURE FOR DEATH

28. 10
15
20
25
5
45-54
Heart
Attack
Rate
in
10
Years
55-64 65-74 75-84
CAC=0 CAC=1-100 CAC>100
Age:
Mayo Clin Proc. 2014 October ; 89(10): 1350–135
CAC – the Ultimate Test

29. 10
15
20
25
5
45-54
Heart
Attack
Rate
in
10
Years
55-64 65-74 75-84
CAC=0 CAC=1-100 CAC>100
Age:
Mayo Clin Proc. 2014 October ; 89(10): 1350–135
CAC – the Ultimate Test

30. Can We Intervene
- to Slow or Stop Progression?

31. The Key is to Slow or Stop
PROGRESSION
“Progression of Coronary Artery Calcium and Risk of First Myocardial Infarction in Patients Receiving Cholesterol-
Lowering Therapy”
Score Increase >15% per yr
Score at Start
100-1000
~50
%
Heart
Events
~3%
Heart
Events
Score Increase <15% per yr
Score at Start
100-1000

32. William Davis MD
Cardiologist

34. Smoking Vs CAC Score…and Taking
ACTION
“Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers” European Heart

35. Smoking Vs CAC Score…and Taking
ACTION
“Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers” European Heart
NON-SMOKERS
CAC Less Than 10 …5 Years Pass by…

36. Smoking Vs CAC Score…and Taking
ACTION
“Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers” European Heart
SMOKERS
CAC Less Than 10
NON-SMOKERS
CAC Less Than 10 …5 Years Pass by…
…5 Years Pass by…

37. Smoking Vs CAC Score…and Taking
ACTION
NON-SMOKERS
CAC More Than 1000
“Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers” European Heart
SMOKERS
CAC Less Than 10
NON-SMOKERS
CAC Less Than 10 …5 Years Pass by…
…5 Years Pass by…
…5 Years Pass by…

38. Smoking Vs CAC Score…and Taking
ACTION
NON-SMOKERS
CAC More Than 1000
“Prognostic value of coronary artery calcium screening in asymptomatic smokers and non-smokers” European Heart
SMOKERS
CAC Less Than 10
NON-SMOKERS
CAC Less Than 10 …5 Years Pass by…
…5 Years Pass by…
…5 Years Pass by…

39. Diabetes and CAC
Your Warranty Revealed…

40. Warranty Periods Explained…
DIABETICS
NON- DIABETICS
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.

41. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
DIABETICS
NON- DIABETICS
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.

42. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
DIABETICS
NON- DIABETICS
DIABETICS ~5 Years
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.

43. Warranty Periods Explained…
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
NON- DIABETICS: warranty for ~15 years…
DIABETICS ~5 Years
DIABETICS
NON- DIABETICS
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

44. Warranty Periods Explained…
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
NON- DIABETICS: warranty for ~15 years…
DIABETICS ~5 Years
DIABETICS
NON- DIABETICS
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

45. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
DIABETICS
NON- DIABETICS
NON- DIABETICS
DIABETICS
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
DIABETICS ~5 Years
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

46. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years… NO WARRANTY FOR ANYONE HERE !!!
DIABETICS
NON- DIABETICS
NON- DIABETICS
DIABETICS
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
DIABETICS ~5 Years
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

47. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
DIABETICS
NON- DIABETICS
NO WARRANTY FOR ANYONE HERE !!!
NON- DIABETICS
DIABETICS
DIABETICS ~5 Years
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

48. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
NON- DIABETICS
DIABETICS
DIABETICS
NON- DIABETICS
NO WARRANTY FOR ANYONE HERE !!!
DIABETICS ~5 Years
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

49. Warranty Periods Explained…
NON- DIABETICS: warranty for ~15 years…
NON- DIABETICS
DIABETICS
DIABETICS
NON- DIABETICS
NO WARRANTY FOR ANYONE HERE !!!
DIABETICS ~5 Years
Re-Check CAC for ‘non-Diabetics’:
1. Who will no longer be zero?
2. Who now has risky Athero burden?
3. Which of these guys have now
become diabetic ??
Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low
Near-Term But Not Long-Term Risk of Mortality
Circ Cardiovasc Imaging. 2016;9:e003528. DOI: 10.1161/CIRCIMAGING.115.003528.
Re-Check CAC for Diabetics:
1. Many of them will no longer be zero
2. their Athero Burden could be approaching cliff !
3. Plaque Rupture & MI’s will begin to ramp !

51. Middle-
aged?
Middle-Risk?

52. Middle-
aged?
CAC
The
Ultimate
Decider
Middle-Risk?

53. Middle-
aged?
CAC
The
Ultimate
Decider
+
Middle-Risk?

54. Middle-
aged?
CAC
The
Ultimate
Decider
+
CAC
5-7 years…
Middle-Risk?

55. Middle-
aged?
CAC
The
Ultimate
Decider
+
CAC
5-7 years…
Middle-Risk?

56. Middle-
aged?
CAC
The
Ultimate
Decider
Trig/HDL ratio
PP Insulin Level
PP Glucose /
A1c
GGT / Ferritin
Blood Pressure
Homocysteine
+
CAC
5-7 years…
sdLDL,
ApoB/ApoA1
Middle-Risk?
Etc. etc.
Adiponectin

57. Middle-
aged?
CAC
The
Ultimate
Decider
Trig/HDL ratio
PP Insulin Level
PP Glucose /
A1c
GGT / Ferritin
Blood Pressure
Homocysteine
+
CAC
5-7 years…
sdLDL,
ApoB/ApoA1
Middle-Risk?
Etc. etc.
Adiponectin

58. Middle-
aged?
CAC
The
Ultimate
Decider
Trig/HDL ratio
PP Insulin Level
PP Glucose /
A1c
GGT / Ferritin
Blood Pressure
Homocysteine
+
CAC
5-7 years…
sdLDL,
ApoB/ApoA1
Middle-Risk?
Etc. etc.
Adiponectin
+

59. Middle-
aged?
CAC
The
Ultimate
Decider
Trig/HDL ratio
PP Insulin Level
PP Glucose /
A1c
GGT / Ferritin
Blood Pressure
Homocysteine
+
CAC
5-7 years…
sdLDL,
ApoB/ApoA1
Middle-Risk?
Etc. etc.
Adiponectin
+

60. Middle-
aged?
CAC
The
Ultimate
Decider
Trig/HDL ratio
PP Insulin Level
PP Glucose /
A1c
GGT / Ferritin
Blood Pressure
Homocysteine
+
CAC
5-7 years…
sdLDL,
ApoB/ApoA1
Middle-Risk?
Etc. etc.
Adiponectin
+
CAC
~2yrs

61. A Recent Irish Example…

62. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
Noel

63. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
Noel

64. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
* Stress Test Good
* Echocardiogram
Good
* All Good – no
worries!
Noel

65. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
* Stress Test Good
* Echocardiogram
Good
* All Good – no
worries!
Our engineer
demands a…
Calcium
Scan
Noel

66. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
* Stress Test Good
* Echocardiogram
Good
* All Good – no
worries!
* CAC=25. Diffuse
Calcification throughout
coronary vessels
* It’s NOT All Good.
Our engineer
demands a…
Calcium
Scan
* It’s NOT “No Worries”.
Noel

67. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
* Stress Test Good
* Echocardiogram
Good
* All Good – no
worries!
* CAC=25. Diffuse
Calcification throughout
coronary vessels
* It’s NOT All Good.
Our engineer
demands a…
Calcium
Scan
* His Framingham Risk was
5%
* CAC = 25 means arteries
of
* His real (MESA) risk is >30%
a 64 year old. (+/- 2 years)
* It’s NOT “No Worries”.
Noel

68. A Recent Irish Example…
44 y.o.
Engineer.
3 children.
Concerned.
* Brother quadruple bypass at
52
* Cousin died of Heart Attack at
50
* Other nasty family history…
* Cholesterol Good
* Other Bloods Good
* All Good – no
worries!
* Stress Test Good
* Echocardiogram
Good
* All Good – no
worries!
* CAC=25. Diffuse
Calcification throughout
coronary vessels
* It’s NOT All Good.
Our engineer
demands a…
Calcium
Scan
* His Framingham Risk was
5%
* CAC = 25 means arteries
of
* His real (MESA) risk is >30%
a 64 year old. (+/- 2 years)
* It’s NOT “No Worries”.
“I’m all over it Ivor…
I’m all over
it”
Noel