The Truth About Coronary Calcium Tests

What A Coronary Calcium Test Can—and Can’t—Tell You About Your Heart Attack Risk

The way most doctors use these tests exemplifies structural failures of the healthcare industry as a whole.

I’ve gotten numerous requests to write an article on coronary calcium tests over the years. Then I met George, whose experience within the medical system finally pushed me to do it. As you’ll see, these tests are widely misused.

But it’s not just that cardiologists misuse the coronary calcium test. The entire system fails to follow protocols I was taught are necessary for proper patient care. The healthcare system now behaves less like a healing profession and more like a self-serving organism, consuming enormous resources while too often harming the very people it exists to serve.

As this story shows, reflexive testing too often substitutes for the more difficult and time-consuming interview process. Diagnoses are never made. Test results are often incompletely shared. Patients are even misled into undergoing invasive procedures that have no chance of helping them. My medical school mentors who taught me how to take a careful history would be rolling in their graves if they knew.

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I wrote this article not to curse the darkness, but to light a candle–and empower you to protect yourself.

Failure #1: Not Listening To The Patient’s Symptoms Before Ordering Tests.

This story focuses on a man named George, who kindly gave me permission to tell his story here.

Back in 2018, George developed pain in his calves. It bothered him enough to go to his doctor. So off he went.

When you go to a doctor with a symptom, the doctor is supposed to ask a bunch of diagnostic questions. These would include questions like “What brings on the pain?” “How long does the pain last?” “What do you do to relieve the pain?” But when I spoke to George years later, he was pretty sure his doctor didn’t ask those kinds of questions.

Instead, his doctor focused on just one possibility, a circulatory problem called intermittent claudication. Intermittent claudication is caused by blockages in the arteries to the legs that limit blood delivery. It can be very serious. So physicians are supposed to ask people about their symptoms to see if the pattern fits. We can easily find out with two questions:

• Does pain start while walking?
• Does it go away when you stop walking, or sit?

If the answers to both are no, then there is at most a very low chance that the patient has claudication. The range is 0-10%, and the doctor should move on to consider other conditions.

On the other hand, if the answer to either one of those two questions is yes, then it could be claudication, and testing needs to be done.

The Rollercoaster Ride Begins…

When I asked George if he’d had claudication symptoms, he said definitely not. Meaning there was no need for further heart testing. In other words, if the very first doctor he saw had been more thorough, it could have saved George the many years of worry I’m about to describe in the rest of his story. 

So even though there was no real reason to send him for a test for intermittent claudication, his doctor sent him anyway. When George returned to review his results, they were normal. So what caused the leg pain? His doctor didn’t pursue it further. Fortunately, his leg pain would later go away on its own. 

Unfortunately, while at the office to find out his first set of results was perfectly normal, his doctor asked him another question. Not about his leg pain, which remains a mystery to this day. But about symptoms George was not the least bit concerned about. As you’ll see, that exchange has since launched George into years of treatments, unnecessary prescriptions, and follow-up visits.

Failure #2: Assuming “Chest Pain” Equals “Heart Problem”

Back at the doctor’s office, after George found out the results of his leg scan were normal, his doctor asked if he ever had chest pain.

George told me, “Not knowing what kind of chest pain he was referring to, I said yes.” George had acid reflux, which can also cause chest pain. Chest pain from acid reflux is often very easy to distinguish from chest pain from a heart problem. But a doctor has to ask the right questions to know the difference.

During my conversation with George, I asked him if he remembers the cardiologist asking diagnostic questions like “Is your pain brought on by overeating?” and “Does exercise bring it on?” and “Is it  relieved by rest?” George remembers being surprised by the lack of clarifying questions. Instead, the primary doctor jumped right to the conclusion that it could be his heart, and sent him to the cardiologist.

Unfortunately, the cardiologist didn’t do a diagnostic rundown, either. However, he was happy to order a bunch of tests.

Failure #3 Using Gastric Reflux as an Excuse to Do Expensive, Invasive Heart Tests

The minute George set foot in the cardiologist’s office, any semblance of diagnostic decency flew out the window. Rather than first determining whether George’s symptoms were even compatible with heart disease, the cardiologist immediately ordered an EKG. Then, an exercise stress test, a CT scan, and finally a nuclear stress test. To me, this is a classic fishing expedition: ordering multiple expensive tests before establishing that there’s a good clinical reason to suspect the disease you’re looking for.

An excuse I frequently hear for ordering tests that aren’t medically indicated is this:

“Better safe than sorry.”

It sounds reasonable, but it ignores a fundamental principle of medicine: every test should answer a question that genuinely needs answering. Tests aren’t harmless. Some expose patients to radiation or invasive procedures; others lead to false positives and unnecessary follow-up. All consume time, money, and attention.

On a more basic level, this practice defies common sense. Because if you haven’t done a basic history, you’re putting the cart before the horse. And putting your patients’ lives at risk.

In George’s case, his doctors should have established whether any of his symptoms actually suggested heart disease before ordering so many heart tests.

Fortunately for George, none of these tests revealed significant blockages. Even though there were no significant blockages, the CT scan showed calcium in the arteries to his heart. Quite a bit. His coronary calcium score was 904 on a scale that starts with 0. That sounds pretty high, right? Well yes, but…. the score can be as high as 5000, and it’s very age dependent. Which leads us to the next failure.

Failure #4: Not Contextualizing a High Coronary Calcium Score As Probably Normal For Age and Sex

Patients like George who come to me concerned about their high scores, and are over 40 years old, have generally been led to believe that their high score is more unusual than it really is. One very disturbing thing that I’ve noticed about some of these reports is that they do not provide you—or your doctor—with one vital piece of information: what number is considered abnormal for your age and sex?

George’s report was typical in that it contained this alarming language: “A calcium score of 401 or higher indicates extensive plaque with a high likelihood of coronary narrowing.” That sounds frightening, especially if your score is much higher than 401. But there’s an important problem with using that number as a universal benchmark. It comes from studies of people who had much higher chance of having heart disease than George. For example, they’d had previous heart attacks, or were diabetics, or had chest pain with exercise. George wasn’t in that situation. It’s like he was an orange being compared to an apple and then told he had abnormally lumpy skin. 

How Coronary Calcium Scores (CAC scores) SHOULD Be Reported

The range of possible coronary calcium scores is wide, starting at 0 and going up over 5000. It tends to go up as we age. The report tells you how far you’re above or below your age-matched average.

But for tests like the CAC score (BTW, CAC stands for coronary artery calcium), simply being above average for your age doesn’t equate to abnormal. In this scenario, a result usually has to fall well outside the normal range—often about two standard deviations from the mean—before physicians should regard it as clearly abnormal. To be considered truly unusual for his age, George’s score would have needed to be over 1609, not 904. The report should reflect that. But it doesn’t.

So as you can see, the report itself is somewhat misleading, but that’s actually a minor issue compared with the deeper problem of CAC testing. It tells you how much calcified plaque you have, but it doesn’t tell you whether you have the kind of plaque that’s most likely to cause a heart attack. To understand this limitation of CAC testing, you need to know that there are several different kinds of plaque with very different consequences for your health.

Which takes us to the next failure:

Failure #5: Not Telling Patients That There Are Different Types of Plaque

Most patients who’ve been advised to get a coronary calcium test are generally under the impression that plaque is plaque. They know you can have different amounts of plaque, but they’ve not been told that there are different types of plaque. This is vital to know because different plaques have completely different impacts on your health.

In reality, there are three types of plaque. Two are very common: stable (or calcified) and unstable (or fatty). A third is less common and also the most dangerous: inflammatory. All plaque starts out fatty and soft—and a little unstable. This kind of fat is potentially dangerous because it is at risk for becoming inflamed. When it becomes inflamed, it is truly dangerous becuase is at great risk for rupturing, which often causes heart attacks.

But the body is smart. Incredibly, it’s got a treatment plan for hardening these softer, potentially dangerous plaques. The body adds calcium and protein to the fat, stabilizing and hardening it. So even though you may have plaque, which sounds bad, if it’s calcified, your body has addressed the issue in the best possible way. 

Three Major Types of Plaque: Fatty, Calcified & Inflamed 

I hope you can see where I’m going with this discussion. As you may be guessing, since it’s called a Coronary Calcium test, the CAC test can only see the plaques that have calcium. It can’t see plaques that are fatty or inflamed. So a high calcium score tells you only that you have a lot of stable, not very dangerous plaques. What it doesn’t tell you is whether or not you also have the potentially dangerous fatty plaques. Nor does it tell you whether or not you have any of the most dangerous, inflammatory plaques.

The thing is, we now have a test that DOES show all three types of plaque! And people should be told about this test. I’ll discuss it below.

Instead of being told the truth about plaque, or that there is a better test, most people are told to take a statin. Including George.

Failure #6: Leading Patients To Believe Statins Can Reduce Coronary Calcium Scores

After George’s doctor told him about that score of 904, he prescribed George a statin to keep his cholesterol down. George recalls his doctor saying that without a statin, his plaque could break off and cause a heart attack. So of course, with that scary image placed in his mind, he started a statin. He was under the impression that taking a statin was going to help reduce his calcium score, thus reversing the atherosclerotic plaque in his arteries. He dutifully took the statin for two years, and then in 2020 requested another CAC test to see if the score had changed.

It changed, alright. But not the way George was expecting. The second score was 1170—hundreds of points higher. The doctor explained this disappointing result as follows: “because the Pravastatin is causing more calcium to stick in your arteries.”

That statement is one of those little lies that drives me crazy. Statins don’t cause calcium to stick in your arteries. The body does that magic act on its own. If statins do anything at all, they may reduce the development of new fatty plaques by reducing the amount of easily oxidizable triglyceride in the blood. But a more effective and safer way to reduce the development of new plaques is through diet. (If you’d like to learn more about when I’d recommend statins, LMK in the comments).

A conscientious physician should tell people that statins will make their score go up instead of allowing them to believe otherwise. 

But few doctors do that. Probably because something in their mind warns them that if they give their patients this counterintuitive information, the patient might start asking pesky questions. 

Which leads me to the next failure.

Failure # 7: Not Telling Patients That The Body Can Put Calcium In Your Arteries Without Drugs

As I mentioned above, the body puts calcium in our arteries all the time. That’s how calcified plaque forms. That’s what causes high CAC test scores. We don’t need drugs for that. Period.

As the body adds calcium to a fatty plaque, it also adds protein, which provides the matrix that supports the calcium (see figure above). At the same time, much of the soft fat is removed. A little cholesterol remains behind, providing waterproofing and serving as part of the plaque’s structure. As plaque changes from fatty to stabilized, it often shrinks somewhat. This observation has been used to suggest that statins shrink plaque. But the real story is that plaque stabilization and shrinkage are both part of the body’s natural healing process. No statins required—if you follow a lifestyle that allows our healing processes to play out.

So I hope you can see that the simple story George was told is already starting to unravel. 

Those questions bring me to Failure #8.

Failure #8: Not Clearly Explaining What Having Calcified Plaque and a High CAC score Means

After I told George the good news, that his calcified plaque is unlikely to cause a heart attack, I had to give him some bad news. The fact that he has calcified plaque means two things. First, that his prior diet had harmed his arteries. His prior diet was high in seed oils and low in protein–two factors that promote oxidative stress and atherosclerosis. Second, anyone with calcified plaque is statistically more likely to have fatty plaque somewhere in their arteries. Fortunately for George, his improved diet probably prevented that—and we now have a way of testing this idea (discussed below).

But the most important thing to know about calcified plaque is that it can block off little tiny arteries. Large coronary arteries give rise to countless tiny branches. These tiny branches dive deep into the heart muscle to supply it with blood. Long before there’s enough plaque to clog the big arteries, there’s often more than enough to clog the little tiny ones. And in this case, it doesn’t matter whether the plaque is fatty or calcified. These occlusions reduce blood flow to the muscle downstream of that tiny artery.

If the body is unable to compensate for this loss of blood flow, that little portion of heart muscle can be damaged. Many such blockages can cause structural changes that make the heart stiff, weak, or both. This condition is called heart failure.

Fortunately, your body has a remarkable backup system for this problem of little blockages that can prevent this from happening.

And now we need to talk about what may be the biggest medical failure of all:

Failure #9 Not Telling You That Your Body Can Bypass Plaques ON ITS OWN (No stent, no surgery required) With Proper Support From YOU

Most non-medical people are led to believe there are only two ways to manage a blocked coronary artery: stents or bypass surgery. That’s not true. Your body has been building its own bypasses your entire life.

This remarkable process is called angiogenesis, meaning the formation of new blood vessels. It’s how your body grows, heals injuries, adapts to exercise, and responds to gradually developing coronary artery disease.

As described above, when plaque slowly accumulates inside a coronary artery, it gradually narrows or obstructs the openings of the tiny branches that supply blood to the heart muscle. Because this process usually unfolds over many months or years, the body has time to adapt. It does so by growing brand new baby blood vessels, called collateral vessels. These tiny collateral vessels can deliver oxygen and nutrients to the heart muscle just as well as the originals did. In fact, people who are really good at growing collateral blood vessels can have a completely blocked major artery and still have completely normal blood flow to their heart.

It’s all about the speed at which a new blockage develops.

If an inflammatory plaque suddenly ruptures and causes a heart attack, blood flow is cut off in minutes. There isn’t enough time for the body to build new vessels. That is why emergency procedures such as stents or bypass surgery can save heart muscle—and save lives.

Stable, calcified plaque is different. It develops gradually, giving the body its opportunity to compensate by building new blood vessels. But not everyone’s body can compensate.

Whether your body builds new blood vessels depends on your physiology.

Growing new blood vessels is an energy-intensive repair process that depends on healthy blood vessels and healthy signaling between cells. Smoking, physical inactivity, diabetes, poor nutrition, and other factors that damage the lining of blood vessels can impair this remarkable ability.

At this point, I should give you a little more of George’s background. George had always taken his health seriously. He didn’t smoke, exercised regularly, and for several years had been following the dietary program I recommend. His second stress test, a nuclear exercise stress test, showed normal blood flow throughout his heart during exercise. In other words, despite having calcified plaque, his heart appeared to be getting all the blood it needed.

Unfortunately, because most patients don’t know that this natural bypass system exists, they also don’t know that not every blockage seen on an angiogram requires a stent or bypass surgery, as I’ll discuss next.

Failure #10: Using Stents and Bypasses In Situations Where They Won’t Save Your Life

Cardiologists know about your body’s ability to bypass itself by growing new blood vessels. But their patients usually don’t. And this makes it all too easy to sell unnecessary procedures. Most people assume that seeing a severe blockage on an angiogram automatically means it needs to be opened with a stent or bypass surgery.

But the truth is, having a blockage does not always mean you need a stent. In fact, studies show that putting stents into people with stable plaque and stable symptoms does not save lives. It may reduce their symptoms. But it’s not a life-or-death thing. Unfortunately, my patients who’ve gotten stents in this scenario were not told the truth. 

According to numerous investigations, including one by USA Today, unnecessary coronary procedures remain a significant problem. These procedures are generally not performed on people with completely normal arteries. They are performed on people who have visible blockages on angiograms. If patients don’t understand the difference between a blockage that requires treatment and one that does not, they are in no position to question the recommendation.

Another survey reported on in this video, found that a substantial percentage of cardiologists acknowledged performing procedures they believed were unlikely to benefit the patient. Regardless of the reasons, this is exactly why patients deserve to understand how coronary artery disease really works before deciding whether an invasive procedure is necessary.

Failure #11: Not Telling Patients That Removing Calcium From Plaque Doesn’t Solve Anything 

A lot of people, including George, have asked me, “How do I get the calcium out of my arteries?” My answer is always the same: You definitely don’t want to do that.

Once plaque is stabilized, it’s as durable and waterproof as cured bathroom tile caulk. I’ve examined plaques removed from carotid arteries back in the day when carotid endarterectomy was commonly performed. They are remarkably tough.

George left his cardiology appointments believing that the calcified plaque in his arteries could break off and kill him. I’ve heard the same concern from many patients over the years. But having a lot of calcified plaque does not, by itself, mean that some area of plaque is more likely to rupture. The danger comes from inflammatory plaque. 

Failure #12: Leading You To Believe That A Little Bit Of Plaque Inevitably Becomes More

Let’s look at the picture almost every cardiologist’s office has hanging on the wall for patients to see.

Typical Misleading Model of Coronary Artery Plaque Progression

This picture is very misleading. It doesn’t show the calcification process at all, leading people to believe there is only one type of plaque and it’s dangerous. That’s not true–as we’ve discussed. This kind of image also gives the impression that heart attacks mainly occur in very large plaques. Also not true. Most heart attacks arise from much smaller plaques, and more than half occur in areas of narrowing so small they are completely invisible on conventional angiograms. And, the picture leads us to believe that, once plaque starts, it’s inevitably going to keep building up. Unless, of course, you take a statin or get a stent. But of course that’s not true either. A healthy diet prevents plaque from building up. 

I could keep going all day with these failures because there are many more. But I’ll finish with one last failure—the one George is currently most frustrated by.

Failure #13: Not Ordering a Test that Can Show All Three Types of Plaque

Cardiologists know about all three types of plaque: stable, fatty, and inflammatory. They know a coronary calcium test shows only the stable, calcified plaques. But what very few cardiologists seem to know—at least as of the date I’m writing this article—is that there is now a test that can show all three types of plaque.

George wanted to meet privately becuase he’d attended my master class where I teach about a new type of technology. It’s called Coronary Computed Tomography Angiography (CCTA) and Artificial Intelligence Quantitative Computed Tomography (AI-QCT). Basically, all that means is it’s an AI-assisted CAT scan of your coronary arteries. Two brand names are Cleerly and Heartflow.

These new tests can identify all three major types of plaque, and can be extremely valuable for someone with a high CAC score or a high LDL who is being told to take a statin, change their diet or just trying to understand their true heart attack risk. They’re more invasive than a simple coronary calcium test because they require IV contrast dye. George wanted to speak with me to make sure he understood the science correctly. It was during that visit that I encouraged him to ask his cardiologist for one of these scans. So he did.

The cardiologist’s response surprised both of us.

His cardiologist told him he had never heard of such a thing. He also said the results wouldn’t change his recommendation—which was to take a statin. Therefore, he wasn’t willing to order it.

Do I think George absolutely needs one of these scans? Probably not. But after spending nearly eight years believing his calcium score meant he was living with a ticking time bomb, I think he deserves the opportunity to answer the question that has worried him all this time:

Does He Actually Have Dangerous Plaque?

In my opinion, that’s the question his medical team should have been trying to answer from the beginning.

And in my opinion, George is very unlikely to have dangerous plaques. I say this because of 1) the healthy dietary changes he has maintained since reading my books years ago, 2) his ability to do heavy activity, 3) his lack of diabetes, hypertension, or other diseases that indicate overall high risk, and 4) his normal exercise stress tests. So, in that sense, this story does have a happy ending. Not thanks to his doctors. Thanks to him being proactive about his health. 

George’s story isn’t unique. I’ve now heard versions of it from far too many people. When I graduated, the healthcare system wasn’t perfect, but in general we patched people up and sent them on their way better than they came in. Today, it’s become a dangerous maze.

The Medical Labyrinth

That’s what I call the system that converts healthy people into patients.

George’s story began with a minor pain in his calves. Instead of getting a diagnosis for his pain, George got a one-way ticket to enter the medical labyrinth.

George spent the better part of eight years being repeatedly told he had a dangerously high coronary calcium score without anyone explaining what that score actually meant. He was never taught the difference between stable plaque and unstable plaque. He wasn’t told that calcification is part of the body’s natural stabilization process. He wasn’t told that his body can often compensate for slowly developing plaque by growing new blood vessels. He was given a statin, which made him feel sluggish and unhealthy. And when he finally asked for a test that could distinguish among all three types of plaque, he was told no.

Fortunately, George has become proactive about his health. Years ago, after reading my books, he developed the confidence he needed to stop his statin. He also ditched the diet that caused plaque to build up in the first place. And now he feels better in his 70s than he did in his 20s. If he hadn’t made these changes, it’s likely that by now another symptom would have lured him deeper into the labyrinth.

I hope that, after reading this article, you now understand coronary artery disease more completely. And I hope this deeper understanding helps keep you, or someone you know, out of the medical labyrinth. If you liked this article, please share. And if you’d like to learn more from me, check out my books and my masterclass. 

Now I’d like to hear from you.

Do you think I’m being unfair in calling out these failures?

Have you had an experience similar to George’s?

Would you want a Cleerly or Heartflow scan if you were in this situation, or would you trust your body?

Have you had a Cleerly or Heartflow scan? Tell me below in the comments—I’d love to hear your thoughts.