Calcium Score Testing to Simplify Pre-op Cardiac Clearance for Cosmetic Surgeons

Calcium Score Testing to Simplify Pre-op Cardiac Clearance for Cosmetic Surgeons

Filiberto Rodriguez, MD, FACS, FAACS

Preoperative cardiac clearance is often needed for older patients desiring elective cosmetic surgery. This is especially true for patients with a history of diabetes, hypertension, or hypercholesterolemia. It is well known that the epinephrine in the tumescent solution that we regularly use often causes transient tachycardia, increased myocardial contractility, and increased afterload (vasoconstriction), which all increase the cardiac workload. If a patient has undiagnosed underlying coronary artery disease (CAD), such increased cardiac work can result in myocardial infarction (MI) during surgery, which nobody wants.

For this reason, cardiac clearance can be very important.  While some patients have some type of health insurance and an established relationship with a primary care provider or cardiologist, which can facilitate cardiac clearance, many of our self-pay cosmetic surgery patients do not. In addition, it is often important to consider the added financial costs associated with cardiac clearance. 

For cardiac clearance, a simple EKG is not enough. The baseline EKG in patients 50 and older provides a baseline for comparison in the event of a subsequent MI during or after surgery. Traditional cardiac clearance involves the use of cardiac stress testing (exercise or adenosine) to detect EKG abnormalities from underlying CAD. Such cardiac stress testing relies on interpretation from cardiologists and is an expensive screening modality. Stress myocardial perfusion scans (MPS) can further help identify intermediate-risk patients likely to have CAD. For MPS, rest thallium-201 images are compared to post-stress technetium-99 images. MPS is obviously more expensive than cardiac stress testing alone.

Coronary artery calcium detected by fast x-ray computed tomography (CT) or electron beam CT is associated with the presence of coronary atherosclerosis. The Calcium Score (CS) test is essentially a simple non-contrast CT scan of the chest to quantify the calcium burden on the coronary arteries. This is a screening test for the presence of coronary artery disease and does not quantify the degree of coronary artery stenosis. Because insurance does not cover CS testing, the CS has not been strongly embraced by the cardiology community, who would prefer to bill for cardiac stress testing. CS, however, has been shown to be more sensitive and specific compared to simple cardiac stress testing.

Recent studies have also demonstrated the relationship between CS and MPS, finding that: “1) an ischemic MPS is associated with a positive calcium scan, but rarely with a calcium score < 100; 2) a calcium score < 100 eliminates the need for a stress test; 3) normal MPS patients frequently have coronary calcium, suggesting a role for coronary calcium scanning in patients with a normal MPS if their risk for CAD is unclear.” (Berman DS, et al. J Am Coll Cardiol. 2004;44: 923-930.)

CS is a non-invasive and low cost (about $100) test that provides meaningful data. In my practice, a low-risk CS (<100) provides good cardiac clearance, whereas intermediate (100-400) or high-risk (>400) scores warrant referral to a cardiologist for additional workup.