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Longevity Science

Executive Physical With Calcium Score: What It Decides

12 min read
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Andrew Le, MD

Andrew founded Renew Health to change how cardiovascular disease is detected and treated.

A cardiac CT scan for coronary calcium is a noninvasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries (RadiologyInfo: Calcium scoring). Is it worth it? In adults at intermediate risk (7.5% to under 20% 10-year risk) or selected adults at borderline risk (5% to under 7.5%), if statin decisions remain uncertain, the 2019 ACC/AHA guideline says it is reasonable to measure a coronary artery calcium score to guide clinician-patient risk discussion (Arnett et al., Circulation 2019).

Your executive physical came back with a calcium score over 300. The physician said to start a statin and come back next year. Nobody told you what is driving the plaque, or how you will know whether it is still growing.

What a calcium score decides

The 2018 AHA/ACC cholesterol guideline says that when a statin decision is uncertain in an intermediate-risk adult, measuring CAC can help (Grundy et al., Circulation 2019):

  • A score of zero can support holding off on a statin, except in cigarette smokers, people with diabetes, and people with a strong family history of premature heart disease.
  • A score of 1 to 99 favors statin therapy, especially from age 55 on.
  • A score of 100 or higher, or at or above the 75th percentile, means statin therapy is indicated unless the clinician and patient decide otherwise.

A score over 300 sits well past that last line. The statin is the guideline answer. The questions that remain are what drove the plaque and what else the plan should treat.

The blood panel behind the calcium score decision

The cholesterol guideline uses blood work before it reaches for a scan. It starts with a 10-year risk estimate from standard factors such as blood pressure, cholesterol, diabetes, and smoking. Risk-enhancing factors then adjust that estimate, including apoB of 130 mg/dL or higher, Lp(a) of 50 mg/dL (125 nmol/L) or higher, hs-CRP of 2.0 mg/L or higher, and triglycerides that stay at 175 mg/dL or higher. In adults 40 to 75 years of age without diabetes, with LDL-C of 70 to 189 mg/dL and a 10-year risk of 7.5% to 19.9%, if a decision about statin therapy is uncertain, the guideline says to consider measuring CAC (Grundy et al., Circulation 2019). A standard lipid panel can be drawn fasting or nonfasting: the guideline says screening can be performed with fasting or nonfasting measurement of lipids.

How an executive physical usually runs

Sutter Health publishes a sample itinerary for an executive health appointment and says services vary by company and by the executive's needs. The sample lists a lab blood draw at 7:00 a.m. and a light breakfast at 7:15 a.m., then carotid artery ultrasound, a nutrition consultation, a stress echocardiogram, and a hearing evaluation from 8:00 a.m. to 11:30 a.m., then a physical examination with a physician (Sutter Health Executive Health Program). Cleveland Clinic's employer page describes a 6-to-8-hour single-day exam and says most test results are available the same day (Cleveland Clinic Executive Health). Mayo Clinic's Executive Health FAQ recommends scheduling your appointment several months in advance (Mayo Clinic Executive Health FAQ, MC1927-43).

Specialist consultation and follow-up

Atlantic Health says a board-certified internal medicine doctor leads the exam and brings in specialists chosen for your specific health needs (Atlantic Health Executive Health). Mayo Clinic's FAQ lists prioritized specialist consults among the executive-level services, describes support after and between appointments, and requires executive patients to have a local primary care provider for personal health needs, including medication refills, throughout the year (Mayo Clinic Executive Health FAQ, MC1927-43). Cleveland Clinic says a written report is prepared by the physician with patient results and clear next steps, and that virtual and in-person visits are available for follow-ups (Cleveland Clinic Executive Health). Sutter Health says its executive health program staff will arrange follow-up appointments if necessary.

What a calcium score cannot see

The 2019 ACC/AHA prevention guideline notes that a score of zero does not rule out noncalcified plaque, and clinical judgment about risk should prevail (Arnett et al., Circulation 2019). CAD can be present without calcium (non-calcified plaque) and may not be detected by this exam (RadiologyInfo: Calcium scoring). On carotid ultrasound, uniformly echolucent plaque is homogeneous, hypoechoic and composed mainly of lipid elements and necrotic structures (Fedak et al., J Ultrason 2020). At Renew, CIMT is how we see the arterial wall (Executive health). See executive physical with CIMT and CIMT vs calcium score.

The 2018 guideline is also candid about gaps. It says it is uncertain when, or whether, to repeat a CAC scan after a score of zero.

Why a rising score on a statin can mislead

In a pooled analysis of eight trials that imaged heart arteries from the inside with ultrasound (n = 3,495), the high-intensity statin group (n = 1,545) saw plaque volume shrink on average. Their plaque calcium went up anyway. Calcium rose in every group, and the smallest rise was in patients on no statin, whose plaque grew (Puri et al., J Am Coll Cardiol 2015). The authors read this as one way statins may stabilize plaque.

So a calcium score that climbs after treatment starts does not, by itself, tell you the plan failed. You need other numbers to judge progress: ApoB and the other drivers on your labs, and repeat imaging of the artery wall read by a clinician.

Preventive longevity strategy after the score

A calcium score informs the statin decision. The 2019 ACC/AHA prevention guideline by Arnett and colleagues says the most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life (Arnett et al., Circulation 2019).

  • Exercise. Arnett and colleagues recommend that adults engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.
  • Diet. The Arnett guideline says a healthy diet emphasizes vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish, and minimizes trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages.
  • Tobacco. The Arnett guideline says all adults should be assessed at every healthcare visit for tobacco use.
  • Team-based care. Arnett and colleagues call a team-based care approach an effective strategy for the prevention of cardiovascular disease.

The AHA's Life's Essential 8 advisory scores cardiovascular health on eight components: healthy diet, participation in physical activity, avoidance of nicotine, healthy sleep, healthy weight, and healthy levels of blood lipids, blood glucose, and blood pressure (Life's Essential 8, PMC10503546). Mayo Clinic's Executive Health FAQ says certified Mayo Clinic wellness coaches can support physical activity and exercise, nutrition and weight loss, stress management and resiliency, healthy sleep, and other lifestyle goals over a series of phone or video appointments (Mayo Clinic Executive Health FAQ, MC1927-43).

When a statin is part of the plan, the 2018 AHA/ACC cholesterol guideline by Grundy and colleagues says to assess adherence and percentage response with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed (Grundy et al., Circulation 2019).

Is an executive physical with a calcium score worth it?

A Cochrane review of 17 randomized trials (15 with outcome data, n = 251,891) found that general health checks had little or no effect on total or cancer deaths, and probably little or no effect on cardiovascular deaths (Krogsbøll et al., Cochrane 2019). A long test day on its own is a weak bet.

A calcium score is different when the result changes a decision. If you are at intermediate risk and unsure about a statin, it is worth it. If you already have a high score, the scan has done its job, and the value now sits in the plan that follows.

Where Renew fits

Renew memberships image the arteries with CIMT. Every Renew membership includes CIMT arterial imaging, advanced labs testing for 33 drivers of arterial damage, a physician, and a care coordinator (Pricing). The drivers span inflammation, metabolic, genetic, infectious, sleep, and oral pathogens (How it works). Month one is a full intake, CIMT imaging, the 33-driver panel, an OralDNA test, and a dental exam. In month two your physician builds a protocol of medications, supplements, nutrition, and exercise based on your drivers.

A steady scan is the first win, because it means the disease stopped progressing.

Performance (primary). Performance includes Full Arterial Reversal plus Coached Strength & Body Composition: monthly physician visits, tune-up labs 4x/year, "Monthly S&C coaching sessions," "Monthly nutritionist sessions," "DEXA body composition scans (2x/year)," and "VO2 Max testing (2x/year)." Performance also adds in-home phlebotomy and an annual Executive Health Report.

Executive (secondary). Executive includes everything in Performance, plus "Weekly S&C coaching sessions," "DEXA body composition scans (4x/year)," "VO2 Max testing (4x/year)," "Meal delivery or personal chef meal prep," "All supplements included & shipped monthly," custom compounded medications, a sleep specialist, CIMT plus advanced arterial imaging, and unlimited physician access.

Your care team works on your arteries together: a Physician, an S&C Coach, a Nutritionist, a Dental Liaison, and a Care Coordinator who is your direct line. Renew operates outside insurance (Pricing). The full tier table, including the lighter Essentials and Reversal plans, is on Pricing.

Frequently asked questions

What is an executive physical with a calcium score?

A cardiac CT scan for coronary calcium is a noninvasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries (RadiologyInfo: Calcium scoring).

Is a calcium score in an executive physical worth it?

In adults at intermediate risk (7.5% to under 20% 10-year risk) or selected adults at borderline risk (5% to under 7.5%), if statin decisions remain uncertain, the 2019 ACC/AHA guideline says it is reasonable to measure a coronary artery calcium score to guide clinician-patient risk discussion (Arnett et al., Circulation 2019).

What does a calcium score of 100 or higher mean?

Under the 2018 AHA/ACC cholesterol guideline, a score of 100 or higher, or at or above the 75th percentile, means statin therapy is indicated unless the clinician and patient decide otherwise (Grundy et al., Circulation 2019). The 2019 ACC/AHA guideline says adults should have a clinician-patient risk discussion before starting a statin (Arnett et al., Circulation 2019).

Does a calcium score of zero mean no plaque?

The 2019 ACC/AHA prevention guideline notes that a score of zero does not rule out noncalcified plaque, and clinical judgment about risk should prevail.

Should I get CIMT or a calcium score?

CAD can be present without calcium (non-calcified plaque) and may not be detected by this exam (RadiologyInfo: Calcium scoring). On carotid ultrasound, uniformly echolucent plaque is homogeneous, hypoechoic and composed mainly of lipid elements and necrotic structures (Fedak et al., J Ultrason 2020). At Renew, CIMT is how we see the arterial wall (Executive health).

Sources

Author and medical review

Written by Andrew Le, MD. Andrew Le, MD reviews patient-facing guidance for Renew Health with a focus on preventive cardiology and functional medicine clarity.

Medically reviewed by Clinical Review Team.

Next step

If your calcium score came back high and the plan stopped at a statin, start with Performance at $999/mo on executive health. Executive at $5,000/mo is listed on the same page.

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