Doctor visit to get Coronary Calcium Scan order - strategy?

[cdamaden]

All,
My regular doctor through the VA was not interested in ordering me a Coronary Calcium Scan. I have another insurance option, which I've decided to explore. So I'll be seeing this new doctor in early December. I'm looking for advice on what I should bring to this appointment in order to leave with an order for the CCS. I'm a 49yo male, no family history of heart disease. I plan to bring this paper:
https://www.ncbi.nlm.nih.gov/pubmed/15262670
This doctor will not have access to any previous blood work. Should I also dive into my lipid lab results, in particular the NMR results? Here are my lab results from 3 different sources over the last year.

2015 Oct 22, Workplace health screening
BMI = BMI = 21.9 / Body fat 12.4%
TC = 227 mg/dL
HDL = 62 mg/dL
TRG = 82 mg/dL
LDL = 148 mg/dL
non-HDL = 165 mg/dL
GLU = 95 mg/dL
The above results was when I was in full paleo mode with lots of grass-fed red meat. I wasn't thrilled with my lipid values but it wasn't on my concern list at the time (I was dealing with brain fog issues).
These labs are from when I learned about my APOE4 status:
2016 Feb 15, True Health Diagnostics
TC = 259
LDL-C = 187
HDL-C = 67
Triglycerides = 79
non-HDL-C = 192
APOB = 126
LDL-P = 1905
Small LDL-P = 641
sdLDL-C = 44.
Over the last year (since learning of my E4/E4 status) I've lowered overall protein intake, increased fats (while lowering saturated fat), and increased my seafood protein portion This was my first blood test after making the changes:
2016 April 19, VA
TC = 175
HDL-C = 48
LDL-C = 115
TRG = 59.8

Since then I've increased my red meat to roughly 40% of my protein and have become more liberal in my use of coconut oil. Here are the results of my most recent test:
2016 Oct 20, Workplace health screening
BMI = 20.5 / Body fat 9.3%
TC = 219 mg/dL
HDL = 100 mg/dL
TRG = 57 mg/dL
LDL = 108 mg/dL
non-HDL = 119 mg/dL
GLU = 101 mg/dL (grrrrrr)

The doctor who does the work health screenings almost fell out of his chair when he compared the two years' results, in particular the increase in HDL. (I was very disappointed with the glucose results because I've been intermittent fasting 16/8, eating low carb -- I think it was just a bad day.)

OK - any thoughts on how best to convince a new doctor to order the CCS?
Thanks,
Chris

[Julie G]

Chris, many of us have used low radiation screening EBTs that don't require a doctor's order for $200-300. Given your past history of elevated small LDL-P, I think you're very wise to check that out.

Looking at your last two cholesterol panels, I'm struck by how dramatically your TG/HDL ratios ratios have improved. (This serves as a good proxy for LDL particle size and is more closely associated with CVD risk than TC alone.) It dropped from 1.250 to 0.550. WOW. Anything under 2 is considered ideal. You can use this calculator to see all of your ratios. FWIW, I've never seen a guy improve his HDL that much. You might consider writing a book .

The elevated glucose may be the result of ketosis. You can order your own A1c and fasting insulin via an online lab to look at that number in a broader context. I'd also love to see an advanced lipid panel given your recent improvements, but know that may be overkill. Most importantly, how are you feeling cognitively since joining the community and tweaking your protocol? Kudos on the improvements, my friend. Keep up the great work.

[Stavia]

Chris what about just keeping it simple and saying you are apoe4/4 and thus at risk of heart disease and you'd like to be proactive? Show him the 2015 test result only!

[cdamaden]

Hi Julie and Stavia,
I don't know for sure why HDL rose as much as it did but I would hazard a guess that it was niacinamide. In May 2016 I started taking 500 mg per day. In August, I bumped it up to 1000 mg/day. As I've mentioned in other posts, I'm working to find the right B vitamin strategy based on my methylation genetics and homocysteine levels.
Overall I feel that I'm on a path of recovery but I need a medical practitioner to guide me past where I am now. My reflux is getting better but other gut issues remain (possible causes for eczema, food sensitivities, body aches) so I need additional testing to see where I am. Plus I would like to have fewer restrictions in my diet. Fortunately I have my first appointment with a doctor at the California Center for Functional Medicine early next month. Beyond those mentioned above, I have several issues to sort through to include: brain fog (much better but not resolved), hormone balance (low T, which I know contributes to brain fog), and malabsorption of nutrients (VCS test results, osteopenia, Vitamin D levels, ...). In the ideal world, my gut gets fully healed leading to the resolution of my other complaints.
Happy to follow the simple path, Stavia. Sometimes there are key phrases or conditions that will get you the golden slippers...
Chris

[slacker]

Sometimes there are key phrases or conditions that will get you the golden slippers...

Hi Chris, at the risk of being a wet blanket (a role at which I am quite adept), I think there is very little you can say to a conventionally trained provider in the US that will encourage them to order the cardiac calcium test (with your lab results, age, and "risk factors". Conventional medicine does not teach about the specialty lipids and most providers are not familiar with them. My opinion is based on working as a primary care provider for adults in the US for almost 20 years. I think your best bet is the self pay route that JulieGee suggested, or seeing a functional medicine doctor. Although not all doctors that advertise as being "functional" are created equal. Some are excellent, some are not. Some are open minded, some are not. Insurance may not cover the test whether it is ordered by a licensed provider or not. It may be worth your time researching the educational background of the provider you are scheduled to see (perhaps already have), or see a doctor like Dr Gundry or Dayspring (who may have a cash pay practice only). Some providers are steering patients towards a blood test called Corus, which I understand is not covered by many insurances, and tends to cost around $600. There are various opinions on which test is best for each individual.
Good luck! We are all traveling through uncharted territory...

[Julie G]

So good to hear that you'll be working with a doc from the CCFM, Chris. Out of curiosity, which one? I'm working with Dr. Schweig and have been very pleased. He's uncovered multiple areas for me to focus on to further optimize my health. I'm sure your CCFM doc will be able to hook you up with your best option for an EBT.

[cdamaden]

Slacker -- oh yes, that's why I posted for advice. Fortunately I do have the back-up options of self shopping or getting an order from my new functional medicine doctor at CCFM. I try to be frugal and use all the resources I can, so I figured since I was going to see the new insurance doctor for another issue I would see if I could squeeze out an insurance-paid heart scan.
Julie -- Dr. Schweig is now booked for months on end. Living in the Bay Area gave me some more flexibility, so I decided to see Dr. Nett. As you know, it's a 3 step process before you know your diagnoses. I'll post when I learn something new...
Chris

[slacker]

I just googled "coronary artery calcium test" in my home town and here's what I found at one of our big three gi-normous hospital chains:
"Because a coronary calcium scan is a screening examination, it is not covered by most insurance companies or Medicare. The patient is responsible for all costs at the time of the exam. The cost is $150 and includes all lab, technical, medical and professional interpretation charges. Self-referrals are accepted. A physician's order is not required. "

Such a deal! I live in the Ohio River valley in a mid-west/southern mid-sized city; you might do as well if not better cost wise in the greater SF Bay area...

[ru442]

Good stuff slacker... my cardiologist agreed to "prescribe" mine based on my good progress with diet and lifestyle changes, but wasn't required as the hospital I affiliate with does them for $49. No insurance coverage.... I suspect this is the case everywhere.

[Julie G]

Wow, great prices, Slacker & RU442! Thanks for sharing.