“Thin on the outside, fat on the inside.” That’s what my cardiologist called me, and I sure didn’t like it — or its abbreviation, TOFI, which sounds like a cross between tofu and toffee.

But the moniker wasn’t the problem. A heart scan had revealed I had too much coronary calcium — plaque — in my blood vessels. With a score of 172, I was at “moderate to high” risk for a heart attack.

This was in 2007, just before I turned 50. As my 40s waned, my total cholesterol, measured in a blood test, had begun to inch up. My triglycerides also had increased.My primary care physician wasn’t concerned. “You really fall into the gray area,” she told me. “We could go either way when it comes to starting you on a [cholesterol-lowering] statin.”

But statins can have side effects, and there’s a debate about whether they are being overprescribed, so I just said no to the meds.

In the United States, the annual death rate attributable to coronary heart disease dropped more than 25 percent from 2004 to 2014. That’s great news. Far from great: Cardiac vascular disease remains the No. 1 killer of men and women, according to the Centers for Disease Control and Prevention.

And, too many heart attacks continue to occur in people considered low or intermediate risk because the traditional risk models aren’t great at predicting heart attacks. Coronary calcium scoring is proving to be a game-changer in determining an individual’s risk.

For me, learning my calcium score, by having a heart scan, proved fortuitous.

Using the traditional risk factors, I had about a 2 percent risk of having a heart attack when I was 50; when my calcium score was added into the mix, my risk jumped more than fourfold, to nearly 9 percent. That made me pay attention in a new way. (To determine your own risk, use the National Institutes of Health calculator: bit.ly/calculator1234 )

I had it at the urging of my cardiologist, Arthur Agatston, who created the “Agatston score,” a formula that measures a person’s amount of coronary artery calcification. He developed the score in the 1980s after seeing the correlation in his patients between high amounts of plaque and the incidence of heart attack. The score, reported in the Journal of the American College of Cardiology in 1990, is now widely accepted as one of the most significant preventive cardiology tools.

“This test is a better predictor than all the risk factors or calculations from various risk factors because it [shows] the actual disease,” Agatston explained when he urged me to have the test done.

I was curious, but not worried. My labs were decent and neither my parents nor my siblings had heart disease. Yes, my grandfather, Arthur Straus, dropped dead from a heart attack, but he was 82, and that was back in 1962. I considered him a distant relative.

I paid $99 for the test, which is not covered by most insurance plans, mine included. According to the Johns Hopkins Medicine website, “Because this test is relatively new, it’s not part of standard guidelines for heart screenings — and not all insurance plans cover it.”

But it’s apt to be used more in the future, especially since the American College of Cardiology and the American Heart Association added coronary calcium scores in its 2018 guidelines for cholesterol management. (But the U.S. Preventive Services Task Force, an independent panel of medical experts that evaluates the effectiveness of clinical tests, has said the current evidence is “insufficient”to add it to traditional risk assessment tools for asymptomatic people.)

The Cleveland Clinic, among most other major U.S. medical centers, recommends heart scans to patients with a family or personal history of coronary artery disease; men over 45, women over 55; past or present smokers; and those with a history of high cholesterol, diabetes or high blood pressure. I am generally wary of tests marketed direct to consumers, which is why it’s important to do your homework ahead of time.

The test itself is a noninvasive CT scan that took about 1o minutes. It was easy: no fasting or injection of contrast. The amount of radiation is about the same as a mammogram or a chest X-ray. It can certainly pay to price-shop around: some places near me in central North Carolina were charging almost $800.

A day after I had the scan, Agatston called me with the unsettling results. My score — that 172 — “is associated with a relatively high risk of heart attack or other heart disease over the next three to five years,” according to the Mayo Clinic site.


Thus began my crash course in cardiology. I am (and was) height and weight proportionate, had a little belly fat, and my total cholesterol numbers did not ring any alarm bells. But those high calcium deposits lit up my scan like a Christmas tree. That’s why Agatston called me “Thin on the outside, fat on the inside.”

Over the years, I’ve come to know others — overweight with much bigger bellies — who scored zero. What about them? I asked the doctor. “Fat but fit,” he explained.

Then he dropped a public health bomb: “Your total cholesterol level is essentially worthless for predicting a future heart attack. Forget your cholesterol level, know your calcium score.” If I didn’t start treatment and change my diet and exercise patterns, Agatston made clear that I was at serious risk of having that “major adverse coronary event” in the next 10 years.

I was “persuaded” and started taking the statin Lipitor, plus a baby aspirin.

Agatston also put me on a ­moderate-protein, high-fat, ­low-carbohydrate eating plan — and challenged me to start high-intensity interval training, an exercise strategy of alternating short periods of intense activity with less intense recovery time until exhaustion. Studies show this can help reduce belly fat, or what is know as visceral fat, that can be particularly bad for one’s health.

Stephen Kopecky, a cardiologist at the Mayo Clinic who focuses on cardiovascular disease prevention, says, “If calcium is seen, especially if a higher calcium score [greater than 100], then the patient would benefit from lifestyle change, including the anti-inflammatory Mediterranean diet, regular physical activity . . . and possibly initiation of a statin.”

Kopecky says “a heart scan for coronary calcium can help motivate patients to change their lifestyle. Studies have shown that when a patient sees calcium in their own coronary arteries on the scan, they are more likely to comply with therapy and change habits.”

I know I upped my game — both in diet and fitness — after learning my score.

It’s been more than 10 years since that life-preserving heart scan.

Now, thanks to the statin and lifestyle changes, I have excellent blood chemistry, with low LDL (the bad cholesterol), low triglyceride levels and high HDL (the good one). I’ve lost some weight, which translates into less belly fat, although I’m still considered TOFI.

But here’s the real deal. Learning that I had significant coronary calcium all those years ago gave me “a long window of opportunity,” as Agatston put it, to understand my risk and to decide how aggressively to be treated. The devil is in the data: My 8.5 percent chance of having a heart attack was the wake-up call I needed not to become one of those fatal heart attack statistics.