Clinical cases of heart disease that might stump even the most seasoned cardiologists
Industry Buzz
[There's a] critical gap in our medical model: the idea that good habits and normal cholesterol can shield everyone from heart disease. They cannot.
—William H. Bestermann Jr., MD
When an internal medicine physician says a stress test can be “totally normal” one day and a patient can “drop dead” the next, clinicians pay attention.
That’s the message William H. Bestermann Jr., MD, drove home in a recent blog post—one that highlights a blind spot baked into modern cardiovascular risk assessment. []
For Dr. Bestermann, the issue is clear: Our medical model still overestimates the protective power of good habits, reassuring numbers, and normal stress tests—and underestimates how much disease can hide beneath the surface.
There's a "critical gap in our medical model: the idea that good habits and normal cholesterol can shield everyone from heart disease. They cannot," he wrote.
Here are two clinical cases that prove just that.
Related: 5 unusual signs of cardiovascular diseaseWhen a normal stress test isn’t reassuring
A man presents with new-onset chest discomfort. The symptoms sounded concerning enough he was immediately sent for an urgent cardiology evaluation.
The cardiologist completed a stress test and EKG that afternoon—both completely normal. The next day, the patient collapsed in a meeting room and lost his pulse. He was fortunate: an AED was on the wall, people knew how to use it, and he walked away neurologically intact.
What happened?
The patient likely experienced a plaque rupture with transient clot formation shortly before the initial evaluation, according to Dr. Bestermann. By the time he was seen by a cardiologist, the clot had dissolved, leaving no fixed obstruction for the stress test to detect. What he did have, however, was a “raw wound”—an inflamed, unstable plaque primed to clot again. And it did.
“A stress test is very little help in this setting," Dr. Bestermann wrote.
The runner with a CAC score of 1,700
Just as unnerving is the case of a fit, nonsmoking male patient in his 60s with pristine habits and no traditional risk factors. He felt great, and he ran regularly—nothing about his lifestyle suggested he had coronary artery disease.
But his coronary artery calcium (CAC) score—a direct measure of established atherosclerotic plaque—came back at nearly 1,700.
The runner’s case, Dr. Bestermann argued, “perfectly illustrates a critical gap in our medical model: the idea that good habits and normal cholesterol can shield everyone from heart disease.”
Why would a seemingly low-risk man accumulate such heavy plaque? Consider the following:
The Barker Hypothesis: Early life nutritional exposures permanently alter organ development and metabolic pathways.
Transgenerational epigenetics: The cardiometabolic stresses of parents or grandparents (eg, famine and high-sugar diets) can leave heritable marks on gene expression.
This runner represents “residual risk” in its purest form: disease shaped long before adulthood, long before running shoes and heart-healthy diets entered the picture.
The limits of traditional risk stratification
These cases expose a fundamental tension in how US clinicians still screen for coronary disease: Risk factors guide screening, but plaques cause events.
And plaque—especially silent, non-obstructive, vulnerable plaque—is exactly what stress tests and lipid panels routinely miss.
That’s why Dr. Bestermann believes CAC scoring fills a critical gap: it directly measures disease burden rather than projecting probability. In his view, waiting for symptoms or abnormal noninvasive testing misses too many patients at the highest risk of sudden events.
Which patients should undergo CAC screening?
1. 'Undetermined' risk patients
For men over 50 and women over 60 with no clear risk factors, CAC may be the best tool for risk reclassification. “You cannot treat a risk you don’t know exists," Dr. Bestermann wrote.
2. Patients with family history should start earlier
If a first-degree relative developed premature CAD before the age of 55 for men or 65 for women, physicians should consider initiating the CAC conversation around age 40–45.
3. Anyone not yet identified as high-risk
At $100–$150 in many regions and a 10-minute, noncontrast scan, CAC can be a low-risk, high-yield test.
Related: Why every patient needs a CAC score—no matter their ageWhy this matters: OMT can’t help a disease you haven’t found
For Dr. Bestermann, the purpose of finding disease earlier is straightforward: to initiate optimal medical therapy (OMT) before a first event occurs, especially given that 25% of patients with coronary disease experience sudden death as the first symptom.
If CAC is zero, risk is near-zero. If it isn’t, clinicians can intensify prevention: high-intensity statins, lifestyle modification, blood pressure optimization, inflammation reduction, and more.
“We cannot mitigate risk effectively if we don’t know the disease is there,” he wrote.