Heart & Vascular Imaging: Beyond the ECG

TL;DR: An EKG checks your heart's rhythm. It does not tell you whether your arteries are clogging up, and for that you need a picture. There are 4 options and they cost very different amounts, so knowing the ladder before you agree to anything matters. An ultrasound of the arteries in your neck and belly is the cheapest, usually covered, often under $100 cash for both, and it tells you whether plaque has started anywhere in your body. A calcium score is $100 to $150 and only sees old, hardened plaque. A CT scan of the heart arteries is about $400 to $450 and also sees the soft plaque, which is the kind that causes most heart attacks. That same CT scan with AI analysis added costs closer to $2,000. It is the same machine, the same trip, and the same radiation. What the extra money buys is a precise measurement you can compare against a scan years from now. If the question is simply whether you have plaque, you do not need the $2,000 version.

A standard ECG only tells us about your hearts electrical rhythm. To understand your risk of a heart attack, we need to see the plumbing and the pump. At Fishtown Medicine, we use advanced heart imaging, including coronary CT angiography (CCTA) with Cleerly AI, to find both calcified and soft plaque before it becomes a problem.

If you are over 40 with any cardiovascular risk factors, the question is no longer "should I get heart imaging," but "which scan answers my question." We help you decide.

What is the difference between the pump and the plumbing?

The difference between the pump and the plumbing is the system we are evaluating. We look at two distinct systems when we work up your heart.

1. The pump (structure): We use echocardiograms (ultrasound) to see how well your heart valves work and how strong the heart muscle is pumping.
2. The plumbing (arteries): We use CT scans (calcium scores or coronary CTAs) to see if there is any plaque buildup in the coronary arteries that could cause a heart attack.

Most patients need a look at both systems at some point, just not always at the same time.

What are the common cardiac studies compared?

Common cardiac studies compared:

Why is coronary CTA with Cleerly the gold standard?

Coronary CTA with Cleerly is the gold standard for advanced cardiovascular imaging because it sees the plaque that causes heart attacks. Unlike a calcium score, which only sees old, calcified plaque, a CCTA can see the young, soft plaque most likely to rupture and cause a sudden heart attack.

This lets us be far more precise in our high cholesterol prevention strategy and in ApoB-targeted treatment. For patients with a family history of early heart disease or elevated Lp(a), the CCTA often changes the entire treatment plan.

A cardiac CT also captures the lungs it passes through, so a small lung nodule sometimes turns up on a scan ordered for the arteries. Our guide to the chest CT explains how those incidental findings are sized, sorted, and followed.

What do these scans cost in Philadelphia?

The distance between the cheapest and the most expensive option on that table is wider than most people expect, and knowing the ladder before you agree to anything matters, because the most expensive version is not always the one that answers your question.

A carotid and abdominal aortic ultrasound is at the bottom. Both are usually covered when there is a reason to order them, and paid in cash the 2 together often come in under $100 at a Philadelphia imaging center. A coronary calcium score runs about $100 to $150 cash and is rarely covered, since insurers still treat it as screening, though it is inexpensive enough that the coverage question seldom decides anything.

The step people are almost never told about is the coronary CT angiogram read the ordinary way, by a radiologist, which runs roughly $400 to $450 cash here. Adding the Cleerly AI analysis to that same scan brings it closer to $2,000, and some commercial plans will cover the underlying angiogram while declining the AI layer on top. That is the same trip to the same scanner and the same radiation dose in both cases. What the higher price buys is measurement: a plaque volume in cubic millimeters, broken out by type, that a scan 3 years from now can be compared against.

If the question in front of us is simply whether plaque exists and how urgently to treat it, the standard read answers it at a fifth of the cost. If we are going to spend years watching whether a plan is working, the measurement is worth paying for. These are cash prices at Philadelphia imaging centers rather than fixed rates, they move, and we confirm the current one and pass through any discount we have before you book anything.

Is there a cheaper way to find out whether plaque has started?

Yes, and it is one of the more useful things a preventive workup can borrow from ordinary radiology. Ultrasound is generally poor at finding plaque, because sound will not travel through bone or gas and most arteries sit too deep to see well. Two of them are the exception. The carotid arteries run close to the surface on either side of the neck, and the abdominal aorta is the largest vessel in the body, running from the heart down through the belly. Both are large enough and shallow enough that ultrasound sees them clearly.

Scanning those 2 vessels answers a narrower question than a coronary CTA, and answering it is often enough to move a decision. Atherosclerosis is a whole-body process rather than a coronary one, so finding plaque in the neck or the aorta tells you the process has already begun somewhere, which turns a conversation about future risk into a conversation about disease you have today. For a 37-year-old weighing whether cholesterol can be handled through food and training alone, that distinction changes the answer.

What these scans cannot do is clear your coronary arteries. A normal carotid study does not mean the vessels feeding your heart are free of plaque, and anyone who tells you otherwise is overreading it. Ultrasound also takes longer than the CT does, because a person is holding the probe and has to work for every image, so plan on more chair time rather than less.

There are 2 more vessels to know about. A renal artery ultrasound looks at the arteries feeding the kidneys, and it is harder to get approved without documented high blood pressure, which is one of several reasons home blood pressure readings are worth taking before an appointment rather than after. An arterial ultrasound of the legs, often paired with an ankle-brachial index, looks for peripheral arterial disease and earns its place when there is leg pain with walking, a smoking history, or diabetes. Neither is a routine screen, and both are inexpensive when the indication is there.

Guidance from the clinic

"I start simple. For low-risk discomfort, we begin with an ECG and basic labs (ApoB, Lp(a)). But if your risk markers are elevated, we do not guess. We get a high-resolution map of your arteries. Finding plaque in your 40s is a gift. It gives us the chance to treat it before it ever becomes a crisis."

What is the clinical sequence for cardiac imaging?

The clinical sequence for cardiac imaging at Fishtown Medicine usually goes:

1. Risk stratification: We start with an ECG, ApoB, Lp(a), and a thorough clinical history.
2. Refine prevention: A coronary CTA gives us the full picture, calcified and soft plaque, to decide if you need a statin today. The same picture is what settles the harder question in the other direction, which is what happens when you stop a statin you have already been taking for years.
3. Investigate symptoms: If you have exertional chest pain, we move to a stress test or coronary CTA.
4. Tissue check: If we suspect heart failure, infiltrative disease, or structural issues, we order an echocardiogram or cardiac MRI.

A note on cost: any discount we negotiate on labs and imaging passes straight through to you, with no markup. Our affordable labs and imaging guide covers how the billing works.

Scientific References

1. Gulati M, et al. "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain." Journal of the American College of Cardiology. 2021.
2. Williams MC, et al. "Coronary Atherosclerosis Imaging by Coronary CT Angiography." Circulation: Cardiovascular Imaging. 2020.
3. Greenland P, et al. "Coronary Calcium Score and Cardiovascular Risk." Journal of the American College of Cardiology. 2018.
4. Maron BA, et al. "Cardiac magnetic resonance imaging in cardiomyopathy." Journal of the American College of Cardiology. 2020.

Dr. Ash is a board-certified internal medicine physician at Fishtown Medicine in Philadelphia. He practices Medicine 3.0 preventive cardiology so your heart lasts as long as your ambition.