Primary Care Caught Patient’s Heart Disease Before Symptoms Surfaced

Elmore had already faced significant dangers that most people never experience. A military veteran in the U.S. Army Nurse Corps and a Purple Heart recipient, he survived being shot during one of two deployments to Afghanistan in 2002. But the life-threatening disease he now faced wasn't one he could see or feel. Up to this point, routine check-ups and preventative testing hadn't revealed the threatening buildup of plaque in his coronary arteries that could have caused a heart attack at any moment. That is, until his primary care physician insisted on one more screening test. It was a fitting push from Diaz, who has his own history of military service in the Army and Air Force, with deployments to Afghanistan and Iraq.

"If Dr. Diaz hadn't urged me to get the coronary calcium score test, I would have had no idea how much risk I was facing," said Elmore, a former nurse practitioner at UC San Diego Health who is now retired. "If I didn't have a trusted primary care doctor, I probably would have continued to brush off further testing and could have easily become a statistic. I'm grateful that he pushed."

There had been no obvious warning signs. No chest pain. No numbness. Nothing resembling the symptoms Elmore had spent years helping patients recognize during his 26-year career as a nurse practitioner. Looking back, he could identify subtle clues, like becoming short of breath during exercise and taking longer to recover after swimming — the sport he had competed in collegiately. At the time, he simply attributed that slight change to aging and retirement.

Left alone, his advanced coronary artery disease likely would have announced itself only once: suddenly, violently and with limited time to act. Instead, the preventative test his primary care doctor urged him to take set off a seamless chain of multi-disciplinary care at UC San Diego Health, spanning preventative screening in primary care, specialized cardiology diagnostics, life-saving open-heart surgery and five months of cardiac rehab.

A Hidden Risk

The number that stopped Diaz cold from Elmore's off-the-charts coronary calcium score is a test many patients are not familiar with.

Diaz had first suggested it to Elmore after routine bloodwork turned up elevated cholesterol and an elevated lipoprotein (a) — a genetic marker tied to a higher lifetime risk of plaque buildup, independent of diet or exercise. Elmore, who felt healthy and had a clean stress test on record, didn't prioritize it. When Diaz brought the test up again the following year, he pointed to something more specific: Doug's family history. Doug's grandfather had died of a heart attack at 55; Doug was already seven years past that age.

For Diaz, ordering it came down to a question he asks himself with every patient: what's their real risk, and what tools haven't been used yet? A coronary calcium score, paired with lipoprotein (a), gives a fuller picture than cholesterol numbers alone — particularly for patients reluctant to start taking a prescription medication to lower cholesterol. For Diaz, the case illustrates why primary care is about more than treating illness after it appears.

"Family medicine allows me to help with preventing illness as well as treating illnesses," Diaz said. "It's a doorway for patients to get more specialized care."

The Number that Changed Everything

Diaz immediately referred Elmore to Pam Taub, MD, cardiologist and director of preventative cardiology at UC San Diego Health. Two weeks later, Taub and Elmore decided together to skip the intermediate step of a CT angiogram and go straight to cardiac catheterization, a more invasive procedure that allows doctors to see, and potentially treat, blockages in real time.

But when Taub found three heart occlusions that couldn't be stented, it was clear Elmore needed cardiac bypass surgery. 

"Many patients can be asymptomatic and not have classic symptoms such as chest pain — the first symptom or manifestation of their disease could be a heart attack," Taub said. "So it is important to get a good history, including family history, and look at blood tests such as LDL cholesterol and lipoprotein (a) and do additional imaging tests, such as a coronary calcium score, as was done in Doug's case."

She credits the strong communication bridge between primary and specialty care at UC San Diego Health as a defining strategy to providing holistic care for patients.

"It is important to aggressively manage risk factors including lipids, blood pressure, weight and blood sugar, with lifestyle and medications (if needed) to prevent cardiac events. With Doug, everything was picked up early and he never had a cardiac event."

Doug already knew his surgeon, Eugene Golts, MD, cardiothoracic surgeon and surgical director of the lung transplant program at UC San Diego Health, having worked with him during his tenure on the transplant team earlier in his career. Once Elmore's operation began, Golts spotted two more lesions beyond the three initially identified. A planned triple bypass became a five-vessel bypass on the table.

From his first cardiology appointment in late May to heart bypass surgery on June 19, 2024, Elmore went from a serious diagnosis to surgery in less than a month.

Afterward, Taub told Elmore something that has stayed with him since: How easily his story could have gone differently — a seemingly healthy person found too late, at home, with no warning at all.