As readers of the blog may know, I have been a very strong proponent of the coronary calcium scan for many years. The scan is a great tool to help determine vascular health and make a decision regarding the treatment of high cholesterol.
I have argued in previous blog posts and videos that patients with a coronary calcium score of zero may be able to avoid medications to lower cholesterol. In the last couple weeks, 2 news items from the cardiology community have bolstered my opinion.
First, a research study was published in the Journal of the American College of Cardiology. Investigators at the Walter Reed Army Hospital in Washington DC enrolled more than 13,000 consecutive patients who underwent coronary calcium scanning between 2002 and 2009.
They divided the patients according to their coronary calcium score into 4 groups: 0; 1-100; 101-400; and >400. They then took note of which patients were treated with a statin drug to lower cholesterol and which ones were not. They followed these patients for about ten years and counted the number of heart attacks and other cardiovascular events occurring in each group.
The study showed that statin treatment did not seem to make a difference at all when the coronary calcium scan was zero, even for patients whose cholesterol level was high. On the other hand, when the calcium score is greater than 100, treatment with a statin seems quite beneficial, at least when considered for the whole group. The main illustration of the paper’s findings is here:
As you can see in the upper left-hand side graph representing people with a coronary calcium score of zero, the rate of heart attacks and other cardiovascular outcomes is identical whether one is taking a statin or not. In the lower panels representing people with coronary calcium scans > 100, however, the people on statins (red line) had much fewer cardiac events than those not on a statin (blue line).
Of course, this is only one study and every study has limitations that must be taken into account. Besides, I always make a recommendation for an individual person based on his or her particular circumstances. In some patients, treatment with a statin may be appropriate even at low or zero calcium score, and vice versa, I may opt not to recommend the drug even if the score is higher. Nevertheless, the findings generally mirror what my general approach has been over the last several years.
The second news item is that one of the main scientific bodies that issues recommendations for the treatment of high cholesterol and high lipid levels has just released its new treatment guidelines at the Annual Meeting of the American Heart Association currently taking place in Chicago.
For the first time ever, cholesterol treatment guidelines are now incorporating the coronary calcium score into the recommendations. The guidelines state that if a person with high cholesterol is deemed to be at “intermediate risk” of future cardiovascular events, then the doctor can consider obtaining a coronary calcium scan and foregoing treatment with statin drugs if the score is zero.
Now, in general, I don’t quite agree with the whole philosophy behind guidelines. These tend to be impersonal and consider patients only in terms of “numbers.” Nevertheless, it is nice to see that the approach I have been advocating for a long time is slowly but surely making its way among the academic leadership! 🙂
–Dr. Accad
PS: If you wonder why it has taken so long for the academic establishment to admit the value of the coronary calcium scan, you may want to watch the documentary Widowmaker on Netflix. I wrote about it in a prior blog post here.
