What if coronary calcium score is included in the risk prediction? I was taken off statin when my score came back zero. My LDL is typically below 100. The ACC statin algorithm is for all males over 65 to be on statin regardless of LDL.
Is that right? Another comment above said messing w the calculator makes it almost impossible to not be in the ‘low risk’ category. I’m looking at my recent physical and need to check out the calculator.
And does anyone know who came up with the calculator? Sadly, I would be surprised if those behind it were not heavily fundded/influenced by big pharma.
The paper being discussed is not about prediction. It is a retrospective study where everyone had the event. A prospective cohort is needed for this to be truly about prediction. And I'm not clear why this needs a study. There will be an entire risk distribution in any population, and the usefulness of risk prediction, even for low risks, will depend entirely on patients' utility functions. If I had a predicted risk of 0.05 of being hit by lightning you can be sure I would seek a safe place. Risk is translated into action on an individual patient basis.
Unfortunately, the only thing predictable is that most doctors and researchers will continue to ignore the wisdom you provided in your summary of the reality concerning predictability of acute coronary disease. It is appropriate that your article comes just before the end of 2025 as this year is the 50th anniversary of a seminal article by Drs. Elliot and Stephen Corday that was published in the American Journal of Cardiology in 1975. The title was "Prevention of Heart Disease by Control of Risk Factors: The Time has Come to Face the Facts." The adherence to the risk factor paradigm of causation has been a boon for researchers, academics, and pharmaceutical companies but has gotten us nowhere in terms of prevention or even early detection of those at risk. Treatment of acute disease has shown measurable improvement in recent years and that is where our attention should be directed. Chasing the chimera of prevention is an enormous waste of time and resources.
This paper appears to be fundamentally flawed due to 'survival bias' (perhaps somewhat ironically given the subject) and 'neglecting the base.'
The headline-grabbing figure (33% of MIs in low risk patients) suggests scoring is unreliable. But this figure is meaningless without data on the size and risk stratification of the original population from which the cases were drawn. For example, if less than 33% of patients were low risk, these patients would be more likely to have MIs than higher risk patients. But if 85% of patients were low risk, they would be more than 11x less likely to have an MI.
The paper's conclusion states that ASCVD screening is inadequate because it misses 'almost half of the at-risk population...' But the study shows no such thing. It shows only that almost half of MIs occur in lower risk patients, which is something entirely different.
Screening may be correctly identifying most of the high-risk population and leading to effective treatments. Indeed, the authors are criticising ASCVD screening for a result that would be seen with any effective screening program: low-risk patients would form a higher percentage of MIs because high-risk patients are being identified, treated and thus removed from the negative outcome group. It may also be the case that low-risk patients are being correctly assessed as having a risk of less than 7.5% over 10 years, with the patients in this study just being part of the unlucky minority. Without data on the original population, we don't know.
In summary, the information in this paper does not support the conclusions it draws and does not tell us anything new or definitive about ASCVD screening.
My husband has one of the genes for blood clotting, but not both, so his risk is elevated but not overly so. He walks 3 miles/day, swims 1 mile/day, doesn't drink, doesn't smoke, we eat at home and cook better than most and has lost 30 lbs sensibly over time. His BP is 110/70, cholesterol is within the desired ranges. His NP days he should go on stations based on the calculator and having 1 of the 2 genes for clotting. We fiddled with the predictive calculator. You basically have to be born on day 1 to not need a statin. I wonder if Sensible Medicine docs have ever tried to plug in data to find "low risk" ? It doesn't exist! Basically everyone is moderate or high. Pharma is making out. And I wonder if we have "statin-ed" our way to brain dysfunction by eliminating all the fats we need to wrap our brain in! In my view, cholesterol is an inflammatory process and stress and lifestyle modification is a much better approach to reducing risk. Unfortunately Americans are lazy, doctors want to CYA and people aren't ready for the truth and work it takes to reduce risk.
Sorry to be so pedantic, but my inner compulsive proofreader can't help it. When I read "His NP days he should go on stations", it took me a while to figure out that you intended "His NP says he should go on statins".
BTW, if I succumbed to my urges I would wrap my brain in chocolate éclairs, but at age 81 I'm not sure that would be a good idea.
My risk of dying in the future is 100%. That is all that counts because the rest is pure meaningless guesswork all devised to get a person suckered into medical torture as in endless tests, drugs, vaccines, procedures, etc...that do nothing to cure any problem as in discovering why the problem exists in the first place.
There is always a reason for EVERY medical malady. Doctors are not trained to find those root causes and that is why modern medicine is an abject failure...just take a long look around and you see the results...more illness and disease than ever.
With 10's of millions getting zipped and zapped and filled with drugs and vaccines and supplements, we should be the healthiest nation on earth.
You fell for the traps that most lay people fall for. First of all, I consider nonfatal MI’s a good thing! It tells you the guy really has a disease and we go after him diligently. A non-fatal MI doesn’t kill you. It just is a shot over the bow.
Always look at the denominator. There’s a lot more lower risk people than there are high risk people ego they’re going to get a good number of first MI.
Americans, even physicians, have been sold this bill of goods that we can prevent everything. It’s a faced lie. Always look at the number needed to treat and the significant side effects of our “treatments”“Youse pays ur money and youse takes ur chances.”
Preventive stents? Hasn’t that idea been disproven? COURAGE,ISCHEMIA.
That distribution is an eye catching view through the unfamiliar end of the telescope. But for me, it is not nearly as illuminating as a retrospective study of the risk-assessed population to see how well the risk assessments held up. Incidence of MI per risk stratum would be a more meaningful number, I think.
I am a retired cardiac nurse/echocardiographer. As you say, the heart and its pathologies are extremely complex. One observation I made over and over is that statistics are really not that helpful for an individual. I don’t think that’s because we don’t have enough data or studies, I think that’s because we place too much weight on our vain hope that we will be able to prevent all disease. We never will. Luck is always a factor, and also the unique response of the individual to their risk factors. I see coronary plaque as a kind of scab on the site that life creates in our coronary arteries. Some scabs are stronger than others. I don’t think we’ll ever really know why, and we shouldn’t believe that we will. Managing risk factors is an entirely different enterprise than treating unstable plaque. Management is about living well, intervention is about preventing imminent death.
Studies should continue, understanding should deepen and grow, but don’t fool ourselves or the patients that we are keeping them safe from MI by managing their risk factors. MI is largely unpredictable, and probably always will be. All of us can improve our health, but none of us can be safe from all disease. Let’s be honest about our goals and how little control we actually have over disease. Then we can work together to make life less painful with less debilitation, while maintaining a healthy respect for the power of Mother Nature. And as you say, have the interventionslists on standby to do their life-saving work when plaque ruptures, which is not a failure of risk management, it’s just plain bad luck.
There are so many good observations in your comment and that of the original article. At my annual physical, my internist now looks at the ASCVD 10 year risk model to determine what preventative steps to take. I’m ‘double’ the risk at 8.54% vs 4.8% risk vs my group.
Based on this she suggests a low dose statin. She also said a calcium scan could give better insight if the low dose statin is justified.
I know I live a healthy lifestyle (low carb, high lean protein diet + vigorous exercise 3x/week) but was not working out the 2 months prior to my physical due to injury so I told her to let me get back to my regimen before starting a lifetime drug.
Now I’m wondering if the calcium score really matters?
I’ve noted that w increasing use of screening colonoscopy the presenting age(s) of colon cancer have adjusted downward. Maybe there is a similar effect re shifting risks of the population that affects the cvd risk scores due to societal changes, for example, improved public awareness advancing seeking medical care after experiencing an episode of chest pain and not waiting to seek medical evaluation, preventing the initial mi.
Here are the disease elimination Wellness Protecting Numbers I have been using since the 1980s.
Wellness Protecting and Disease Prevention Goal “Numbers”/Insights (In the Walking Well & modified appropriately for health issues)
1. Non-HDL cholesterol: goal less than 90 (75 in those with documented ASCVD)
2. Triglycerides: goal less than 100
3. A1C diabetes test: 5.5 or less at age 55, not above 6.2 at age 62 or older
4. Blood sugar: 90 at 90 minutes after a meal
5. Cardiac HS CRP: 1.0 or less
6. Blood pressure: near 110-115/60-70
7. Less than 12% sodium in any one serving from any one container, at any one meal
8. PSA: 1.0 or less.
9. TSH: 0.35-3.50
10. Hemoglobin: about 14
11. Lp(a): goal 15 or less
12. Homocysteine: goal 7 or less
13. Uric acid: goal 5.5 or less
14. BUN: 12 or less
15. Magnesium: 2.1+: relates to diabetes prevention and present when diet is near vegan
16. Potassium: 4.1- 4.5
17. 25 hydroxy (OH) vitamin D3: 50-66 ng/mL
18. Percent body fat: 15% in men, 20% in women: manifested as abdominal clear lines of definition/demarcation = “CLOD/D.”
What if coronary calcium score is included in the risk prediction? I was taken off statin when my score came back zero. My LDL is typically below 100. The ACC statin algorithm is for all males over 65 to be on statin regardless of LDL.
Is that right? Another comment above said messing w the calculator makes it almost impossible to not be in the ‘low risk’ category. I’m looking at my recent physical and need to check out the calculator.
And does anyone know who came up with the calculator? Sadly, I would be surprised if those behind it were not heavily fundded/influenced by big pharma.
The paper being discussed is not about prediction. It is a retrospective study where everyone had the event. A prospective cohort is needed for this to be truly about prediction. And I'm not clear why this needs a study. There will be an entire risk distribution in any population, and the usefulness of risk prediction, even for low risks, will depend entirely on patients' utility functions. If I had a predicted risk of 0.05 of being hit by lightning you can be sure I would seek a safe place. Risk is translated into action on an individual patient basis.
Unfortunately, the only thing predictable is that most doctors and researchers will continue to ignore the wisdom you provided in your summary of the reality concerning predictability of acute coronary disease. It is appropriate that your article comes just before the end of 2025 as this year is the 50th anniversary of a seminal article by Drs. Elliot and Stephen Corday that was published in the American Journal of Cardiology in 1975. The title was "Prevention of Heart Disease by Control of Risk Factors: The Time has Come to Face the Facts." The adherence to the risk factor paradigm of causation has been a boon for researchers, academics, and pharmaceutical companies but has gotten us nowhere in terms of prevention or even early detection of those at risk. Treatment of acute disease has shown measurable improvement in recent years and that is where our attention should be directed. Chasing the chimera of prevention is an enormous waste of time and resources.
This paper appears to be fundamentally flawed due to 'survival bias' (perhaps somewhat ironically given the subject) and 'neglecting the base.'
The headline-grabbing figure (33% of MIs in low risk patients) suggests scoring is unreliable. But this figure is meaningless without data on the size and risk stratification of the original population from which the cases were drawn. For example, if less than 33% of patients were low risk, these patients would be more likely to have MIs than higher risk patients. But if 85% of patients were low risk, they would be more than 11x less likely to have an MI.
The paper's conclusion states that ASCVD screening is inadequate because it misses 'almost half of the at-risk population...' But the study shows no such thing. It shows only that almost half of MIs occur in lower risk patients, which is something entirely different.
Screening may be correctly identifying most of the high-risk population and leading to effective treatments. Indeed, the authors are criticising ASCVD screening for a result that would be seen with any effective screening program: low-risk patients would form a higher percentage of MIs because high-risk patients are being identified, treated and thus removed from the negative outcome group. It may also be the case that low-risk patients are being correctly assessed as having a risk of less than 7.5% over 10 years, with the patients in this study just being part of the unlucky minority. Without data on the original population, we don't know.
In summary, the information in this paper does not support the conclusions it draws and does not tell us anything new or definitive about ASCVD screening.
My husband has one of the genes for blood clotting, but not both, so his risk is elevated but not overly so. He walks 3 miles/day, swims 1 mile/day, doesn't drink, doesn't smoke, we eat at home and cook better than most and has lost 30 lbs sensibly over time. His BP is 110/70, cholesterol is within the desired ranges. His NP days he should go on stations based on the calculator and having 1 of the 2 genes for clotting. We fiddled with the predictive calculator. You basically have to be born on day 1 to not need a statin. I wonder if Sensible Medicine docs have ever tried to plug in data to find "low risk" ? It doesn't exist! Basically everyone is moderate or high. Pharma is making out. And I wonder if we have "statin-ed" our way to brain dysfunction by eliminating all the fats we need to wrap our brain in! In my view, cholesterol is an inflammatory process and stress and lifestyle modification is a much better approach to reducing risk. Unfortunately Americans are lazy, doctors want to CYA and people aren't ready for the truth and work it takes to reduce risk.
Sorry to be so pedantic, but my inner compulsive proofreader can't help it. When I read "His NP days he should go on stations", it took me a while to figure out that you intended "His NP says he should go on statins".
BTW, if I succumbed to my urges I would wrap my brain in chocolate éclairs, but at age 81 I'm not sure that would be a good idea.
Pedestrians with poor eyesight should get glasses so they don’t get hit by a bus. Most people that get hit my a bus can see fine but are unlucky.
thank you this
My risk of dying in the future is 100%. That is all that counts because the rest is pure meaningless guesswork all devised to get a person suckered into medical torture as in endless tests, drugs, vaccines, procedures, etc...that do nothing to cure any problem as in discovering why the problem exists in the first place.
There is always a reason for EVERY medical malady. Doctors are not trained to find those root causes and that is why modern medicine is an abject failure...just take a long look around and you see the results...more illness and disease than ever.
With 10's of millions getting zipped and zapped and filled with drugs and vaccines and supplements, we should be the healthiest nation on earth.
Jonn,
You fell for the traps that most lay people fall for. First of all, I consider nonfatal MI’s a good thing! It tells you the guy really has a disease and we go after him diligently. A non-fatal MI doesn’t kill you. It just is a shot over the bow.
Always look at the denominator. There’s a lot more lower risk people than there are high risk people ego they’re going to get a good number of first MI.
Americans, even physicians, have been sold this bill of goods that we can prevent everything. It’s a faced lie. Always look at the number needed to treat and the significant side effects of our “treatments”“Youse pays ur money and youse takes ur chances.”
Preventive stents? Hasn’t that idea been disproven? COURAGE,ISCHEMIA.
That distribution is an eye catching view through the unfamiliar end of the telescope. But for me, it is not nearly as illuminating as a retrospective study of the risk-assessed population to see how well the risk assessments held up. Incidence of MI per risk stratum would be a more meaningful number, I think.
I am a retired cardiac nurse/echocardiographer. As you say, the heart and its pathologies are extremely complex. One observation I made over and over is that statistics are really not that helpful for an individual. I don’t think that’s because we don’t have enough data or studies, I think that’s because we place too much weight on our vain hope that we will be able to prevent all disease. We never will. Luck is always a factor, and also the unique response of the individual to their risk factors. I see coronary plaque as a kind of scab on the site that life creates in our coronary arteries. Some scabs are stronger than others. I don’t think we’ll ever really know why, and we shouldn’t believe that we will. Managing risk factors is an entirely different enterprise than treating unstable plaque. Management is about living well, intervention is about preventing imminent death.
Studies should continue, understanding should deepen and grow, but don’t fool ourselves or the patients that we are keeping them safe from MI by managing their risk factors. MI is largely unpredictable, and probably always will be. All of us can improve our health, but none of us can be safe from all disease. Let’s be honest about our goals and how little control we actually have over disease. Then we can work together to make life less painful with less debilitation, while maintaining a healthy respect for the power of Mother Nature. And as you say, have the interventionslists on standby to do their life-saving work when plaque ruptures, which is not a failure of risk management, it’s just plain bad luck.
There are so many good observations in your comment and that of the original article. At my annual physical, my internist now looks at the ASCVD 10 year risk model to determine what preventative steps to take. I’m ‘double’ the risk at 8.54% vs 4.8% risk vs my group.
Based on this she suggests a low dose statin. She also said a calcium scan could give better insight if the low dose statin is justified.
I know I live a healthy lifestyle (low carb, high lean protein diet + vigorous exercise 3x/week) but was not working out the 2 months prior to my physical due to injury so I told her to let me get back to my regimen before starting a lifetime drug.
Now I’m wondering if the calcium score really matters?
The bad luck of being overly poisoned with toxins.
John - this was taught/discussed by Krumholz in a recent editorial.... "the map is not the territory".
https://www.jacc.org/doi/10.1016/j.jacc.2025.09.1588
I’ve noted that w increasing use of screening colonoscopy the presenting age(s) of colon cancer have adjusted downward. Maybe there is a similar effect re shifting risks of the population that affects the cvd risk scores due to societal changes, for example, improved public awareness advancing seeking medical care after experiencing an episode of chest pain and not waiting to seek medical evaluation, preventing the initial mi.
Seems what you’ve really concluded here is that even low risk individuals should be taking a statin.
No, no risk individuals should be taking statins, BP meds and blood thinners. The more the merrier. The goal is everyone should be on drugs for life.
Fear, uncertainty and doubt... FUD. So much of medicine is powered by it.
FEAR - an uncredited ACRONYM for you - I heard it from Paul Hedderman, and it's great for medical thinking.
False
Evidence
Appearing
Real