I would also add the burden of incidentalomas. Many a pulmonary nodule, etc lead to additional follow up testing and worry. I wish we would talk about this more. More testing is not always better.
You site taskforce recommendations, which is an anathema to good medicine. Because it dismisses individual thought and discretionary action. The taskforce recommendations for testing PSA says do not test PSA in older men. So, how are you suspect prostate cancer in older men? CAC -- spell it out. Coronary Artery Calcification studies is a tool. If your score is zero, there is real value. Just like stress treadmills. How predictive is that modality? What is the value of 256 slice CT coronary angiograms?
Just to shore up a common thread I am seeing: The reader will notice I did not argue CAC scoring leads to too much downstream testing as the I do not believe the randomized evidence supports this notion.
So, I’m female 59 healthy, fit, eat right. My only issue is slightly elevated cholesterol(230), it’s been like this since my 20s. I do not tolerate statins but every time I go see a doctor I’m pressured to take them. I paid for and did a CAC, score is zero. So, not thinking I need a statin…
Historical Review of the Use of Relative Risk Statistics in the Portrayal of the Purported Hazards of High LDL Cholesterol and the Benefits of Lipid-Lowering Therapy
Statins actually INCREASE CAC, hence statins proponents don't recommend a CAC once someone takes one.
So the benefits are vastly overstated about statins via RRR while their bad effects (side effects) are stated in ARR format.
How disingenuous!
CAC isn't anything anyone can "treat," but it would be damned helpful if how it actually gets there could be studied. Not clinically helpful, yet, but research has put so much investigation into cholesterol that they've missed the etiology of CAC. It begins as microcalcifications! It's not initially visible w/o new technology, but calcium is there...at the beginning of plaques!
Much like we now can "see" microplastics and nano plastics with new technologies - and we still need to look even smaller than we tend to now - we need to actually LOOK for microcalcifications in arteries, in organs. But we're stuck on looking at cholesterol.
"So the benefits are vastly overstated about statins via RRR while their bad effects (side effects) are stated in ARR format." You are right. This is the key, but you fall into the trap of using acronyms, which is spinning out of control in medicine. There are no benefits from statins if you look at the "absolute" statistics, not "relative" statistics. Relative statistics is widely used to sell you something. Anything.
I fought a local battle against coverage of CAC Scores from ~2011 until ~2022 while serving as the Medical Director for a mid-sized PPO-TPA providing employer-sponsered health plans. I reviewed the data frequently during these years and never saw adequate evidence to support the effectiveness of this testing. I am not surprised to see the opinions stated here...
When the shameless CAC proponents write “in appropriately selected patients”, I have an urge to inform them of the bridge I have for sale. I would even discount it further for those learned individuals.
Everyone and their kitchen sink knows that, if the floodgates were allowed to open, everyone and their dog would get one, “appropriately selected” be damned. And the downstream unnecessary (and potentially harmful) testing is real in a profit based system like that of the US.
If the proponents really wanted to put their $ where their pie-hole is, that’s easy. Conduct a proper trial of using CAC as a strategy, and show hard outcome benefits. Only then should they publish fawning editorials in Circ….or at least could do so without shame.
The best reason not to pay for it is that paying through third parties for readily affordable goods and services is an economic absurdity. Adding items to "insurance" coverage just adds to the insurance premium so the price is not really reduced, and in the offing the whole transaction substantially raises the cost overall as well as the complexity of providing the service. As far as whether it's valuable the doctor and patient cooperatively should decide, but that becomes impossible to realistically determine if a third party is involved in payment.
What about low-income patients? Is the test as important as a month of cell phone coverage? Radiology groups can always reduce the price for appropriate individuals as doctors did in former days or organizations such as the AHA or the ACC can sponsor low cost or free tests if they are convinced of its value.
I found getting my CAC score of zero at age 76 was well worth the $75 the University charged for it. I stopped taking the statin that was recommended by ACC guidelines for all males my age regardless of our LDL (mine is less than 100mg/dl without statin). At my age, one less medicine to take is helpful.
Brilliant. I'd also suggest the rationale—identify 'high risk', start statins, reduce CV events—is also provably wrong. Obese, sedentary men with mean cholesterol 270 and genetically high risk saw no mortality benefit with statins in WOSCOPS, and no major statin meta-analysis has shown either a mortality reduction for those without heart disease, or less 'serious illness' (hospitalizations, basically). Thus events won't be fewer—they'll probably rise with muscle problems and diabetes. Excellent piece, thank you.
I haven't read the whole study but wonder why there is no mention in the summary or analysis of whether the calcium score had any predictive value at all. The clear inference is that the "preventive" treatments applied to those testing positive are not useful for men in this age range. I hate to say it but, given the frequency of useless testing and "preventive" treatments, insurance companies may be one of the more accurate assessors of the value of screening and preventive treatment in this and many other areas of medicine today.
This is a great column. Few writers on health policy appreciate the downsides to insurance coverage. The reflexive view is if something has the potential to help, insurers should pay for it--and governments should force them to if they won't do so voluntarily. But insurance coverage is not all upside. It drives up consumption and prices, often greatly. Generally speaking, insurance should cover only treatments that are far too expensive for people to purchase directly.
“A 40-year-old, falsely secured by his score of zero, stopped his statin not realizing all his previous testing demonstrated he would greatly benefit from risk factor modification.“
Great post. Thank you so much.
I would also add the burden of incidentalomas. Many a pulmonary nodule, etc lead to additional follow up testing and worry. I wish we would talk about this more. More testing is not always better.
You site taskforce recommendations, which is an anathema to good medicine. Because it dismisses individual thought and discretionary action. The taskforce recommendations for testing PSA says do not test PSA in older men. So, how are you suspect prostate cancer in older men? CAC -- spell it out. Coronary Artery Calcification studies is a tool. If your score is zero, there is real value. Just like stress treadmills. How predictive is that modality? What is the value of 256 slice CT coronary angiograms?
Just to shore up a common thread I am seeing: The reader will notice I did not argue CAC scoring leads to too much downstream testing as the I do not believe the randomized evidence supports this notion.
Please see the EISNER trial for reference: https://www.jacc.org/doi/10.1016/j.jacc.2011.01.019.
So, I’m female 59 healthy, fit, eat right. My only issue is slightly elevated cholesterol(230), it’s been like this since my 20s. I do not tolerate statins but every time I go see a doctor I’m pressured to take them. I paid for and did a CAC, score is zero. So, not thinking I need a statin…
Cholesterol doesn't matter. But even if it did, yours is normal and your thinking is correct.
BTW, the skeptical cardiologist does not seem to know about
https://pubmed.ncbi.nlm.nih.gov/37143855/
And since I don't have a paid subscription, I can not post to his false claims.
Just as CAC will "save lives," so, too, will statins, etc.
Not. Not even close.
Until someone can actually think about what causes a cardiovascular event (nope, not cholesterol), we're stuck in stupid.
Please see:
Historical Review of the Use of Relative Risk Statistics in the Portrayal of the Purported Hazards of High LDL Cholesterol and the Benefits of Lipid-Lowering Therapy
https://pmc.ncbi.nlm.nih.gov/articles/PMC10153768/
Statins actually INCREASE CAC, hence statins proponents don't recommend a CAC once someone takes one.
So the benefits are vastly overstated about statins via RRR while their bad effects (side effects) are stated in ARR format.
How disingenuous!
CAC isn't anything anyone can "treat," but it would be damned helpful if how it actually gets there could be studied. Not clinically helpful, yet, but research has put so much investigation into cholesterol that they've missed the etiology of CAC. It begins as microcalcifications! It's not initially visible w/o new technology, but calcium is there...at the beginning of plaques!
Much like we now can "see" microplastics and nano plastics with new technologies - and we still need to look even smaller than we tend to now - we need to actually LOOK for microcalcifications in arteries, in organs. But we're stuck on looking at cholesterol.
Like dummies....
"So the benefits are vastly overstated about statins via RRR while their bad effects (side effects) are stated in ARR format." You are right. This is the key, but you fall into the trap of using acronyms, which is spinning out of control in medicine. There are no benefits from statins if you look at the "absolute" statistics, not "relative" statistics. Relative statistics is widely used to sell you something. Anything.
I fought a local battle against coverage of CAC Scores from ~2011 until ~2022 while serving as the Medical Director for a mid-sized PPO-TPA providing employer-sponsered health plans. I reviewed the data frequently during these years and never saw adequate evidence to support the effectiveness of this testing. I am not surprised to see the opinions stated here...
Excellent column.
When the shameless CAC proponents write “in appropriately selected patients”, I have an urge to inform them of the bridge I have for sale. I would even discount it further for those learned individuals.
Everyone and their kitchen sink knows that, if the floodgates were allowed to open, everyone and their dog would get one, “appropriately selected” be damned. And the downstream unnecessary (and potentially harmful) testing is real in a profit based system like that of the US.
If the proponents really wanted to put their $ where their pie-hole is, that’s easy. Conduct a proper trial of using CAC as a strategy, and show hard outcome benefits. Only then should they publish fawning editorials in Circ….or at least could do so without shame.
The best reason not to pay for it is that paying through third parties for readily affordable goods and services is an economic absurdity. Adding items to "insurance" coverage just adds to the insurance premium so the price is not really reduced, and in the offing the whole transaction substantially raises the cost overall as well as the complexity of providing the service. As far as whether it's valuable the doctor and patient cooperatively should decide, but that becomes impossible to realistically determine if a third party is involved in payment.
What about low-income patients? Is the test as important as a month of cell phone coverage? Radiology groups can always reduce the price for appropriate individuals as doctors did in former days or organizations such as the AHA or the ACC can sponsor low cost or free tests if they are convinced of its value.
OK. Now do statins.
I found getting my CAC score of zero at age 76 was well worth the $75 the University charged for it. I stopped taking the statin that was recommended by ACC guidelines for all males my age regardless of our LDL (mine is less than 100mg/dl without statin). At my age, one less medicine to take is helpful.
Excellent example thank you for sharing
Brilliant. I'd also suggest the rationale—identify 'high risk', start statins, reduce CV events—is also provably wrong. Obese, sedentary men with mean cholesterol 270 and genetically high risk saw no mortality benefit with statins in WOSCOPS, and no major statin meta-analysis has shown either a mortality reduction for those without heart disease, or less 'serious illness' (hospitalizations, basically). Thus events won't be fewer—they'll probably rise with muscle problems and diabetes. Excellent piece, thank you.
I haven't read the whole study but wonder why there is no mention in the summary or analysis of whether the calcium score had any predictive value at all. The clear inference is that the "preventive" treatments applied to those testing positive are not useful for men in this age range. I hate to say it but, given the frequency of useless testing and "preventive" treatments, insurance companies may be one of the more accurate assessors of the value of screening and preventive treatment in this and many other areas of medicine today.
This is a great column. Few writers on health policy appreciate the downsides to insurance coverage. The reflexive view is if something has the potential to help, insurers should pay for it--and governments should force them to if they won't do so voluntarily. But insurance coverage is not all upside. It drives up consumption and prices, often greatly. Generally speaking, insurance should cover only treatments that are far too expensive for people to purchase directly.
“A 40-year-old, falsely secured by his score of zero, stopped his statin not realizing all his previous testing demonstrated he would greatly benefit from risk factor modification.“
Seriously?