Finding incidental CAC has become common. A recent guideline document says this is heart disease and should be treated with meds. Let's assess this strong statement.
The whole concept of CAC as a disease is flawed.The CAC score is considered to show a linear relation between calcification severity and cardiovascular event all related to atherosclerosis. Yet , the large majority of patients with a zero score do not have any atherosclerosis on (CT) angiography. When these few cases are related to the events at zero we find a U shaped relationship between calcification severity and event rate. So , this U shaped or Bell shaped curve means that moderate calcification could point at a repair mechanism where only both extremes (too little and too much calcification)cause clinical events but the large majority in the middle is probably just fine and a repair mechanism for atherosclerotic disease. It could explain why vascular calcification is so extremely common
On the flip side we have been doing EBCT almost 20 years. It has been very helpful encouraging people at high risk to actually change their life (the scan is convincing). It ended many work ups for atypical chest pain, neg trop and score of 0. (Did not miss soft plaque over the years) . We found severe disease a few times a year. Lastly it helped decide on adding statins. Overall a very useful test when used by docs appropriately
The AHA and its committees are ideologically captured. The Lipid Hypothesis (despite being debunked: https://tinyurl.com/z5d7zy6c) is religion, and when faith is the basis for belief, logic and scientific method depart. The new guideline is suffused with Lipid Hypothesis presumption, with class IA rec's given out like stents in a Cath lab—inappropriately, in most cases. Thank you for this. Dr. Mandrola. More soon on the silliness of the new guidelines... .
There’s very often a natural way to fix health problems. Food, nutraceuticals, botanicals etc. I do a lot of PubMed searches for recent articles and research. It’s not just about drugs. I was doing IV phosphatidylcholine for neuropathic pain, and found that it drastically lowered my cholesterol. No statins required.
This is so helpful! Given the magnitude of information being published it is useful to know the right questions to ask about the studies that any recommendation is based on. I sometimes think a major objective of the pharmaceutical industry is to put everyone on statins at birth. i am saying this as a retired employee of a major pharmaceutical company.
To be clear, big pharma doesn't have nearly as much sway over clinician behavior as it once did. At least in primary care, which is where you see LLT being prescribed the most. That said, what IS still influencing clincian behavior is our fee for service reimbursement models, which incentivizes clincians to order more tests and perform more procedures than talk about lifestyle change. I suspect the reason we're seeing a big push for CAC scans is so cardiology groups and hospitals can convince insurers to cover the cost of scans, and thus create a new revenue stream for them.
Guidelines like this are precisely why I have become increasingly disgruntled with the composition of guideline committees, as well as their work product, over the past 15 years.
If nonsense such as the example listed here (and several more on Dr. James Stein’s substack on this topic) can garner a class 1 recommendation (based on such laughable “evidence”), it renders “class 1 recommendations” meaningless, makes a mockery of the guideline process, and furthers public distrust of so-called “experts”. I would be ashamed to have my name on that document, and those esteemed professional associations should be ashamed to have been party to such a farce.
How many of the authors have this bio? I only checked one so far:
Dr. Morris has been a speaker for Liposcience, Genzyme, Aegerion, Merck, and AstraZeneca; is a consultant to Aegerion, Genzyme, and Liposcience; and has a relationship with the American College of Cardiology.
Cholesterol centered legacy medicine at work. Yes statins do work but do we need this massive push to medicate so many with statins and soon other medications to lower LDL<60. From an endocrinologist perspective we are seeing insulin resistance be a clear predictive of cardiovascular disease Something that is missing from the cholesterol debate. There are people with normal LDL who have heart attacks likely due to insulin resistance.
A perspective randomized trial of intervention in this population would be ideal – but very difficult given the high prevalence of statin use.
Until then, the large observational studies of individuals with calcium – whether normal aging or disease – demonstrates a high correlation with cardiovascular outcomes…. Enough to influence me to recommend simple and relatively and expensive steps (aspirin, and a statin) when there is calcium. I don’t think the data is adequate to support more aggressive treatment techniques.
A radiologist here - although I personally had a dedicated CAC CT done at age 55- recommendations like this make me want to ignore incidental findings on radiology studies in a (futile) attempt to have some impact on decreasing US healthcare costs …
I wish I understood all of this better. I'm 63, in excellent health, physically very active, and not overweight, but I have a high lipoprotein A (109), indicative of hereditary heart/stroke conditions (both my parents had heart disease, and my mom had several strokes. She died at 78; my dad died at 92).
I lowered my cholesterol to below 200, and my LDL to 120, through supplements (red yeast rice, berberine, plant esters, and garlic), and I suspect that in another few months, my LDL will go under 100.
I'm having a CT scan of my heart later this month. My doctor has recommended statins. I'm opposed to them; they ruined my mom's legs. Further, red yeast rice has the same active ingredient as statins, I understand.
I wish I had someone SENSIBLE in my medical community to discuss this with. I'm looking for a functional/integrative medicine practitioner in my area.
The whole concept of CAC as a disease is flawed.The CAC score is considered to show a linear relation between calcification severity and cardiovascular event all related to atherosclerosis. Yet , the large majority of patients with a zero score do not have any atherosclerosis on (CT) angiography. When these few cases are related to the events at zero we find a U shaped relationship between calcification severity and event rate. So , this U shaped or Bell shaped curve means that moderate calcification could point at a repair mechanism where only both extremes (too little and too much calcification)cause clinical events but the large majority in the middle is probably just fine and a repair mechanism for atherosclerotic disease. It could explain why vascular calcification is so extremely common
On the flip side we have been doing EBCT almost 20 years. It has been very helpful encouraging people at high risk to actually change their life (the scan is convincing). It ended many work ups for atypical chest pain, neg trop and score of 0. (Did not miss soft plaque over the years) . We found severe disease a few times a year. Lastly it helped decide on adding statins. Overall a very useful test when used by docs appropriately
"I don’t understand the urge to make recommendations in the absence of evidence.'
let me help you:
$$$$
I’m a fan of coronary calcium evaluation and believe incidental identification should be qualitatively reported, but a class 1 recommendation?
The AHA and its committees are ideologically captured. The Lipid Hypothesis (despite being debunked: https://tinyurl.com/z5d7zy6c) is religion, and when faith is the basis for belief, logic and scientific method depart. The new guideline is suffused with Lipid Hypothesis presumption, with class IA rec's given out like stents in a Cath lab—inappropriately, in most cases. Thank you for this. Dr. Mandrola. More soon on the silliness of the new guidelines... .
There’s very often a natural way to fix health problems. Food, nutraceuticals, botanicals etc. I do a lot of PubMed searches for recent articles and research. It’s not just about drugs. I was doing IV phosphatidylcholine for neuropathic pain, and found that it drastically lowered my cholesterol. No statins required.
This is so helpful! Given the magnitude of information being published it is useful to know the right questions to ask about the studies that any recommendation is based on. I sometimes think a major objective of the pharmaceutical industry is to put everyone on statins at birth. i am saying this as a retired employee of a major pharmaceutical company.
To be clear, big pharma doesn't have nearly as much sway over clinician behavior as it once did. At least in primary care, which is where you see LLT being prescribed the most. That said, what IS still influencing clincian behavior is our fee for service reimbursement models, which incentivizes clincians to order more tests and perform more procedures than talk about lifestyle change. I suspect the reason we're seeing a big push for CAC scans is so cardiology groups and hospitals can convince insurers to cover the cost of scans, and thus create a new revenue stream for them.
Guidelines like this are precisely why I have become increasingly disgruntled with the composition of guideline committees, as well as their work product, over the past 15 years.
If nonsense such as the example listed here (and several more on Dr. James Stein’s substack on this topic) can garner a class 1 recommendation (based on such laughable “evidence”), it renders “class 1 recommendations” meaningless, makes a mockery of the guideline process, and furthers public distrust of so-called “experts”. I would be ashamed to have my name on that document, and those esteemed professional associations should be ashamed to have been party to such a farce.
How many of the authors have this bio? I only checked one so far:
Dr. Morris has been a speaker for Liposcience, Genzyme, Aegerion, Merck, and AstraZeneca; is a consultant to Aegerion, Genzyme, and Liposcience; and has a relationship with the American College of Cardiology.
That speaks volume loud and clear.
How do you like this: “Editorial: Clinical Guidelines as a Continuous Work in Progress: Moving at the Speed of Science”
Where have we heard “speed of science” before????
Cholesterol centered legacy medicine at work. Yes statins do work but do we need this massive push to medicate so many with statins and soon other medications to lower LDL<60. From an endocrinologist perspective we are seeing insulin resistance be a clear predictive of cardiovascular disease Something that is missing from the cholesterol debate. There are people with normal LDL who have heart attacks likely due to insulin resistance.
Spot on. These new “guidelines” are garbage.
Agree,
A perspective randomized trial of intervention in this population would be ideal – but very difficult given the high prevalence of statin use.
Until then, the large observational studies of individuals with calcium – whether normal aging or disease – demonstrates a high correlation with cardiovascular outcomes…. Enough to influence me to recommend simple and relatively and expensive steps (aspirin, and a statin) when there is calcium. I don’t think the data is adequate to support more aggressive treatment techniques.
A radiologist here - although I personally had a dedicated CAC CT done at age 55- recommendations like this make me want to ignore incidental findings on radiology studies in a (futile) attempt to have some impact on decreasing US healthcare costs …
I wish I understood all of this better. I'm 63, in excellent health, physically very active, and not overweight, but I have a high lipoprotein A (109), indicative of hereditary heart/stroke conditions (both my parents had heart disease, and my mom had several strokes. She died at 78; my dad died at 92).
I lowered my cholesterol to below 200, and my LDL to 120, through supplements (red yeast rice, berberine, plant esters, and garlic), and I suspect that in another few months, my LDL will go under 100.
I'm having a CT scan of my heart later this month. My doctor has recommended statins. I'm opposed to them; they ruined my mom's legs. Further, red yeast rice has the same active ingredient as statins, I understand.
I wish I had someone SENSIBLE in my medical community to discuss this with. I'm looking for a functional/integrative medicine practitioner in my area.