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.
PS. This is what really got me. From the Take-Home Messages, which is what most people will read: "CAC scoring in men at least 40 years of age and women at least 45 years of age can improve risk assessment and guide LDL-C and non–HDL-C goals." Read the guidelines in detail and you'll find that the recommendation is more selective, but as a take-home message, this reads as an endorsement of screening anyone 40 or 45 and older. And it's being reported that way.
Of the three supporting references, I was senior author on one (ref 38) and middle author on another. The supporting text reads: "The presence of carotid plaque on vascular imaging is also associated with an elevated ASCVD risk, even among patients with CAC=0 (refs 12, 38, 39). It is, therefore, encouraged to initiate LLT among patients with carotid plaque."
Seriously? The point of reference 38, from MESA, was that carotid plaque is common as people age, with substantial variation by age, sex, and race/ethnicity. If found in a young woman, yes: think about why it is there and use it as evidence to identify and address risk factors, not necessarily even a statin (smoking, for example). In most others, it does not move the dial. We even included a table of expected prevalence of carotid plaque by age, sex, and race/ethnicity precisely so that findings could be interpreted in context. This flattens nuanced population data into a rationale for treating an enormous number of people. So much for being academic.
“All normal scans and lab tests indicate a serious chronic condition that requires multiple drugs for the remainder of the patient’s life,” says every medical association receiving mega bucks from Big Pharma.
Shouldn't the incidental finding of cardiac calcification support ordering of a cardiac calcium scan. What is the validity of statin prescribing for scores over 300?: The Agatston Coronary Artery Calcium Score in Statin Users: Recent Insights from the CAC Consortium and Pathways Forward
Looks like an example of intervention bias -- people are trained to think, or are incentivized to think, that doing something is better than doing nothing. In other words, we have a solution, now we just need to conjure up a problem for it.
What should a clinician do when the evidence is insufficient? Or the balance between benefit and harm is uncertain? In this situation, a guideline panel should make a recommendation against action. Why against action? Clinicians must prioritize interventions that have clear value. In so doing, they can focus their limited time and energy on activities of proven value - and not get distracted by things of dubious benefit.
I think it is extremely important to look at the age of the patient when assessing incidental coronary calcium. There’s a huge difference between a 50 year-old and an 80 year old who has incidental coronary calcium. Any 50 year-old with coronary calcium needs lipid lowering because their future cardiovascular risk is extremely high.
More like my wallet is empty again and we need to make more re-funding-it recos. Show me which heart drugs (meds) are not toxic and poisonous. Then I might use them. Otherwise, the internal body knows best if you get rid of the chemical toxins that invade and destroy its pristine environment.
Couldn't agree more. What's with this obsession with one of the least effective therapies to ever get approval (LLT for people who haven't yet had an event). The prescription for all such patients is the same- diet (Mediterranean), exercise, sleep, social engagement, don't drink or smoke.
I would appreciate your review of the entire document in future posts. I suspect this “firm recommendation “ is but the tip of the exaggerated benefits iceberg.
A very welcome post about this issue! We're making people sick and overmedicated. I usually say to my sick patients: "keep exercising, enjoy life, eat helathy food, sleep and stay away from doctors".
PS. This is what really got me. From the Take-Home Messages, which is what most people will read: "CAC scoring in men at least 40 years of age and women at least 45 years of age can improve risk assessment and guide LDL-C and non–HDL-C goals." Read the guidelines in detail and you'll find that the recommendation is more selective, but as a take-home message, this reads as an endorsement of screening anyone 40 or 45 and older. And it's being reported that way.
Dear John,
Of the three supporting references, I was senior author on one (ref 38) and middle author on another. The supporting text reads: "The presence of carotid plaque on vascular imaging is also associated with an elevated ASCVD risk, even among patients with CAC=0 (refs 12, 38, 39). It is, therefore, encouraged to initiate LLT among patients with carotid plaque."
Seriously? The point of reference 38, from MESA, was that carotid plaque is common as people age, with substantial variation by age, sex, and race/ethnicity. If found in a young woman, yes: think about why it is there and use it as evidence to identify and address risk factors, not necessarily even a statin (smoking, for example). In most others, it does not move the dial. We even included a table of expected prevalence of carotid plaque by age, sex, and race/ethnicity precisely so that findings could be interpreted in context. This flattens nuanced population data into a rationale for treating an enormous number of people. So much for being academic.
Great read. Check out James H Stein, MD, Substack writing “bias is not a crime…” Regarding same recommendations. Also a really good take.
Why make a recommendation in the absence of evidence? Why didn't anyone speak out?
Money. Same reason as the last time. That's why.
When you limit the profit to a maximum percentage, you need to sell to a larger pool of people. TAM is a simple concept in finance.
Thank you for your attention to this matter.
The guidelines don’t say to start LLT, just consider it in decision making, reflecting the lack of randomized evidence. I think
this is a reasonable statement, but probably should be a 2A recommendation
“All normal scans and lab tests indicate a serious chronic condition that requires multiple drugs for the remainder of the patient’s life,” says every medical association receiving mega bucks from Big Pharma.
Yes, " why doesn't this get called out?" . So many people are being made scared and taking a medication without really understanding the consequences
Shouldn't the incidental finding of cardiac calcification support ordering of a cardiac calcium scan. What is the validity of statin prescribing for scores over 300?: The Agatston Coronary Artery Calcium Score in Statin Users: Recent Insights from the CAC Consortium and Pathways Forward
Looks like an example of intervention bias -- people are trained to think, or are incentivized to think, that doing something is better than doing nothing. In other words, we have a solution, now we just need to conjure up a problem for it.
In other words, a drug searching for a disease is like a hammer searching for a nail.
What should a clinician do when the evidence is insufficient? Or the balance between benefit and harm is uncertain? In this situation, a guideline panel should make a recommendation against action. Why against action? Clinicians must prioritize interventions that have clear value. In so doing, they can focus their limited time and energy on activities of proven value - and not get distracted by things of dubious benefit.
I think it is extremely important to look at the age of the patient when assessing incidental coronary calcium. There’s a huge difference between a 50 year-old and an 80 year old who has incidental coronary calcium. Any 50 year-old with coronary calcium needs lipid lowering because their future cardiovascular risk is extremely high.
Where is the data to support this statement? What is known about ARR in asx patients with + CAC scores treated with lipid meds?
More like my wallet is empty again and we need to make more re-funding-it recos. Show me which heart drugs (meds) are not toxic and poisonous. Then I might use them. Otherwise, the internal body knows best if you get rid of the chemical toxins that invade and destroy its pristine environment.
Wondering:
1). What percent of the population (over the age of 75) DO NOT have CAC?
2). Why the big rush to treat everyone (past the age of 10) with a statin?
Couldn't agree more. What's with this obsession with one of the least effective therapies to ever get approval (LLT for people who haven't yet had an event). The prescription for all such patients is the same- diet (Mediterranean), exercise, sleep, social engagement, don't drink or smoke.
I would appreciate your review of the entire document in future posts. I suspect this “firm recommendation “ is but the tip of the exaggerated benefits iceberg.
A very welcome post about this issue! We're making people sick and overmedicated. I usually say to my sick patients: "keep exercising, enjoy life, eat helathy food, sleep and stay away from doctors".