Written by KFF Health News’ Paula Span
Many of Lynda Hollander’s paternal family had undergone significant surgery, and a lengthy list of them suffered from heart disease. She remarked, “I didn’t want to take a chance,” when she was in her mid-50s and noticed that her cholesterol was beginning to rise after menopause.
According to a cardiologist, Hollander had a moderate chance of experiencing a significant cardiac event, such as a heart attack, during the following ten years, depending on her age, sex, blood pressure, cholesterol, and other factors.
Usually, doctors advise these patients on the value of diet and exercise, but Hollander, a social worker in West Orange, New Jersey, who is now 64, didn’t see much opportunity for improvement. Despite my occasional slip-ups, she was already a committed runner, and she ate a generally healthy diet. Her cholesterol didn’t go down when she tried to reduce weight.
Hollander had never heard of a coronary artery calcium test, but her doctor explained that it could provide her a more accurate estimate of her risk of atherosclerotic heart disease. Ms. Hollander had never heard of a coronary artery calcium test, but her doctor explained that it could give her a more accurate assessment of her risk of atherosclerotic heart disease. A quick and painless CT scan would show whether plaque—fatty deposits—was forming in the arteries that went to her heart.
Ruptures in plaque can result in clots that obstruct blood flow and cause heart attacks. Hollander’s benefit from taking a statin, which could lower plaque and stop more from forming, would be determined by the results of the scan.
According to Michael Blaha, co-director of Johns Hopkins University’s preventive cardiology program, the test is being used by more patients each year. According to his research team, the number of calcium scans increased fourfold between 2006 and 2017, while Google searches for related terms increased even more dramatically.
According to him, it is still underutilized in relation to its worth.
One reason is that, despite the test’s relative affordability—it can cost up to $300 at times, although it normally costs $100 or less—patients must typically pay for it out of pocket. Although some doctors contend that Medicare should pay it, it rarely does.
Individuals who have no calcification and a CAC score of zero are not candidates for cholesterol-lowering medications since their risk is lower than what their first evaluations suggest. Hollander’s score, however, was in the 50s—not very high, but not insignificant.
According to her, it was the first sign of what was happening inside my arteries.
Cardiologists typically prescribe statins to patients with calcium levels above zero and recommend higher intensity statins when scores surpass 100, though standards vary. Patients who are over 300 may require even more intensive treatment because their risks are comparable to those of those who have previously experienced a heart attack.
Since then, Hollander has been taking a little amount of rosuvastatin (brand name: Crestor) together with a non-statin medication called evolocumab (Repatha).
This is the standard procedure for calcium testing. It is not a universal screening test. It is solely meant for a restricted group of asymptomatic patients between the ages of 40 and 75 who have never experienced a heart attack or stroke and are not already taking cholesterol medications.
The test answers a direct question: should I take a statin or not?
For the time being, medications are not required if a physician determines that the 10-year risk of atherosclerotic cardiovascular disease is 5% or less. Philip Greenland, a Northwestern University preventive cardiologist and co-author of a recent review published in JAMA, stated that if the risk is greater than 20%, it is undeniably significant enough to need medication.
“It’s more uncertain in the in-between range,” he said, referring to the intermediate risk of 7.5% to 20% and the borderline risk of 5% to 7.5%.
These evaluations already take risk factors like diabetes and smoking into account, so why add another one?
According to Blaha, mathematical modeling is used to generate a risk score from a sizable population. We can conclude that this number represents the heart disease risk for thousands of individuals. However, applying them to a single person has many restrictions.
However, a calcium scan creates a picture of a person’s arteries. Northwestern University researcher and cardiology fellow Alexander Zheutlin gives patients their pictures so they can view the lighter-colored calcifications.
Because they frequently deal with patients who are unwilling to take statins, cardiologists are generally advocates of calcium testing. Even though statins have an established track record of lowering heart attacks, strokes, and cardiac deaths, people who feel fine can be reluctant to begin taking medications they will take for the rest of their lives.
A quarter of the nearly 5,700 persons surveyed in 2019 who were advised to take statin therapy were not receiving it. Ten percent of them had refused to take a statin, and thirty percent had begun taking one but stopped, mostly due to side effect concerns.
According to a recent expert consensus study by the American College of Cardiology, muscle pain—the most prevalent complaint among statin users—occurs between 5% and 20% of the time. Citing studies demonstrating that complaints of muscle soreness were comparable whether patients took statins or placebos, researchers believe that the concern over side effects is exaggerated.
According to Zheutlin, the perceived risk is far higher than the actual risk.
Cardiologists contend that lowering dosages or switching to alternative statins typically resolves the issue, though it may not be much consolation to those who are experiencing agony. A non-statin cholesterol medication will work better for some patients.
For instance, Hollander experienced nighttime muscle pains that would wake me up. Hollander now self-injects Repatha twice a month and takes Crestor three days a week as her doctor recommended fewer doses.
(Statins also slightly raise the risk of diabetes and carry a very low risk of rhabdomyolysis, a serious disorder that causes muscle breakdown.)
A few warnings: No randomized clinical research has been conducted to demonstrate if calcium testing ultimately lowers the risk of heart attacks and cardiac mortality. Because of this, the independent U.S. Preventive Services Task Force has deemed the available data insufficient to support widespread use of calcium scans, even though some professional associations support them as a tool for treatment decision-making.
With numerous confounding variables, such a trial would be costly and challenging to conduct. Additionally, since a positive outcome would cause patients with zero scores to completely skip cholesterol medications, pharmaceutical corporations are reluctant to sponsor one.
However, after three years, those who had calcium scans experienced a decrease in cholesterol and a markedly lower risk of heart disease than those who had not. This was the conclusion of a recent Australian research of asymptomatic people with family histories of coronary artery disease.
According to Greenland, who was not engaged in the study, the test results in more statin prescriptions, greater statin adherence, less atherosclerosis progression, and less plaque formation. It tilts the balance.
People 75 and older are another issue. According to Zheutlin, lead author of a recent JAMA Cardiology research, CAC testing can be both overused and underutilized, and the majority will have arterial plaque, making the value of a scan less obvious.
Lowering cholesterol may become less important for older persons because they are more likely to suffer from chronic illnesses and other health problems. In a few years, a research that is currently accepting volunteers over 75 should provide answers to several questions regarding dementia, calcium scans, and statins.
Cardiologists, meanwhile, view calcium scans as a compelling instrument.
“It is really annoying,” Zheutlin remarked. Statins are inexpensive, secure, and efficient medications that may be purchased at any drugstore to help prevent heart attacks. According to him, more patients may consent to take CAC tests if their findings prove to be more significant than those of standard risk assessments alone.
Stephen Patrick, 70, a former computer executive in San Francisco, got there thanks to a calcium scan. “I was borderline on cholesterol for years, but I was able to beat it back with lots of exercise and less cheese toast,” he added. I was proud that I wasn’t taking any medications.
His doctor recommended a calcium scan last fall because both his total and LDL cholesterol levels were higher than advised. He received a score of 176.
His cholesterol levels have significantly decreased after he started taking atorvastatin (Lipitor) every day. He said, “I might have tried it anyway.” But I needed to focus more because of the calcium score.
The New York Times is a partner in the production of The New Old Age.
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