Coronary Calcium Case Study: A Sexagenarian’s Decision on Statin Therapy

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My friend David’s story (absent my input) is likely being repeated daily in doctor’s offices nationwide. His account follows.

David’s Decision

As I strolled into my primary care physician (PCP)’s office this past September for my annual checkup & flu shots, I had no idea that I was about to become a “case study” for the renowned Skeptical Cardiologist. Had I known, I would have faced the annual ritual with considerably more trepidation!

Brief bio: 66-year-old male, never-smoker, no medications, family history of congestive heart failure. Brooklyn resident, reasonably active flaneur, and vegetarian for 20 years. (A favorite New Yorker cartoon reads: “At first I was a vegetarian for diet reasons; then later for political reasons; but now just to annoy people”).

Luckily for me, as it turned out, I am also a son of Oklahoma, where I had the good fortune long ago to become friends with the Skeptical Cardiologist. (My late father-in-law, a native New Yorker, was fond of saying to me: “You can take the boy out of Oklahoma, but you can’t take Oklahoma out of the boy.” I’m still unsure whether that was a compliment, or an insult!)

The checkup was routine until my labs, excerpted below, arrived via email:

  • Cholesterol 224 mg/dL
  • HDL cholesterol 95 mg/dL
  • LDL Cholesterol 114 mg/dL
  • Total cholesterol-to-HDL ratio 2.4

At the top of the report my PCP had written, “I have reviewed your recent results. Overall your labs look very good. My only concern is your cholesterol. You have a high good HDL cholesterol, but you are getting to the point where a statin medication may be helpful.”

None of this meant anything to me; I didn’t know which kind was the “good” cholesterol; I didn’t know the difference between a statin and a stent! But the prospect of starting a medication prompted me to attempt to educate myself.

When I told the Skeptical Cardiologist, via text message, what my PCP had said, he observed that like many PCPs, mine had done a rather poor job at communicating why a statin drug might be necessary.

On the recommendation of the Skeptical Cardiologist, I read every article on his statins page. I further learned about a test called the coronary artery calcium (CAC) scan, and read many articles about that as well. I decided that the scan might help determine not only whether I should take a statin, but also whether I am at risk of dropping dead at any minute, which seems like a good thing to keep in the back of one’s mind.

I chose a diagnostic center on E. 84th Street in Manhattan, mostly because of its proximity to Central Park and to the Metropolitan Museum of Art — both are prime locations for flaneuring after the test! For those who may be unfamiliar with the term flaneur, it is said to refer to the act of doing nothing, raised to an art form.

The test itself took 15 minutes. Outside, the day was fine, and Central Park’s fall foliage was glorious, so after a socially-distanced repast al fresco on the Upper East Side, I spent the rest of the day wandering all over the park’s spectacular woods.

Later, my neighbor Peter, with whom I share an occasional socially-distanced martini in my rear garden, advocated on behalf of statins. My same age, he’s been taking them for 15 years, and says they’re great as “they knock the cholesterol right down.” Everyone seems to be taking them! Even the diagnostician who did my CAC scan said she takes one! Should all men over 60 take a statin? Was I getting statin FOMO?

A few days later, the Skeptical Cardiologist texted my CAC results:

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No need for a statin!? This seems like good news indeed!! At the least, it will inform my discussions with my PCP. I am very glad I invested in the CAC scan, and that I took the time to educate myself via the Skeptical Cardiologist’s blog.

Skeptical Cardiologist’s Comments

When you enter in David’s numbers to the guideline-recommended risk estimator, the smartphone app estimates his 10-year risk of heart attack or stroke at 9.1%. As I’ve pointed out pretty much any male in his 60s will get a 10-year risk estimate >7.5% from this calculator, which per the guidelines should trigger discussion of drug treatment with a statin to lower both the LDL cholesterol and the long term risk of heart attack/stroke.

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The MESA risk calculator helps refine David’s risk by incorporating additional conventional risk factors (like family history) and, most importantly, the CAC score, which measures subclinical atherosclerosis.

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As you can see after incorporating the zero CAC score, the more precise estimate of David’s 10-year risk is 1.5%. This is extremely low and adding a statin therefore makes little sense.

It also makes no sense to take aspirin at this low risk level.

Anthony C. Pearson, MD, is a noninvasive cardiologist and professor of medicine at St. Louis University School of Medicine. He blogs on nutrition, cardiac testing, quackery, and other things worthy of skepticism at The Skeptical Cardiologist, where a version of this post first appeared.

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