The very word makes some people ill: STATINS. This group of medications introduced in the late 1980’s to lower cholesterol have both been credited with saving lives on the one hand and being the biggest medical fraud on the other hand. For years it has been known that some people prescribed statins develop side effects including muscle aching and brain fog that are reversible on stopping the medication. Recently the headlines have focused on the risk of developing diabetes type 2 in those at risk for diabetes. This risk may be double or even triple the incidence of those not on a statin according to recent reports. Like all medication, statins should be used only in those that may benefit and only in those that have atherosclerosis. But how do you know if you have atherosclerosis? The easiest way is a heart calcium CT scan.
What is a heart calcium scan (CAC or coronary artery calcium)? It is a simple CT of the heart performed without injection of any medications. A CAC permits the easy identification of calcification (plaque) in the three heart arteries. By good fortune, the density of arteries is different than the fat they sit in and the muscle and blood that are nearby in the heart. Calcium comprises about 20 percent of plaque in arteries but is such a different density than the rest of the heart that even small amounts show up like a beacon of illness without exercise, IV placement, or sedation. A software program permits a score, called the Agatson score, to be calculated with zero being the best result and numbers in the tens, hundreds and even thousands indicating increasing burdens of calcified heart artery plaque.
The CAC score is the most accurate way to detect silent heart disease and also the strongest predictor of future cardiac events like heart attack and death. The scan can be done for as little as $75 so there is easy availability to all who do not know they have early heart disease but want to find out. There is no role for measuring the CAC in those who have had a heart stent, bypass surgery, or known blocked arteries.
If you have not heard of a CAC score it may be because it has not been promoted as much as more expensive and invasive stress tests and heart catheterizations. This dilemma is the focus of a provocative documentary called The Widowmaker. Although you may need a prescription from your health care provider for a CAC, after watching this documentary, I am quite certain you will want to know your heart calcium score.
How can a heart calcium CT scan help you discuss the need for a statin that your health care provider may be offering? A scientific report this week supports the view that many do not need statins and the CT scan is the best way to evaluate this. The study looked at an elderly population because cardiovascular risk increases dramatically with age. Therefore, nearly all of the elderly could be offered a statin after calculating a risk-based statin eligibility in the elderly. The researchers wanted to assess if it was possible to limit overtreatment and identify truly low risk individuals who can say no to a statin.
They studied 5,805 BioImage participants with a mean age of 69 years followed for almost 3 years. They analyzed 13 potential markers that could be used to determine risk over time: coronary artery calcium score (CAC)=0, CAC score≤10, no carotid plaque, no family history, normal ankle-brachial index, test result <25th percentile (carotid intima-media thickness, apolipoprotein B, galectin-3, high-sensitivity C-reactive protein, lipoprotein(a), N-terminal pro–B-type natriuretic peptide, and transferrin), and apolipoprotein A1 >75th percentile.
They found that a CAC of 0 and a CAC≤10 were the strongest negative risk markers. A lab test called galectin-3 (which I measure on all patients) also could be used to lower the predicted risk followed by the absence of carotid plaque on an ultrasound. Results obtained by other candidate markers were less impressive.
They concluded that individuals with CAC score of 0, a CAC score≤10, a low galectin-3, or no carotid plaque had remarkably low cardiovascular risk.
These new data provide a platform to evaluate if you really need a statin. It is smart to ask the question if the risk (although low) is greater than any predicted benefit. Whether you are 69 years old like the study participants, or 49 years old, asking for a CAC scan, a blood level of galectin-3, and a carotid ultrasound (the method we use at my clinic, is wise advice.