Thanks I appreciate it! That's a really neat tool on average. What do you think? The average risk going out to 80 years old is to have a heart attack for a healthy person? Seems like being a former smoker (20 yrs no smoking) and a family history (moms side) of coronary disease puts my numbers in the 12-15% realm
This is a great question and a point I will likely discuss in detail in a full article here. A. Low risk does not mean no risk. B. About 10% of patients with a CAC=0 have plaque on a CTCA so therefore were not properly risk assesed and lastly a very small % of a very large number ie patients with a CAC of 0 is still a very big number. More to come.
I am well aware of him. I think he is making big bets on low-quality data but the only data we have. I think most people who dont plan on making extreme longevity their goal would be better off focusing on the core factors rather than trying to optimise the minor aspects of longevity with low quality evidence to support their use.
My calcium score is 57. Mild heart disease. I am trying statins low dose- for years- but I get muscle pain in my legs. Tried Pravachol (the best) rovastatin etc. My LDL is 131. Dr is suggesting repatha. Would do you suggest getting my
my LDL down in range without muscle pain. Also I have had hemorrhagic stroke so there is a question of how low should we get my LDL? Below 70? Too low?
But I need to find something I can tolerate. Thank you!!
It’s not something I use. Some mixed evidence and not (yet) available in Ireland. I think when it comes to TG lowering diet is an excellent option as opposed to LDL lowering where I think diet is not a great option.
1. How would that LDL reduction graph look for different dosage of statins? What is the baseline dosage for the graph? 10 mg? 20 mg? 40 mg?
2. Is there a good mechanistic understanding of how LDL causes atherosclerosis? If so, could you recommend some links? OR are we primarily going off of strong correlation?
A quick Google search will answer question 1 but in general responses vary by dose from about 10-50% reduction. Re Q2 LDL-C is causal and the mechanisms have been well described for decades. https://pubmed.ncbi.nlm.nih.gov/28444290/
Years ago I started taking Lipitor and shortly thereafter I started having short term memory loss. My doctor took me off of it and the problem went away.
I can't give individual medical advice here and would strongly suggest a good conversation with your cardiologist about how to best reduce your future risk. At a minimum in post MI patients LDL-C target is <1.4 (55) but in some cases we aim even lower eg <1.0 (39 ) but all decisions need to be made in the context of your individual case which is only known by your cardiologist.
CAC and CT angio both negative for coronary artery disease, but CIMT shows a different story with several areas of transitioning plaque and increased intimal thickness for my age showing some definite risk for stroke. Largest plaque is around 24% stenosis. I'm 68. Definitely changed my mind in favor of lipid lowering therapy. What are your feelings about CIMT as a screening tool?
In my view atherosclerosis is atherosclerosis no matter what the territory and I act accordingly. I do not use CIMT that frequently but it has its value.
I am hopeful that PCSK9 therapies become more widespread in the near future. I was told by my cardiologist that while PCSK9 demonstrably lowers LDL and ApoB, this therapy has not been proven to reduce risk of adverse cardiovascular events, while Statins have been proven to do so. He implied that it might be some other action of statins, such as stabilizing plaque deposits, that accounts for the benefit rather than simply lowering LDL/ApoB. Then of course there is the cost of PCSK9 treatment. In any case, I agree with the need to weigh the pros and cons.
The mechanism of lowering ApoB is not likely to make that much of a difference, what matters most is the end result. PCSK9's do have MACE data (https://www.nejm.org/doi/full/10.1056/NEJMoa1801174). Your cardiologist may have been referring to Inclisiran where outcome trials are still pending.
Thanks as always for the ordered and balanced way you present your knowledge. It is very accessible and helpful.
Where does one find the lifetime risk calculator you referenced
http://www.lpaclinicalguidance.com
Thanks I appreciate it! That's a really neat tool on average. What do you think? The average risk going out to 80 years old is to have a heart attack for a healthy person? Seems like being a former smoker (20 yrs no smoking) and a family history (moms side) of coronary disease puts my numbers in the 12-15% realm
The CAC and MI graph shows almost a non-existent 10 yr risk for those with a CAC=0
Just wondering how this squares with the quote below thanks?
"About one-fourth to one-third of the total incident cardiovascular disease (CVD) events occur in those with a CAC of zero"
Zero Coronary Artery Calcium Score Desirable, but Enough? 2020
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.119.045026
This is a great question and a point I will likely discuss in detail in a full article here. A. Low risk does not mean no risk. B. About 10% of patients with a CAC=0 have plaque on a CTCA so therefore were not properly risk assesed and lastly a very small % of a very large number ie patients with a CAC of 0 is still a very big number. More to come.
Thanks - will look forward to that post
Hi Paddy
Was wondering if you've heard of Bryan Johnson and his 'Don't Die' philosophy and if so what is your opinion on him?
I am well aware of him. I think he is making big bets on low-quality data but the only data we have. I think most people who dont plan on making extreme longevity their goal would be better off focusing on the core factors rather than trying to optimise the minor aspects of longevity with low quality evidence to support their use.
My calcium score is 57. Mild heart disease. I am trying statins low dose- for years- but I get muscle pain in my legs. Tried Pravachol (the best) rovastatin etc. My LDL is 131. Dr is suggesting repatha. Would do you suggest getting my
my LDL down in range without muscle pain. Also I have had hemorrhagic stroke so there is a question of how low should we get my LDL? Below 70? Too low?
But I need to find something I can tolerate. Thank you!!
Hi Paddy
Any thoughts on Vaskepa in addition to statins?
It’s not something I use. Some mixed evidence and not (yet) available in Ireland. I think when it comes to TG lowering diet is an excellent option as opposed to LDL lowering where I think diet is not a great option.
Very nicely written.
1. How would that LDL reduction graph look for different dosage of statins? What is the baseline dosage for the graph? 10 mg? 20 mg? 40 mg?
2. Is there a good mechanistic understanding of how LDL causes atherosclerosis? If so, could you recommend some links? OR are we primarily going off of strong correlation?
A quick Google search will answer question 1 but in general responses vary by dose from about 10-50% reduction. Re Q2 LDL-C is causal and the mechanisms have been well described for decades. https://pubmed.ncbi.nlm.nih.gov/28444290/
Years ago I started taking Lipitor and shortly thereafter I started having short term memory loss. My doctor took me off of it and the problem went away.
LDL-C 51 mg/dL (well below 70 mg/dL target), post MI, CAD & RCA stenting:
1. should the individual take statins?
2. And if yes, how low should LDL-C target be?
I can't give individual medical advice here and would strongly suggest a good conversation with your cardiologist about how to best reduce your future risk. At a minimum in post MI patients LDL-C target is <1.4 (55) but in some cases we aim even lower eg <1.0 (39 ) but all decisions need to be made in the context of your individual case which is only known by your cardiologist.
CAC and CT angio both negative for coronary artery disease, but CIMT shows a different story with several areas of transitioning plaque and increased intimal thickness for my age showing some definite risk for stroke. Largest plaque is around 24% stenosis. I'm 68. Definitely changed my mind in favor of lipid lowering therapy. What are your feelings about CIMT as a screening tool?
In my view atherosclerosis is atherosclerosis no matter what the territory and I act accordingly. I do not use CIMT that frequently but it has its value.
It does for me, as it definitely changed the strategy. I've heard from several others that had the same findings as me, so I found it very useful!
What if your CAC score is 0, but you have elevated Lipoprotein A?
Your risk is increased. Lp(a) is an independent risk factor for coronary disease.
Thank you…trying to figure out if I should take a statin. Over all cholesterol is within normal limits, but LDL is 102. It all gets confusing.
I am hopeful that PCSK9 therapies become more widespread in the near future. I was told by my cardiologist that while PCSK9 demonstrably lowers LDL and ApoB, this therapy has not been proven to reduce risk of adverse cardiovascular events, while Statins have been proven to do so. He implied that it might be some other action of statins, such as stabilizing plaque deposits, that accounts for the benefit rather than simply lowering LDL/ApoB. Then of course there is the cost of PCSK9 treatment. In any case, I agree with the need to weigh the pros and cons.
The mechanism of lowering ApoB is not likely to make that much of a difference, what matters most is the end result. PCSK9's do have MACE data (https://www.nejm.org/doi/full/10.1056/NEJMoa1801174). Your cardiologist may have been referring to Inclisiran where outcome trials are still pending.