This test tells you more about your risk of heart attack

A long list of paternal parents from Lynda Hollander had heart disease and many had undergone major surgeries. So, when she struck the middle of the fifties and saw her cholesterol level crawling after menopause, she said: “I did not want to try my luck.”

A cardiologist declared to Hollander that on the basis of factors such as age, sex, cholesterol and blood pressure, it faced a moderate risk of a major heart event, as a heart attack, over the next 10 years.

Doctors generally advise such patients on the importance of food and exercise, but Hollander, now 64, social worker in West Orange, New Jersey, did not have much room for improvement. She was already a serious runner, and although “I fall from the wagon from time to time”, her diet was fundamentally healthy. Attempts to lose weight did not drop your cholesterol.

His doctor explained that a calcium test of the coronary artery, something that Hollander had heard of, could provide a more precise estimate of his risk of atherosclerotic heart disease. A brief and painless computed tomography, this would indicate whether the calcifications and the plate developed in the arteries leading to its heart.

When the plate breaks can cause clots that block blood circulation and trigger heart attacks. Analysis would help determine if Hollander would benefit from a statine, which could reduce the plate and prevent more from forming.

“The test is used by more people each year,” said Michael Blaha, co -director of the Johns Hopkins University Preventive Cardiology Program. The quadrupled calcium analyzes from 2006 to 2017, reported its research team, and research on Google of related terms increased even more strongly.

However, “it is still underused from its value,” he said.

One of the reasons is that, although the test is relatively inexpensive – sometimes up to $ 300, but often $ 100 or less – patients usually have to pay for this. Medicare rarely covers it, although some doctors argue that it should.

Patients with a zero -free CAC score – without calcification – have a lower risk than their initial assessments and are not candidates for hypocholesterolical drugs. But the Hollander’s score was in the 1950s – not high but not negligible.

“It was the first indication of what was going on in my arteries,” she said.

Although the directives vary, cardiologists generally offer statins to patients with calcium scores on zero and suggest higher intensity statins when scores exceed 100. At more than 300, the risks of patients approach those of people who have already had heart attacks; They may need even more aggressive treatment.

Since then, Hollander has taken a low dose of Rosuvastatin (brand brand: Crestor), supplemented by a non -statin medication, a called evolocumab (Repatha).

This is how calcium tests are supposed to work. It is not a screening test for everyone. It is intended only for selected asymptomatic patients, aged 40 to 75, who have never had a heart attack or stroke and are not already under cholesterol medication.

The test helps answer a sharp question: Statin, or not statin.

If a doctor calculates the risk at 10 years of atherosclerotic cardiovascular disease at 5% or less, drugs are useless for the moment. More than 20%, “there is no doubt that the risk is high enough to justify drugs,” said Philip Greenland, preventive cardiologist at the Northwestern University and co-author of a recent review in Jama.

“This is the intermediate range where it is more uncertain,” he said, including the “limit” risk from 5% to 7.5% and the “intermediate” risk from 7.5% to 20%.

Why add another measure to these assessments, which already integrate risk factors such as smoking and diabetes?

“A risk score is derived from a large population, in mathematical modeling,” said Blaha. “We can say that this score describes the risk of heart disease in thousands of people. But there are a lot of limits to apply them to an individual. ”

A calcium analysis, however, produces an image of the arteries of an individual. Alexander Zheutlin, a cardiology scholarship and researcher at the Northwestern University, shows patients their images, so that they can see the lighter color calcifications.

Cardiologists tend to be fans of calcium tests because they regularly meet patients who hesitate to take statins. People who feel good can hesitate to start drugs they will take for the rest of their lives, despite the proven history of statins to reduce heart attacks, cerebral vascular accidents and cardiac deaths.

In 2019, a survey of nearly 5,700 adults for which a statin was recommended revealed that a quarter was not in treatment. Among these, 10% had refused a stature and 30% had started and then was interrupted, mainly citing the fear of side effects.

A consensus report of experts from the US Cardiology College recently put the rate of muscle pain, the most common complaint of users of statins, at 5% to 20%. Researchers consider the fear of exaggerated side effects, citing studies showing that muscle pain relationships were comparable, that patients take statins or placebos.

“The real risk is much, much lower than the perceived risk,” said Zheutlin.

This can be little comfort for people with suffering, but cardiologists argue that dose reduction or the transition to different statins usually solves the problem. Some patients will do better on a non -statina medication in cholesterol.

Hollander, for example, suffered from “muscle cramps that would wake me up at night”. His doctor advised fewer doses, so Hollander now takes Crestor three days a week and self-injected the repathing twice a month.

(Statins also have a very low risk of dangerous condition, rhabdomyolysis, which causes muscle degradation, and they slightly increase the risk of diabetes.)

Certain warnings: no one has taken a randomized clinical trial to show whether calcium tests ultimately reduce heart attacks and cardiac deaths. This is why, although several professional associations approve of calcium analyzes to help determine the treatment, the independent working group of the American preventive services has qualified the current evidence of “insufficient” to recommend a generalized use.

Such a trial would be expensive and difficult to climb, with many confusing variables. And pharmaceutical companies are not eager to take out one, because a successful result could mean that patients with zero scores completely avoid cholesterol.

But a recent Australian study of asymptomatic patients with family history of coronary disease revealed that after three years, those who had undergone calcium scans had a sustained reduction in cholesterol and a significantly lower risk of heart disease than those who had not been tested.

The test “led to more statins prescriptions, better membership of statins, unless the increase in atherosclerosis and the growth of the plaque,” said Greenland on the study, in which it was not involved. “It tips the scale.”

Another concern: people aged 75 and over. Most will have a arterial plate, which makes the advantages of a “less clear” scan, said Zheutlin, the main author of a recent article in Jama cardiology stressing that CAC tests can be both overused and underused.

Since the elderly faces more chronic diseases and medical problems, abandonment of cholesterol can become a lower priority. A study now listed for participants over 75 should answer certain questions about statins, calcium analyzes and dementia in a few years.

Meanwhile, cardiologists consider calcium analyzes as a persuasive tool.

“It’s incredibly frustrating,” said Zheutlin. With statins, “we have cheap, safe and effective drugs available in any pharmacy” which help prevent heart attacks. If the results of CAC tests prove more influential than traditional risk assessments, he said, more patients could agree to take them.

A calcium scan helped Stephen Patrick, 70, a retired technological framework in San Francisco, reaching this point. “For years, I was on the edge of cholesterol, and I managed to repel it with less cheese toast” and a lot of exercise, he said. “I was not on medication and I was proud of it.”

Last fall, with its total LDL total and higher than recommended, his doctor suggested a calcium scan. His score: 176.

He takes Atorvastatin (lipitor) daily, and his cholesterol level has dropped considerably. “I might have tried anyway,” he said. “But the calcium score meant that I had to pay more attention.”

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