The skeptical cardiologist was in Atlanta recently visiting his Life Coach (LCOSC). Oddly enough, the wife of the LCOSC (who I’ll call Lisa) had just undergone a coronary calcium scan and it came back with a high score. Most women her age (58 years old) have a zero score but hers came back at 208 .
What is the significance of a calcium score of 208 in this case?
The CT scan for calcium (discussed by me in more detail here) focuses entirely on quantifying the intense and very specific kind of x-ray absorption from calcium. The three-dimensional resolution of the scan is such that the coronary arteries which supply blood to the heart can be accurately located and the amount of calcium in them very accurately and reproducibly added up. Calcium is not in the arteries normally and only accumulates as atherosclerotic plaque builds up over time. The build up of fatty plaque (atherosclerosis) is the major cause of coronary artery disease (CAD, sometimes termed coronary heart disease (CHD)) which is what causes most heart attacks and most death in both men and women in the U.S.
We can enter Lisa’s numbers into the online MESA calculator to see how she compares to other white 59 year old women. The calculator tells us that 72% of her peers have a zero calcium score and a score of 208 is higher than 95% of her peers. Although the 95th percentile is a good place to be for SAT scores it is not for atherosclerosis. This means substantial amount of fatty atherosclerotic plaque has built up in the arteries and puts the individual at significantly greater risk for heart attack and stroke. A calcium score of 100-300 confers a 7.7 times increased risk compared to an individual with similar risk factors with a zero calcium score.
Most of the risk factors that we can measure to assess one’s risk of heart attack (blood pressure, diabetes, smoking) were absent in Lisa. Her cholesterol levels had risen in the last 10 years but when I entered her numbers (total cholesterol 221, HDL 68) into the ASCVD risk estimator her 10 year risk came back at 2.5%. This is considered low and no treatment of cholesterol would be advised by the new guidelines.
The only clue that her cardiologist would have that Lisa has advanced premature atherosclerosis is that her mother had coronary heart disease at an early age, something we call premature CAD. Her mom at the age of 62 suffered a heart attack and had a stent placed in one of her coronary arteries. The occurrence of significant premature CAD in a parent or sibling substantially increases the chances that a patient will have premature CAD and the earlier it occurred in the parent or sibling the higher the risk.
Some of this excess risk is transmitted by measurable risk factors such as hypertension and hyperlipidemia and some through lifestyle factors but the majority of it is through genetic factors that we haven’t fully identified.
How much of an individual’s risk for heart attack is determined by genetics versus lifestyle?
A large Swedish study found that adopted men and women with at least one biological parent with CHD were 1.5 times more likely to have CHD than adoptees without. In contrast, men and women with one adoptive parent were not at increased risk.
Since 2007 an intense project to identify genetic factors responsible for CAD has been underway at multiple academic centers. Thus far 50 genetic risk variants have been identified. According to Dr. Robert Roberts
” All of these risk variants are extremely common with more than half occurring in >50% of the general population. They increased only minimally the relative risk for coronary artery disease. The most striking finding is that 35 of the 50 risk variants act independently of known risk factors, indicating there are several pathways yet to be appreciated, contributing to the pathogenesis of coronary atherosclerosis and myocardial infarction. All of the genetic variants seem to act through atherosclerosis, except for the ABO blood groups, which show that A and B are associated with increased risk for myocardial infarction, mediated by a prolonged von Willebrand plasma half life leading to thrombosis”
How well do the standard risk factors capture the individuals risk for heart attack?
The standard approach to estimating risk fails in about 25% of individuals as it does not accurately convey the high risk of the patient with family history and it overestimates risk in many elderly individuals who have an excellent family history.
It is in these patients that testing for the actual presence of atherosclerosis, either by vascular screening or coronary calcium is helpful.
Reducing The Excess Risk of Premature CAD
For many individuals there are clear-cut lifestyle changes that can be implemented once advanced CAD is identified: cigarette smoking cessation, weight loss through combinations of diet and exercise with resulting control of diabetes, However, many patients like Lisa, are non-smokers, living a good lifestyle, eating an excellent diet with plenty of fresh fruit, vegetables, fish and healthy oils and without obesity or diabetes. There is no evidence that modifying lifestyle in this group is going to slow down an already advanced progression of atherosclerosis.
Patients like Lisa have inherited predisposition to CAD, it is not due to their lifestyle.
Lisa’s cardiologist suggested she get a copy of Dr. Esselstyn’s book “Prevent and Reverse Heart Disease”. This book, based on the author’s experience in treating 18 patients with advanced CAD espouses an ultra low fat diet. The author declares that “you may not eat anything with a face or a mother (meat/poultry/fish)” and bans full fat dairy products and all oil (“not even a drop”)
Such “plant-based diets” (codeword for vegan or vegetarianism) lack good scientific studies supporting efficacy and are extremely hard to maintain long term. There is nothing to suggest that Lisa’s long term risk of heart attack and stroke would be modified by following such a Spartan dietary regimen.
Her cardiologist did recommend two things proven to be beneficial in patients with documented advanced CAD: statins and aspirin.
Taking a statin drug will arrest the atherosclerotic process and reduce risk of heart attack and stroke by around 30% as I’ve discussed here and here.
An aspirin is now indicated since significant atherosclerosis has now been documented to be present as I’ve discussed here.
We can blame a lot of heart disease on lifestyle: poor diets and lack of exercise are huge factors leading to obesity, diabetes, hypertension and hyperlipidemia, but in many patients I see who develop heart disease at an early age, lifestyle is not the issue, it is the genetic cards that they have been dealt.
Until we develop reliable genetic methods for identifying those at high risk it makes sense to utilize methods such as vascular screening or coronary calcium to look for atherosclerosis in individuals with a family history of premature CAD.
Once advanced atherosclerosis is identified, we have extremely safe and effective medications that can help individuals like Lisa deal with the cardiovascular cards they have been dealt.
9 thoughts on “Dealing With The (Cardiovascular) Cards You've Been Dealt”
I’m a Hospital Medicine doc here in OKC. I’m 43 and have been on a Paleo diet for the past 4 or 5 years. Strictly organic food, pastured eggs, grass fed beef, low glycemic foods. I was recently surprised to see my cholesterol total at 251, LDL of 183, HDL of 45, triglycerides of 113. I’ve started Lipitor 10 mg per day and was already on a B-blocker and aspirin for grade I hypertension.
I’ve read Esselstyn and Fuhrmans dietary books and I have some confusion on how to eat from here on. I work out with weights and like to keep my muscle . I’m lean, less than 10% body fat( 6 ft tall, 215 lbs). I hate to give up those pastured meats / eggs, but I would if I need to do so. My diet is already fairly rich in nuts and seeds, lots of vegetables. What is your advice on any dietary recommendations that I need to do but not end up depriving my muscles from the recommended vegan diet that Esselstyn would say someone like me should be doing?
Thank you for any advice you have.
Dathan Jay MD
Yep, started taking atorvastatin 80mg yesterday (was on prevastatin before).
Definitely skeptical of the plant-based diet, not only b/c of the thin evidence, but I travel a lot for work and it would be impossible for me to follow it on the road.
Thanks, for this and other info on your site. On Sunday I was admitted to the hospital with unstable angina. A catheter dye test revealed 75% blockage in my LAD, so I got myself stented.
I am in the same boat as Lisa (though I am a man). I’m 44 years old and (other than heart disease) in good health, not overweight, nonsmoker, active, have been taking statins for 15 years–but my father, mother and maternal grandfather all had premature CAD. Those are my cards. 🙂
Now, as you would expect, the staff here at the hospital is recommending a low-fat/low-cholesterol diet, and an acquaintance with CAD is exhorting me to take up the “plant-based” diet. Your site has given me a lot to think about as I move forward to manage my disease.
Glad the site was helpful. I see high intensity statin therapy in your future. Take the plant-based diet recommendations with the grain of salt I have implanted in my posts on Esselstyn, Ornish, and Pritikin and not the communion wafer the vegetarian evangelists proffer.
Hi Dr Anthony,
Why is it that John, age 44 who has been taking Statins for 15 years would get arterial blockages. Why didn’t the Statins stop that. I mean he was only 29 when he started them, and he states he has otherwise been healthy.
Thank you so much for your discussions!
The simple answer is that statins don’t prevent all arterial blockages.
In John’s case I would need much more information to see exactly what happened and why.
For example, was John smoking, what dose and type of statin was he taking and did he have diabetes?
Also, what was the nature of the blockages and how were they diagnosed?
I have found some patients who have inherited a particularly aggressive tendency to build up plaque in their arteries. These have familial or inherited hypercholesterolemia with extremely high LDL levels and these types of patients may benefit from seeing lipid specialists who have techniques to remove the LDL from the blood periodically called aphaeresis (https://thefhfoundation.org/diagnosis-management/treatment-for-hofh).
Always listen to your body, Dr. Pearson recommended a calcium score test on me after a stress test and eco cardiogram, good thing, my calcium test came back at 1798. That is over 4 times the “at risk” level. Thanks Dr. Pearson for saving my life.
Tim Lanham
I expected WOLCOSC, not Lisa.
Very interesting! Thank you!