The Widowmaker: Stents versus Calcium Scans

I’ve just finished watching a documentary on Netflix called The Widowmaker which alternately had me fascinated, disgusted, bored, excited, and angry.

This movie is about the treatment of coronary artery disease and what we can do about the large number of people who drop dead from heart attacks, some 4 million in the last 30 years.

The documentary, as all medical documentaries tend to do, simplifies, dumbs down and hyperbolizes a very important medical condition. Despite that it makes some really important points and I’m going to recommend it to all my patients.

At the very least it gets people thinking about their risk of dying from heart disease which remains the #1 killer of men and women in the United States.

Perhaps it will have more patients question the value of stents outside the setting of an acute heart attack. This is a good thing.

Perhaps it will stimulate individuals to be more proactive about their risk of heart attack. This is a good thing.

Take a look. Think about it. If you decide you might benefit from a coronary calcium scan of your heart let me know.

I’ll dissect this movie in detail in subsequent posts. There are a lot of inaccuracies  but some fundamental and important points are made that patients need to now.

Stents do not prevent heart attacks.

Standard risk factors do not do well at predicting who will have a heart attack.

-ACP

12 thoughts on “The Widowmaker: Stents versus Calcium Scans”

  1. Hi Dr. – Just saw your blog and did a search for calcium scores and your blog came up. Not asking for a prognosis here – just some understanding I guess.

    A 57 yr old male – nonsmoker, good shape, never get sick, no chest pains, walk 2-4 miles every 2 days, not overweight… the perfect 57 year old… except…

    I had a calcium score test 5 years ago and it was a total of 289. Test just taken and have a score of 696 – good news is didn’t increase 30% per year as I have read most do.

    Full blood work shows very low C-reactive protein, low homocysteine, very low PLAC score – in other words, NO inflammation. However, I do have very high LP(a) – must run in my family, at 106. Metabolic Syndrome Traits less than 1.0. Normal HDL and Trig. – though high LDL due to the LP(a).

    I am now trying to find my third cardiologist as the first one, after seeing the calcium score, wanted to put me on Crestor, aspirin and started talking stents, hospitals, etc.

    The second one (supposedly a holistic) still wanted me on statins (even though statins do not lower LP(a) ).. but wanted me to become a vegan (I’m not – I eat Paleo) and pay her to join her exercise gym – even though I don’t necessarily need more exercise.

    In panic mode, I now take slo-nicain 1500mg, vitamin D, high Vit. C (The Pauling theory) Vit. K., Fish oil tablets, garlic tablets and L-Arginine.

    Before these damn calcium tests and my detailed blood work, I never took any supplements, felt fine, never got sick, and ate right.

    So my question is this – I am tempted to go back to what I was doing – as I was before; continue to exercise and eat right and let the chips fall where they may.

    Correct me if I am wrong, but we really don’t know what causes heart issues – if we did, there would be a cure and it would no longer kill anyone. The best we can do is eat right (though there is disagreement here on what) exercise and don’t smoke. All of which I do.

    Ok – rant over… thanks for listening to my frustration and confusion as to my non-condition, condition. 🙂

    1. Danny,
      I think you will find helpful the post I wrote on “Dealing with the Cardiovascular Cards you’ve been dealt” as you fall into the category of some one who is living an extremely healthy lifestyle yet has developed advanced atherosclerosis.
      Your very high coronary calcium score indicates a lot of plaque in the coronary arteries and a very high risk for heart attack and sudden death.
      You should definitely be taking a baby aspirin daily and you should strongly consider taking a statin drug (see my post, https://theskepticalcardiologist.com/2014/08/02/statin-drugs-have-benefits-beyond-cholesterol-lowering/).
      The 5 or 6 over the counter things you are taking have not been shown to benefit your condition. In fact, although I used to utilize niacin , recent studies have shown no benefit and I no longer prescribe it.
      I suspect you have a fear of statins based on misinformation on the internet and you may want to read my post on ” are statins destroying my heart” .
      Statins have been proven safe and effective. They are not without side effects like all medications, supplements and vitamins but in your case the benefits likely outweigh those downsides.

      1. Thanks for your comments – I do appreciate them. And by-the-way, if you cannot tell, I am a natural born skeptic myself. I was thrown out of my Sunday school class when I was 8 years old and things just kind of went downhill from there. 😉

        As to your suggestion, I read your suggested blog posts and one thing did strike me – that I have never heard before. That is the point that Statins are very complicated and really do more than “lower chol.”. You also stated in the blog that at this point, this is all the medication that is available for someone like myself.

        The reason that statement is important to me is that I think (eventually) the cause for heart issues will not be as simple as cholesterol. Unfortunately cholesterol has been so demonized in the public that most people almost equate it with poison and battery acid. As you know, we would all die without it. So it’s just “easier” to speak to an uneducated public that we have to lower the level of “poison” cholesterol from your body to stop heart attacks.

        Unfortunately, as you also know, the majority of people who have heart attacks have normal or low levels of cholesterol. http://newsroom.ucla.edu/releases/majority-of-hospitalized-heart-75668
        And my true skepticism about statins kicks in when cardiologists are now beginning to admit that, well, maybe the low-fat diet wasn’t the best thing and now maybe some fat is now good for you. Woops! Could the same be said of statins in the years to come?

        And though I did not talk about my 78 year old mother (who hiked with me on Mt. Rainer when she was here over the summer) – she and I are conducting a little experiment. Of her friends that are getting dementia or alzheimer’s, how many were taking a statin? She asks this question to them or their family once she hears of the diagnosis. The percentage so far? About 88%. Would they have gotten it anyway? Who knows. Though she has friends in their 80’s and 90’s that do NOT take a statin, and they seem perfectly fine. Perhaps statins are not a good idea for people in their 80’s and 90’s?

        Regardless, you have made me question, like a good skeptic should, my hesitation to take a statin.

        Thanks again –

      2. One point I am continually trying to make to patients and readers is (as I wrote here) “we are not concerned with cholesterol levels. What we are concerned with is atherosclerotic cardiovascular disease (ASCVD) and its downstream consequences including heart attack and stroke.”
        And a second point I’m continually making is that fat in the diet, even if it raises cholesterol levels is not necessarily increasing our risk for ASCVD.
        This does not invalidate, however, statin effectiveness because statins have multiple effects that reduce ASCVD progression.
        Your mom’s sample size is not sufficient to allow determination of statins causing dementia. Much larger randomized studies have not shown any increased risk of dementia with statins.
        However, effectiveness of statin in really old people may be much less than younger people and side effects more likely so I have often stop or lower statin dosages in this population.

      3. That is an interesting study I had not seen. They were looking at plaque using intravascular ultrasound, not coronary CT.
        Overall, those patients on statins had regression of plaque volume which is good. It is felt that lipid rich plaques are the ones that rupture and cause heart attack/stroke. As these types of plaque undergo treatment with statins they are felt to transform to less rupture prone forms with more fibrosis and calcification. Thus “The current analysis provides supportive evidence for the possible plaque-stabilizing effects of statins via inducing micro calcification.”
        So I don’t see this study as worrisome.
        Calcium is really not the major concern in arteries. Calcium is just depositing into the plaques as they mature.
        Calcium is only a marker of the presence and extent of atherosclerosis.

  2. As previously discussed, I went for another Calcium score test after one year of a modified diet and numerous supplements (and no Statins.) Thought you might enjoy seeing the results. 🙂

    The Agatston score did go up from 696 to 824, an 18% increase. However, the calcium volume score decreased dramatically from 617 to 332, a 46% decrease! The left circumflex had the largest drop in volume at 61% with virtually no increase in the Agatston score. My LAD artery no longer has the largest Agatston score – now it is the RCA.

    This “separation” between the Agatston score and the calcium volume score interested me, so with some additional research, I located this study that appeared in JAMA: http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=106223

    In summary, it basically states that in a Calcium score test, it might be the progression (or in my case the regression) of calcium volume that is important, not the Agatston score (which is more a measure of calcium density).

    In addition, I also went for another blood test (also after one year) which showed my Lp(a) level dropped from 106 to 64, LDL from 226 to 167, Trig from 147 to 106 and an HDL increase from 41 to 50. C-reactive, Insulin and Homocysteine are all in the green. There were several more biomarkers, (Apo A, B, etc.) but suffice it to say, they all improved.

    So in summary, these changes in test results were the result of three things;

    1. Change of diet (greatly reduced sugar, carbs with an increase in grass-fed protein, full-fat butter, eggs, no industrial oils with minimal eating of processed foods.)

    2. Slight increase in exercise. (Weight decrease equaled about 10 pounds from 171 to 161 at 5’8″).

    3. Supplements of slo-nicain 1500mg, vitamin D, high Vit. C (The Pauling theory) Vit. K., Fish oil tablets, garlic tablets and L-Arginine. I have since stopped taking the Niacin.

    I have also moved back to Texas and a sunnier climate – which should help with the vitamin D.

    Though I don’t care to get back into the Statin debate, for me at least, I feel that through diet, exercise and some inexpensive supplements, I have been able to slow and/or stop the progression of CVD.

    Just thought you would like the update! Thanks and enjoy the blog. 🙂

    1. Thanks for the update, Danny! I’m glad to see the dietary changes-reducing sugar and carbs and eating full fat butter, eggs and minimal processed foods had favorable effects on your biomarkers. I don’t think any of your supplements/vitamins contributed.
      The JAMA article is intriguing and I’ll start reporting out both the Agatson (AJ-130) score as well as volume and start tracking this in my patients who get serial studies.
      As the authors state in their discussion “Statins appear to have their salutary effects on CVD risk by reducing the lipid core in unstable plaque,11 and statin therapy may increase calcium density in such plaques, along with a more favorable prognosis” so tracking volume calcium score could turn out to be a useful marker of effectiveness of both drug and lifestyle treatment, something that is sorely lacking right now. Of course, I have to insert the obligatory “more research is needed in this area!”.

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