As I strolled into my PCP’s office this past September for my annual checkup & flu shots, I had no idea that I was about to become a “case study” for the renowned Skeptical Cardiologist. Had I known, I would have faced the annual ritual with considerably more trepidation!
Brief bio: 66 y/o male, never smoker, no medications, family history of congestive heart failure. Brooklyn resident, reasonably active flaneur, vegetarian for 20 years (a favorite New Yorker cartoon reads: “At first I was a vegetarian for diet reasons; then later for political reasons; but now just to annoy people”).
Luckily for me, as it turned out, I am also a son of Oklahoma, where I had the good fortune long ago to become friends with the Skeptical Cardiologist. (My late father-in-law, a native New Yorker, was fond of saying to me: “You can take the boy out of Oklahoma, but you can’t take Oklahoma out of the boy.” I’m still unsure whether that was a compliment, or an insult!)
The checkup was routine until my labs, excerpted below, arrived via email:
Cholesterol 224 H
HDL Cholesterol 95
LDL Cholesterol 114 H
Total Cholesterol / HDL Ratio 2.4 L
At the top of the report my PCP had written these words:
I have reviewed your recent results. Overall your labs look very good. My only concern is your cholesterol. You have a high good HDL cholesterol, but you are getting to the point where a statin medication may be helpful.
None of this meant anything to me; I didn’t know which kind was the “good” cholesterol; I didn’t know the difference between a statin and a stent! But the prospect of starting a medication prompted me to attempt to educate myself.
I had never been more than a very casual reader of the Skeptical Cardiologist’s blog, but I knew it contained a great deal of valuable information. When I told the Skeptical Cardiologist, via text message, what my PCP had said, he observed that like many PCPs, mine had done a rather poor job at communicating why a statin drug might be necessary.
On the recommendation of the Skeptical Cardiologist, I read every article on his statins page. I further learned about a test called the Coronary Artery Calcium (CAC) scan, and read many articles about that as well. I decided that the scan might help determine not only whether I should take a statin, but also whether I am at risk of dropping dead at any minute, which seems like a good thing to keep in the back of one’s mind.
I chose a diagnostic center on E. 84th Street in Manhattan, mostly because of its proximity to Central Park and to the Metropolitan Museum of Art — both are prime locations for flaneuring* after the test!
The test itself took 15 minutes. Outside, the day was fine, and Central Park’s fall foliage was glorious, so after a socially-distanced repast al fresco on the Upper East Side, I spent the rest of the day wandering all over the park’s spectacular woods:
Later, my neighbor Peter, with whom I share an occasional socially-distanced martini in my rear garden, advocated on behalf of statins. My same age, he’s been taking them for 15 years, and says they’re great; he says “they knock the cholesterol right down.” Everyone seems to be taking them! Even the diagnostician who did my CAC scan said she takes one! Should all men over 60 take a statin? Was I getting statin FOMO?
A few days later, the Skeptical Cardiologist texted my CAC results:
No need for a statin!? This seems like good news indeed!! At the least, it will inform my discussions with my PCP. I am very glad I invested in the CAC scan, and that I took the time to educate myself via the Skeptical Cardiologist’s blog. I wish to extend my great thanks to the Skeptical Cardiologist for his generosity in sharing his blog with the public.
*Postscript: For those who may be unfamiliar with the term flaneur: it is said to refer to the act of doing nothing, raised to an art form. More information may be found here.
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My friend David’s story (absent my input) is likely being repeated daily in doctor’s offices nationwide. Doctors typically start with the guideline-recommended risk estimator available as a smartphone app.
When you enter in David’s numbers the app estimates his 10 year risk of heart attack or stroke at 9.1%. As I’ve pointed out pretty much any male in his sixties will get a 10 year risk estimate >7.5% from this calculator which per the guidelines should trigger discussion of drug treatment with a statin to lower both the LDL cholesterol and the long term risk of heart attack/stroke.
The MESA risk calculator helps refine David’s risk by incorporating additional conventional risk factors (like family history) and most importantly the CAC score which measures subclinical atherosclerosis.
As you can see after incorporating the zero CAC score, the more precise estimate of David’s 10 year risk is 1.5%. This is extremely low and adding a statin therefore makes little sense.
It also makes no sense to take aspirin at this low risk level.
Proflaneuringly Yours,
-ACP
