I am a layperson from a family of physicians. My oldest brother was an internist (geriatrician) who was an early adopter of what became known as Evidence Based Medicine. I listened and learned from him that except for acute & critical disease or trauma which require immediate attention, it is important to look beyond the 1st order questions & risks to the cumulative risks of 2nd, 3rd, etc testing and treatment that follows.
Unfortunately, our current medical-industrial complex doesn’t support that sort of questioning so it takes real effort to do it. I’m fortunate to have had the teachers to help me learn what questions to ask but I worry about all those who don’t and a system that often rejects it anyway. I’ve seen the effects in the obscene costs overtesting and medicalization of routine life that doesn’t benefit from it. I learn from each of your articles, and fortunately my cardiologist friend is a fan of yours too. Please keep it up.
Another excellent paper. You’ve been doing a great job on this seek for truth. Statins are surely overstated and one should speculate if the heavy incentives from pharmaceutical companies may have something to do with it. And also, the steep increase in cardiovascular diseases and deaths in the last 3 years should trigger more profound investigations. Was there any new thing( like a therapy; drug; injection) that has been introduced and forced to population in the last 3 years that could(just an hypothesis) be blamed for it? Or should everyone keep on ignoring the elephant in the room?
Thanks for the information. I think the point about ARR vs RRR is important. I didn’t see anything in the analysis/review you shared about the risks of statins to balance out the minimal cardiac ARR from their use. With a significant family history of CAD & hyperlipidemia, I’ve been taking AtC for nearly 20 years and tolerate it well. As per Dr. Mandrola’s commentary on the use of CAC above, my positive scans taken 10 yrs apart show moderate increase, which has only been used to continue the recommendation for statin use since I have no other symptoms of CAD, including during regular vigorous exercise at high altitudes (skiing/hiking). I’ll take a 1-2% ARR under those circumstances unless there are other well-documented risks of which I’m unaware.
That’s correct, our analysis in JAMA Int Med, says nothing about CAC, but it provides an updated ARR and RRR for statin therapy in primary and secondary prevention, to help people with decision-making.
If someone has already had a CAC score and it’s low (below 100), I think most guidelines for lipid management, recommend against statin therapy.
I got talked into one of these a few years ago as part of a regular physical, and the hospital clinic physician urged a whirlwind of testing, monthly visits, and dire warnings. Since I had zero symptoms, and it felt like a high pressure fear mongering sales pitch, I ignored him. I don’t intend to spend my waning years in waiting rooms in any case.
Thank you. Reminded of a quote I hope I don't butcher too badly "hard to make a person accept something is not good to do, when they make a lot of money doing it."
Being conservative in accepting treatment as the patient I occasionally am, I refused my cardiologist's insistence on a statin, knowing that the statin would trigger my lymphocytic colitis that always waits in the wings. Besides, I "knew" I didn't need a statin – healthy me. Imagine my horror when the CAC came back over 1,400! (One thousand four hundred.) So much for proving my health. That was about fifteen years ago. I've since learned that such scores in very vigorously active subjects such as myself are generally quite stable. No statin. So far, so good.
Hello! I just had my first CAC Heart scan and my number was 1441. I have been very active my whole life, I'm 60 years old and have had 'high' cholesterol ever since 30 or before. I now have to see a cardiologist this week. May I ask, did you have any stents put in and what have you done for your heart health since learning your score? I'm fearful of any doctor going into my body. I appreciate any response.
I usually agree, almost worshipfully, with Mandrola. But I feel his presentation here is inadequate and many of the comments are entirely wrong. Yes, I am a board certified cardiologist with 50 years of experience who has essentially achieved the abolition of symptomatic coronary artery disease by attending to the MULTIPLE risk factors, NOT just cholesterol. However, even though I am for as little radiation as possible, including dental films, depending upon risks or symptoms, I believe in doing coronary calcium scores rather liberally. A coronary calcium score of over 100 increases ischemic risk 10 times and above 300, 30 times--those are NOT 100% values. Because of insurance requirements, if the score returns above 50, I do recommend a standard stress test & statins which the vast majority of patients are agreeable to. There are natural alternatives to statins that are somewhat effective and I will go with the flow if that is the patient's insistence. Diet-weight-exercise are crucial. Risk reduction in general is crucial besides for cholesterol as there are also other ischemia-inducing risk factors: triglycerides, percent body fat, blood pressure, A1c, uric acid, Hb, BUN, magnesium, potassium, values that must be achieved in order to reduce future risk to essentially zero: "risk regression to zero." After the standard stress test, if abnormal, then a CT angiogram vs an echo stress test preferred over nuclear. I have not moved to PET or MRI studies yet. If those are suggestive, then coronary angiogram with judgment for doing just medical treatment, angioplasty/stent, or even open heart surgery. In inexperienced hands, these decisions can often be made incorrectly. Regardless, then proceed in any case with the entire approach of risk regression to zero ensues. I am neither bragging nor complaining when I recommend an article that I wrote published in the European literature Medical Research Archives January, 2023, describing this entire approach: "The Unhappening of Heart Disease." A video of my 12/7/23 Department of Medicine Grand Rounds presentation will soon likely be on the St. Francis Hospital in Hartford Connecticut website for those with the patience to bear with me.
"Even if you believed CAC scans could reliably enhance risk prediction (we don’t)"
There is strong evidence that CAC score test is one of the very few tests with VERY strong predictive power for an individual regarding probability of having a coronary hear event in next 5-10 years
The data you cite here are “review articles” and meta analyses which suggest “prediction” of “CAD” (without regard to its severity) and various “associations”.
Do you have RANDOMIZED and PROSPECTIVE data showing that CAC utilized as part of a diagnostic strategy or algorithm independently (and causally) reduces future hard clinical outcomes?
Also, in basic logic, the burden of proof rests with someone asserting that “something works”. It is not on someone saying it doesn’t (that’s just accepting the null hypothesis).
First, some conflict of interest statements might be useful. I wonder what his investment firm invests in. Bullish on Siemens, perhaps?
Second, this guy is blindly lauding his post CAC care which was in fact borderline malpractice. 2 DES in a guy with no symptoms and low risk non-invasive testing? Wow. Let’s hope he doesn’t have trauma or need emergency surgery any time in the next 6 months and has to interrupt his DAPT prematurely….then develops stent thrombosis. Or replaces his mild native chronic stable CAD (which you can treat with meds) with exuberant interstitial hyperplasia and ISR (which you can’t really).
OTOH, can’t blame him for thinking he “prevented” MI and maybe even “averted death” with his unnecessary treatments….since much of the medical community still don’t understand that….including many cardiologists (although for the latter cohort, it might have a lot to do with “it is difficult to get a guy to understand something, when his salary depends on his not understanding it”).
It is also used in the ER to end the work up in a low risk person. Admittedly this is at our heart hospital but neg troponins and zero score -do not need cardiac workup maybe GI . It also is very useful in a clearly high risk individual with medical fear or in denial . These folks clearly do not need a scan they need common sense , but the scan is all they will do. It comes back in the thousands and then they agree to a workup their symptoms etc would have triggered anyway. Have seen many cases of that. No test is bad it's the individuals using the data
We were also blasted in the July issue I think in 2005 or something consumer reports. They said we were Hart scammers doing heart scans. In 2009 Medicare database said we had the lowest risk of death in the United States for myocardial infarction. We were in the top 1% nationwide for patient satisfaction and we have the lowest cost of care. Our reward was the affordable care act, made it illegal for us to expand or add services . We sold the Hosp do you want to guess what happened to the cost of care?
The last sentence (statins reduce your risk by 25%) of Dr. John's otherwise compelling piece are problematic . The meta-analysis he cites is from 2010, and the various studies used for the meta-analysis were obviously older still.
Statins have become much more controversial in recent years, and many practitioners feel they should be prescribed more sparingly.
Perhaps the best-known such practitioner is Dr. Aseem Mahotra, from the UK. Here is a link to a 2019 article written by him. Worth a read, no matter where you stand on statins.
Ted, thanks for commenting. I believe in using evidence as much as possible. I also believe that patients should have total freedom to make choices. Statins have been the most studied drug of any drug in all of medicine. Literally nearly 200,000 patients have been in trials. These trials consistently show 20-25% reductions in future cardiac events. Some people think that it is worth taking a pill. Others don't. The other aspect of LDL-C lowering is that it might be most effective to start early.
In trials, the side effects are not different than placebo. But I will agree that we don't have data out past 10 years. So there are unknown-unknowns, as with any drug.
I've long held that statin drugs could be over the counter. We could put a risk calculator in the aisle and let people put there numbers in--risk w statins, risk without statins. Then they can decide.
"I've long held that statin drugs could be over the counter. We could put a risk calculator in the aisle and let people put there numbers in--risk w statins, risk without statins."
I don't know about that.
1. Would MDs get out of business of ordering lipid tests and Rx recommendations? Do you want MDs to really only be car mechanics fixing the actually broken car and to get out of the oil change maintenance business that can be handled by non-mechanics at Jiffy Lube? Why? Maybe that's right. I don't know.
2. Risk calculators almost always provide point estimate rather than range. What do you think about that? Which risk calculator would you use?
3. To paraphrase Mary in front of Lazarus's tomb: death stinks. But is an MI in 80s or 90s a "risk" or a "feature" of corporeal creatures?
Yes it is relative risk reduction. The absolute risk reduction depends on the patient and the timeframe we are considering. So in my case, some years ago based on my health data, I computed an absolute risk of MI over 10 years (I think? could have been 5) of around 24%. If statins reduce this by 25% relatively, that drops my risk by about 6% - so absolute risk reduction = 6% in my case. But if your absolute risk was 1% over 10 years, statins would only drop that by 0.25%.
I was put ion a statin in 2018 after a stent was put in but after reading all the studies on their lack of efficacy and the side effects, I have stopped taking it. Am I wise to do so or dumb?
I don’t understand the logic here. This individual had a 90% blockage . Are you saying it’s better he get stented after the heart attack, assuming he survives it? There are many diseases that present as asymptomatic that we routinely treat upon medial findings such as prostate cancer, breast cancer etc.
One of the first lessons we learn in cardiology is that most heart attacks come from 10-20% blockages that you can hardly see. A 90% blockage is often old and stable. It's why those trials are all negative. Click on the links and look at the results.
You don’t understand the logic, because you don”t have the knowledge to. We usually think that because we have some ideas and common sense, we can understand the complexity of a specialty that needs years of study.
How do you know? Remember the outcome of a heart attack can be binary , live or die . So far nobody can make an argument for not stenting a 90% blackage.
As others have pointed out, there are multiple randomized controlled trials demonstrating that, with some subtleties and rare exceptions, there is no benefit to routine revascularization for stable/chronic 90% blockages. Most ‘heart attacks’ do not arise from these sorts of lesions.
I suggest googling “ischemia trial”, “Orbita”, and “Orbita 2” to get a sense of what revascularization (which includes both stents and surgery) does and doesn’t do.
I agree that CAC scan results should not lead to a preventive stent placement, but it is a useful test for people with suboptimal lipid metrics. My LDL-C was 100, did a CAC scan and turned out my score was 418. I was immediately put on statins which probably aligns with your philosophy. My primary doctor really did not recommend a CAC scan, a cardiologist friend did and I am grateful. Advocating against CAC scans because of the actions of a few people does not seem the right strategy.
As a layman, my general thought is that we ought to put more focus on metabolic disease & insulin resistance. If we can avoid those, we avoid (or at least make less likely) a lot of downstream things such as T2 diabetes, obesity, high blood pressure, etc.
Unfortunately it is not entirely clear how to avoid metabolic disease & insulin resistance. It is clear that the prevalence of these is increasing dramatically, and this is a public health nightmare. Anyway, I would like to encourage cardiologists to push / lobby / educate and see if we can get more funding behind research that looks at how to avoid these things, instead of how to treat these things.
My perception - possibly very wrong, please correct me if so - is that our scientific funding is 99% focused on treating disease (say, GLP-1 drugs for obesity) and 1% focused on how to prevent disease.
An ounce of prevention is worth a pound of cure. But we don’t really know how to prevent right now.
Amen. I have seen asymptomatic patients get revascularization and have complications from it based on CAC scans. I have had quite tense conversations with asymptomatic patients with increased CAC scores who insist on having a stress test. It becomes a runaway train. Many patients and doctors believe more is always better.
Interesting thought provoking article . I recommend ultrasound scans not certain if they are as useful but they do give a startup picture without radiation. If a pt has a 98% blockage of the LAD and no collateral would u still recommend waiting and using medical intervention? Seems so risky but as you and others have mentioned so is surgical intervention.
I am a layperson from a family of physicians. My oldest brother was an internist (geriatrician) who was an early adopter of what became known as Evidence Based Medicine. I listened and learned from him that except for acute & critical disease or trauma which require immediate attention, it is important to look beyond the 1st order questions & risks to the cumulative risks of 2nd, 3rd, etc testing and treatment that follows.
Unfortunately, our current medical-industrial complex doesn’t support that sort of questioning so it takes real effort to do it. I’m fortunate to have had the teachers to help me learn what questions to ask but I worry about all those who don’t and a system that often rejects it anyway. I’ve seen the effects in the obscene costs overtesting and medicalization of routine life that doesn’t benefit from it. I learn from each of your articles, and fortunately my cardiologist friend is a fan of yours too. Please keep it up.
Here is our more recent systematic review and meta-analysis of statin studies https://blog.maryannedemasi.com/p/new-analysis-shows-statins-have-minimal-benefits?r=p03ac&utm_campaign=post&utm_medium=web
Another excellent paper. You’ve been doing a great job on this seek for truth. Statins are surely overstated and one should speculate if the heavy incentives from pharmaceutical companies may have something to do with it. And also, the steep increase in cardiovascular diseases and deaths in the last 3 years should trigger more profound investigations. Was there any new thing( like a therapy; drug; injection) that has been introduced and forced to population in the last 3 years that could(just an hypothesis) be blamed for it? Or should everyone keep on ignoring the elephant in the room?
Thanks for the information. I think the point about ARR vs RRR is important. I didn’t see anything in the analysis/review you shared about the risks of statins to balance out the minimal cardiac ARR from their use. With a significant family history of CAD & hyperlipidemia, I’ve been taking AtC for nearly 20 years and tolerate it well. As per Dr. Mandrola’s commentary on the use of CAC above, my positive scans taken 10 yrs apart show moderate increase, which has only been used to continue the recommendation for statin use since I have no other symptoms of CAD, including during regular vigorous exercise at high altitudes (skiing/hiking). I’ll take a 1-2% ARR under those circumstances unless there are other well-documented risks of which I’m unaware.
That’s correct, our analysis in JAMA Int Med, says nothing about CAC, but it provides an updated ARR and RRR for statin therapy in primary and secondary prevention, to help people with decision-making.
If someone has already had a CAC score and it’s low (below 100), I think most guidelines for lipid management, recommend against statin therapy.
I got talked into one of these a few years ago as part of a regular physical, and the hospital clinic physician urged a whirlwind of testing, monthly visits, and dire warnings. Since I had zero symptoms, and it felt like a high pressure fear mongering sales pitch, I ignored him. I don’t intend to spend my waning years in waiting rooms in any case.
Thank you. Reminded of a quote I hope I don't butcher too badly "hard to make a person accept something is not good to do, when they make a lot of money doing it."
Being conservative in accepting treatment as the patient I occasionally am, I refused my cardiologist's insistence on a statin, knowing that the statin would trigger my lymphocytic colitis that always waits in the wings. Besides, I "knew" I didn't need a statin – healthy me. Imagine my horror when the CAC came back over 1,400! (One thousand four hundred.) So much for proving my health. That was about fifteen years ago. I've since learned that such scores in very vigorously active subjects such as myself are generally quite stable. No statin. So far, so good.
Oh, and: Statins increase calcification. We're told that that's good, that it stabilizes plaque. Like having your cake and eating it too?
Speaking of cake, statins also increase your likelihood of acquiring a diabetes diagnosis.
No thank you, on both counts.
Hello! I just had my first CAC Heart scan and my number was 1441. I have been very active my whole life, I'm 60 years old and have had 'high' cholesterol ever since 30 or before. I now have to see a cardiologist this week. May I ask, did you have any stents put in and what have you done for your heart health since learning your score? I'm fearful of any doctor going into my body. I appreciate any response.
I usually agree, almost worshipfully, with Mandrola. But I feel his presentation here is inadequate and many of the comments are entirely wrong. Yes, I am a board certified cardiologist with 50 years of experience who has essentially achieved the abolition of symptomatic coronary artery disease by attending to the MULTIPLE risk factors, NOT just cholesterol. However, even though I am for as little radiation as possible, including dental films, depending upon risks or symptoms, I believe in doing coronary calcium scores rather liberally. A coronary calcium score of over 100 increases ischemic risk 10 times and above 300, 30 times--those are NOT 100% values. Because of insurance requirements, if the score returns above 50, I do recommend a standard stress test & statins which the vast majority of patients are agreeable to. There are natural alternatives to statins that are somewhat effective and I will go with the flow if that is the patient's insistence. Diet-weight-exercise are crucial. Risk reduction in general is crucial besides for cholesterol as there are also other ischemia-inducing risk factors: triglycerides, percent body fat, blood pressure, A1c, uric acid, Hb, BUN, magnesium, potassium, values that must be achieved in order to reduce future risk to essentially zero: "risk regression to zero." After the standard stress test, if abnormal, then a CT angiogram vs an echo stress test preferred over nuclear. I have not moved to PET or MRI studies yet. If those are suggestive, then coronary angiogram with judgment for doing just medical treatment, angioplasty/stent, or even open heart surgery. In inexperienced hands, these decisions can often be made incorrectly. Regardless, then proceed in any case with the entire approach of risk regression to zero ensues. I am neither bragging nor complaining when I recommend an article that I wrote published in the European literature Medical Research Archives January, 2023, describing this entire approach: "The Unhappening of Heart Disease." A video of my 12/7/23 Department of Medicine Grand Rounds presentation will soon likely be on the St. Francis Hospital in Hartford Connecticut website for those with the patience to bear with me.
"Even if you believed CAC scans could reliably enhance risk prediction (we don’t)"
There is strong evidence that CAC score test is one of the very few tests with VERY strong predictive power for an individual regarding probability of having a coronary hear event in next 5-10 years
Links:
https://pubmed.ncbi.nlm.nih.gov/35003981/
https://pubmed.ncbi.nlm.nih.gov/36233709/
https://pubmed.ncbi.nlm.nih.gov/36233709/
https://www.ahajournals.org/doi/full/10.1161/CIRCIMAGING.119.010153
https://onlinelibrary.wiley.com/doi/abs/10.1111/eci.13892
Feel free to provide evidence for your claims; however, claims without evidence are nothing more than opinions
The data you cite here are “review articles” and meta analyses which suggest “prediction” of “CAD” (without regard to its severity) and various “associations”.
Do you have RANDOMIZED and PROSPECTIVE data showing that CAC utilized as part of a diagnostic strategy or algorithm independently (and causally) reduces future hard clinical outcomes?
Also, in basic logic, the burden of proof rests with someone asserting that “something works”. It is not on someone saying it doesn’t (that’s just accepting the null hypothesis).
A CAC of zero has very high negative predictive value. It does not at all follow that a high CAC predicts a benefit from revascularization.
Yikes. So many facepalms.
First, some conflict of interest statements might be useful. I wonder what his investment firm invests in. Bullish on Siemens, perhaps?
Second, this guy is blindly lauding his post CAC care which was in fact borderline malpractice. 2 DES in a guy with no symptoms and low risk non-invasive testing? Wow. Let’s hope he doesn’t have trauma or need emergency surgery any time in the next 6 months and has to interrupt his DAPT prematurely….then develops stent thrombosis. Or replaces his mild native chronic stable CAD (which you can treat with meds) with exuberant interstitial hyperplasia and ISR (which you can’t really).
OTOH, can’t blame him for thinking he “prevented” MI and maybe even “averted death” with his unnecessary treatments….since much of the medical community still don’t understand that….including many cardiologists (although for the latter cohort, it might have a lot to do with “it is difficult to get a guy to understand something, when his salary depends on his not understanding it”).
It is also used in the ER to end the work up in a low risk person. Admittedly this is at our heart hospital but neg troponins and zero score -do not need cardiac workup maybe GI . It also is very useful in a clearly high risk individual with medical fear or in denial . These folks clearly do not need a scan they need common sense , but the scan is all they will do. It comes back in the thousands and then they agree to a workup their symptoms etc would have triggered anyway. Have seen many cases of that. No test is bad it's the individuals using the data
We were also blasted in the July issue I think in 2005 or something consumer reports. They said we were Hart scammers doing heart scans. In 2009 Medicare database said we had the lowest risk of death in the United States for myocardial infarction. We were in the top 1% nationwide for patient satisfaction and we have the lowest cost of care. Our reward was the affordable care act, made it illegal for us to expand or add services . We sold the Hosp do you want to guess what happened to the cost of care?
Is that 25% relative risk? What is the absolute risk?
The last sentence (statins reduce your risk by 25%) of Dr. John's otherwise compelling piece are problematic . The meta-analysis he cites is from 2010, and the various studies used for the meta-analysis were obviously older still.
Statins have become much more controversial in recent years, and many practitioners feel they should be prescribed more sparingly.
Perhaps the best-known such practitioner is Dr. Aseem Mahotra, from the UK. Here is a link to a 2019 article written by him. Worth a read, no matter where you stand on statins.
https://www.europeanscientist.com/en/features/do-statins-really-work-who-benefits-who-has-the-power-to-cover-up-the-side-effects/
Ted, thanks for commenting. I believe in using evidence as much as possible. I also believe that patients should have total freedom to make choices. Statins have been the most studied drug of any drug in all of medicine. Literally nearly 200,000 patients have been in trials. These trials consistently show 20-25% reductions in future cardiac events. Some people think that it is worth taking a pill. Others don't. The other aspect of LDL-C lowering is that it might be most effective to start early.
In trials, the side effects are not different than placebo. But I will agree that we don't have data out past 10 years. So there are unknown-unknowns, as with any drug.
I've long held that statin drugs could be over the counter. We could put a risk calculator in the aisle and let people put there numbers in--risk w statins, risk without statins. Then they can decide.
"I've long held that statin drugs could be over the counter. We could put a risk calculator in the aisle and let people put there numbers in--risk w statins, risk without statins."
I don't know about that.
1. Would MDs get out of business of ordering lipid tests and Rx recommendations? Do you want MDs to really only be car mechanics fixing the actually broken car and to get out of the oil change maintenance business that can be handled by non-mechanics at Jiffy Lube? Why? Maybe that's right. I don't know.
2. Risk calculators almost always provide point estimate rather than range. What do you think about that? Which risk calculator would you use?
3. To paraphrase Mary in front of Lazarus's tomb: death stinks. But is an MI in 80s or 90s a "risk" or a "feature" of corporeal creatures?
We give a break down of Absolute and relative risk reduction in a recent analysis Here is a more recent systematic review and meta-analysis of statin studies https://blog.maryannedemasi.com/p/new-analysis-shows-statins-have-minimal-benefits?r=p03ac&utm_campaign=post&utm_medium=web
Yes it is relative risk reduction. The absolute risk reduction depends on the patient and the timeframe we are considering. So in my case, some years ago based on my health data, I computed an absolute risk of MI over 10 years (I think? could have been 5) of around 24%. If statins reduce this by 25% relatively, that drops my risk by about 6% - so absolute risk reduction = 6% in my case. But if your absolute risk was 1% over 10 years, statins would only drop that by 0.25%.
I was put ion a statin in 2018 after a stent was put in but after reading all the studies on their lack of efficacy and the side effects, I have stopped taking it. Am I wise to do so or dumb?
The statin may be doing more for you than the stent.
Dumb
I don't think we really know the answer to your question.
I don’t understand the logic here. This individual had a 90% blockage . Are you saying it’s better he get stented after the heart attack, assuming he survives it? There are many diseases that present as asymptomatic that we routinely treat upon medial findings such as prostate cancer, breast cancer etc.
One of the first lessons we learn in cardiology is that most heart attacks come from 10-20% blockages that you can hardly see. A 90% blockage is often old and stable. It's why those trials are all negative. Click on the links and look at the results.
The "plumbing analogy" has created an obstacle both for patients and MDs.
Thank you for your article.
Why then are 70% blockages always stented ?
You don’t understand the logic, because you don”t have the knowledge to. We usually think that because we have some ideas and common sense, we can understand the complexity of a specialty that needs years of study.
Than explain the logic in getting the stent when the 90% blockage becomes the inevitable heart attack .
A 90% blockage does not in fact become an inevitable heart attack.
How do you know? Remember the outcome of a heart attack can be binary , live or die . So far nobody can make an argument for not stenting a 90% blackage.
As others have pointed out, there are multiple randomized controlled trials demonstrating that, with some subtleties and rare exceptions, there is no benefit to routine revascularization for stable/chronic 90% blockages. Most ‘heart attacks’ do not arise from these sorts of lesions.
The answer is that “stenting” don’t reduce the chance of a heart atack.
No. This explain the Dunning-Kruger effect.
I suggest googling “ischemia trial”, “Orbita”, and “Orbita 2” to get a sense of what revascularization (which includes both stents and surgery) does and doesn’t do.
I agree that CAC scan results should not lead to a preventive stent placement, but it is a useful test for people with suboptimal lipid metrics. My LDL-C was 100, did a CAC scan and turned out my score was 418. I was immediately put on statins which probably aligns with your philosophy. My primary doctor really did not recommend a CAC scan, a cardiologist friend did and I am grateful. Advocating against CAC scans because of the actions of a few people does not seem the right strategy.
As a layman, my general thought is that we ought to put more focus on metabolic disease & insulin resistance. If we can avoid those, we avoid (or at least make less likely) a lot of downstream things such as T2 diabetes, obesity, high blood pressure, etc.
Unfortunately it is not entirely clear how to avoid metabolic disease & insulin resistance. It is clear that the prevalence of these is increasing dramatically, and this is a public health nightmare. Anyway, I would like to encourage cardiologists to push / lobby / educate and see if we can get more funding behind research that looks at how to avoid these things, instead of how to treat these things.
My perception - possibly very wrong, please correct me if so - is that our scientific funding is 99% focused on treating disease (say, GLP-1 drugs for obesity) and 1% focused on how to prevent disease.
An ounce of prevention is worth a pound of cure. But we don’t really know how to prevent right now.
Now do a blog on unnecessary back surgery please.
Amen. I have seen asymptomatic patients get revascularization and have complications from it based on CAC scans. I have had quite tense conversations with asymptomatic patients with increased CAC scores who insist on having a stress test. It becomes a runaway train. Many patients and doctors believe more is always better.
Interesting thought provoking article . I recommend ultrasound scans not certain if they are as useful but they do give a startup picture without radiation. If a pt has a 98% blockage of the LAD and no collateral would u still recommend waiting and using medical intervention? Seems so risky but as you and others have mentioned so is surgical intervention.
Keep up the great work and Thank You