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.
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.
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
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
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.
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?
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 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.
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.
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.
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
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.
Is that 25% relative risk? What is the absolute risk?
"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
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.
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?
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
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.
I'd like the data/analysis updated. One study (abstract) from 2020. Anything more recent?
Meg