I disagree with your views regarding CAC scores. There is evidence that for those with a positive CAC score, taking action to limit the annual increase in CAC score to less than 15% reduces the risk of a cardiovascular incident tremendously.
I had a similar discussion with my cardiologist when he put me on a statin: He said that since I had a positive CAC score there is no point retesting. So I then asked him how exactly am I supposed to validate if the combination of treatments I started is effective (i.e. Rosuvastatin, Aged Garlic Extract & Nattokinase). The doctor said I would know if I get symptoms like angina.
The only problem with that logic is that in 50% of cases, the first symptom is a heart attack and death!! So the current medical logic seems to be: Take your statin, control your blood pressure, and hope for the best! If you get a heart attack and survive, then we will unplug your arteries with our little roto rooter (aka stent). 
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José
#64
In my view, you replace the cardiologist (fire the person) and hire one who will do as you requested.
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Well as an Emergency Physician - I can tell you that the ratio of sudden deaths to diagnosed Acute Myocardial Infarctions is a small one these days. But yes, you don’t want your first symptom to be death. However, in most cases, getting serial CAC’s adds nothing of making sure all the maximal treatment is utilized to normalize metabolic risks and vascular risks. The CAC changes nothing once I have someone on ideal therapy with pristine numbers.
However, if they are thumbing their nose at actually having ideal numbers - then sure, order another one to motivate them.
Along with that, the only time I even waste my time arguing with patients on things is when they are wanting me to do something clearly harmful.
This particular test is simply a cost issue. The radiation is low risk. If the patient wants something that costs them money and there isn’t risk to them, and isn’t bad practice - I simply order it. Not even a need to think about it - even if I disagree with the logic. It ultimately is that person’s life and their need to have control and data.
Ordering serial CACs Won’t be a routine part of my practice, unless I see compelling data in the context I mentioned prior to recommend this - but won’t deny someone who wants an order for it.
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Glad to hear you are flexible with patients in that regard. I would only say that even if maximal treatment is utilized to normalize risks, and all blood markers are “good”, it may or may not be enough to effectively control the disease. I’ve seen studies showing that lowering LDL/ApoB reduces risk significantly for some patients and not others. So how does one know if a given treatment regimen is working? There needs to be some objective measure of progress. Now I’m not sure if CAC is the ideal metric (at least it is cheap and non-intrusive). Maybe a CT Angiogram would be better as it shows soft plaque as well.
"Conclusions - Progression of CAC was significantly greater in patients receiving statins who had an MI compared with event-free subjects despite similar LDL control. Continued expansion of CAC may indicate failure of some patients to benefit from statin therapy and an increased risk of having cardiovascular events.
Statins reduce risk by only 30%, and a direct measurement of change in atherosclerosis burden may provide a clue to the persistent risk measured in subjects at risk. On sequential computed tomography scans, the progression of coronary calcification was significantly greater in patients who had an event compared with event-free subjects despite similar low-density lipoprotein control."
https://www.ahajournals.org/doi/10.1161/01.ATV.0000127024.40516.ef?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
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I don’t think the studies are doing what I was referring to:
Lp(a) negative, maximum APOB in 70’s
Lp(a) positive, maximum APOB in 50’s
SBP goals in 110’s
HbA1C ~ 4.7%
Low saturated fat, diverse diet, mostly plants with fiber >40 grams/day
Regular mix of exercise
It’s a package deal - at that point I’m maximizing therapy, and really don’t have much I’d alter irrespective of the CAC.
If someone isn’t doing all those things - then I’d encourage them to do so - if multiple choices outside those - then IF I think a worsening CAC would dissuade them from their life choices - then do it - but if not - then probably little value.
Looking at only lipids, and also not knowing Lp(a) status is inadequate and was never the situation to which I was referring.
I’m pretty comfortable with this approach for my patients - but sure, do a CAC - it’s cheap and repeatable. Just don’t see a logical reason to do it if optimizing the modifiable items.
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AnUser
#68
They are effective, except the nattokinase and aged garlic extract which might only improve surrogate endpoints. You don’t have to validate anything.
I would look at adjunctive therapies like PCSK9i.
The best you can do is look at apoB, non-HDL-c, Lp(a), blood pressure. The lower apoB / non-HDL-c and Lp(a) the better.
See this post hoc analysis showing a plaque regression dependent on LDL-c decrease with Evolocumab:
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This is what my Kaiser health care professional has to say about getting a CAC score. (I’ve never had one.)
So according to him, just go away and take your 10mg rosuvastatin until you have reached a bad state, then call me. Seems like an inadequate approach, but I’m not a health care professional.
And I don’t even have the option to waste my money if I want to, as Kaiser will not make a referral 'outside; where I can pay
I will credit the guy for prescribing the statin. From 2016, when my cvd was first identified, until late 2023 when I switched to him, the intervening health care professionals showed zero interest. (‘Lots of old people have that.’) When I brought this up to him last September, he was the first one to offer treatment.
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José
#70
If you have not already seen, review a CT using Cleerly analysis.
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Thanks. Will investigate this. It looks interesting.
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You’re doubtless right – but at that point, having serial CAC adds no actionable information, rendering it an exercise in mere worrisome watching.
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Just saw your post: “Positive CAC is ADVANCED CARDIOVASCULAR DISEASE.”
My CAC score is 0.96. (I am 74).Does this mean I have advanced cardiovascular disease? I know I have genetic risks – they are most certainly the reason I have any disease.
Please clarify
AnUser
#74
Yes according to Sniderman any CAC above 0 is that, but most people your age has it, so it’s normal but not good, and probably very hard to not have CAC turn positive.
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