Grace is grace despite of all controversy. (Lucio in Shakespeare's Measure for Measure)

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They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

Once identified, behaviors can modify plaque and statins do exactly that-turn soft plaque *(that can become vulnerable and rupture) into hard plaque that is stable. There is increased risk with more plaque burden of all kinds, but risk actually goes down significantly when there is less soft plaque. It's all about risk management at that point not at all about lowering your calcium score. The disease process really starts early in life and there is cumulative damage to the vessels over time made worse by so many things...

All scores will increase over time. Identifying CAD plaque and quantifying it can allow a patient to try to take better care of themselves going forward-eat better, exercise more *(if needed-although less here in the triathlon world) and for many, but not all-taking a medication to lower long term cardiac risk like a statin.

Dr. Attia is a great champion for heart disease and I enjoy his videos. He does help people learn about the disease and the process.

Talking about heart disease in general.


Talking about CAC


CAC discussion starts ~ 1:11:00

1. 
   All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

Everyone should absolutely understand that any non- heart healthy diet is very significantly contributory to CAD and soft plaque formation. There is no argument from me that plant based, dash, ornish and mediterranean diets all are much better than most western diets. But diet can only lower risk by about 15%. Statins work adjunctively with diet to lower risk and actually work far better absolutely.

And it is awfully difficult to modify patients behavior-especially eating. People do like to eat...




I think there is always more to learn about CAD. But once risk is identified, there are coronary vessels that have plaque and taking a statin is the BEST known treatment for mitigating risk. Once treated and at lower risk, progression is slowed and plaque becomes more stable. Then you can not only enjoy exercise but also know there is truly lower risk. And I'd say were are certainly far along enough to say that confidently.

Stress tests are done to evaluate whether there is elevated risk from a physiologic standpoint. Is there a significant blockage causing EKG changes suggesting higher risk? You can certainly have higher or lower risk with elevated coronary scores and that's why patients with high numbers get additional testing to re-classify risk.

I also agree that Lp(a) and ApoB are truly important and help identify risk. We are still learning the best way to treat elevated numbers for these. This may be a bit busy, but perhaps helpful to some.

I am no cardiologist but two of our pts have had strokes with catheter angiograms. I would take the non invasive route.

My wife and I always have ate relatively healthy. Red meat used to be once or twice a week. But most meals had some meat.

We now have converted to Mediterranean diet. Our grocery bill is way less than pre pandemic despite all the food inflation and the food is actually pretty good. I am trying to live like a Sardinian peasant did one hundred years ago. Unfortunately I still get around in my truck.

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They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

After obtaining my coronary calcium score, and finding out it was high, my cardiologist had suggested an angiogram. I asked for coronary CT angiography but insurance would not pay for it. Since my concern for potential coronary blockages was high, I told the cardiology office I’d pay for the test out of pocket. It’s amazing the difference in prices among the different imaging centers in the area. Some as high as $2400 for this test. I found one for $760 and proceeded to have this done two days ago.

Coronary CT angiography is a quick test but can require you to get there an hour beforehand so they can give you medicine to lower your heart rate. My resting heart rate was 42, so I didn’t need the pre-CT med and was able to proceed straight to the test after an IV. The CT technologist said they have had to cancel people’s scans previously because they were unable to get their heart rates low enough to obtain quality scans

Today, I was supposed to go in for an echo of my heart and a treadmill stress test. I have a tear at the myotendinous junction in my right calf so I was unable to do the stress test. When I first walked in for my echo, the tech asked if I’d seen the results of my angiogram. I had not and she proceeded to tell me it was “abnormal with an 80-90% blockage”. I asked which vessel and she said “your circumflex, but that was the only vessel with blockage”. This was confusing to me because my coronary calcium score broke down the score (or calcium) for each coronary artery and my score was very high for my left anterior descending and a little less for my right coronary artery. All other coronary arteries were scored as “zero”. She was nice enough to ask the cardiologist if he would go ahead and see me today since my angiogram was read as abnormal.

When I saw the cardiologist, he started off by saying “your echo was normal except you have an ‘athlete’s heart’ and this is because you are a runner”. Next, he says “now let’s talk about your angiogram”. At this point, I was sure he was about to explain that I needed a stent placed. Instead, he says “you have no blockages anywhere”. This was a HUGE relief and he proceeded to explain the shape of my circumflex artery made it appear to have a blockage when in fact it was actually not blocked at all. He showed it to me on my angiogram.

So, the coronary calcium score was a good learning lesson and forced me to dig deeper into my cardiac health. Looks like I’m one of those endurance athletes who has a high calcium score but open arteries. I’m thankful for the knowledge and expertise of these heart specialists

That’s great news to hear!
Looks like tonight is a celebration-
:)

Knowledge is powerful

Have any Canadians here travelled to the US to have this done? Any issues with doing that?

Here in Canada, you first have to convince your doc to send you to a heart specialist, and if they agree to that, then wait a year+ to see said specialist, and then try to convince them that you need the test....

Holy SHIT!

So happy for you

When I read 80 - 90% blockage I felt horrible for you


So very glad you were able to speak with the cardiologist right away instead of being worried about it for days or weeks

Huge congratulations

How relieved do you feel?

How did you feel thinking it was 80-90% blocked?

Thank you. To some, this may sound strange but I actually got teary eyed when I got out to my car. I think the idea of having significant coronary disease was weighing on me a lot more than I realized. But, I was certainly overjoyed and very thankful to have the great test result.

I had convinced myself I’d likely need a stent placed (best case scenario) but was scared the testing would find significant enough disease I’d end up needing a CABG (open heart surgery). Whatever was needed, I was going to do it because my ultimate goal is to live as long as possible. So, when she said she read the report and the circumflex was described as 80-90% blocked, I was kind of relieved and thought to myself “ok, it’s only one vessel so maybe this means I’ll just need a stent and will not have to undergo open heart surgery”.

When the cardiologist clarified that I actually had no blockages in any of my vessels, I could’ve hugged every person in that office.

Doesn’t sound strange at all

So happy for you buddy

And I would have give you a great big hug back

Now go out and eat steak every day lol. Just kidding

Enjoy the relief

From someone just recently diagnosed, I wanted to say thanks to all for sharing information here. I also have a question: does anyone have a cardiologist in California that they are happy with? The first cardiologist I saw does not have any knowledge of athletes, and seemed somewhat surprised that I am struggling with statins and training and muscle soreness. (She told me there were no known issues with that.)

Background: 54yo, completely asymptomatic (FTP 350w with no issues at all at high intensity), recently returned CAC score of 467. When I asked for the CAC referral my dr said insurance probably wouldn't pay for it because I had no risk factors, but now I am obviously very glad I did the test. I am just now trying to catch up and learn what all this means, and all the links and videos are very helpful. Thanks especially to dtoce for generously sharing his knowledge.

I’m glad you had the testing done and you are being proactive. Our data points (age, CAC score, FTP) are all very similar, so I felt like I was reading my story to a degree. I started taking Atorvastatin 20mg as soon as I found out my CAC score was above 400. Fortunately, I’ve not really noticed muscle soreness nor fatigue, but I’ve heard of plenty of other athletes who’ve had a similar complaint as you.

Like you, my insurance would not cover further testing (angiography) for my elevated CAC score because I was asymptomatic. It weighed on my mind enough that I finally decided to pay out of pocket for CT angiography of my coronary arteries. I hope all continues to be well with you

so glad you had that done and now know that you can modify risk going forward-

Jae had great advice for people for primary prevention in terms of going low and slow. I've quoted it below from the "statins: experience training and racing on them" thread

This is where we move away from evidence-base medicine. As you are aware, the CV outcomes trials for statins were evaluated with on-label regimens, which were daily administration. However, the totality of evidence strongly supports the LDL hypothesis, and intermittent regimens, so long as LDL is efficaciously reduced, should translate into reduced CV events.
There are so many permutations of intermittent statin regimens, and are in balance with what you can tolerate versus your LDL-C goals. This is why partnering with an experienced lipidologist who specializes in statin intolerance can help. Your case is even more special because your regimen needs to fit an endurance athlete’s lifestyle (I refuse to believe your tibia fracture can permanently set you back! We will cheer you from the sidelines to start running again once recovered!!!). Again, with the usual caveats to take anything a stranger online will say with a grain of salt and to partner with your doc:
1) Since your presentation is primary prevention and not secondary prevention due to ACS, it means you can probably afford to go “low and slow”.
2) Depending upon your level of intolerance: if very intolerant, might start with 2.5 mg or 5 mg rosuvastatin once weekly. If you can tolerate, can start or titrate to twice weekly (eg. Mon/Thurs) or 3 times weekly (eg. Mon/Wed/Fri) 2.5 to 5 mg rosuvastatin. Switching to fluvastatin or pravastain is also on the table if the above does not work. Also, you can further titrate rosuvastatin dose to achieve your goals or add ezetimibe help achieve LDL-C goals if needed. PCSK9 inhibitors are also available, but is much more expensive and not sure if it is cost-effective for you.
3) The elimination half-life of rosuvastatin is ~19 hours. It will take about 3-5 doses on whichever regimen to achieve “steady-state”, to see where you land before making further changes or titrations. Suffice to say, intermittent regimens will result in higher “peak trough fluctuations” in plasma concentration. You can leverage this peak trough fluctuation to your benefit in terms of timing your exercise sessions!
4) I would take the statin at night (ie, before bedtime). While long duration statins like rosuvastatin tend to allow time of administration at any time of day, you are trying to get the most “bang for your buck”—most cholesterol synthesis occurs at night, which means at least on those days you take the statin, the highest concentrations of the nightly-administered statin occurs at the time when it is most needed. Taking the statin at night also gives you a practical way to manage exercise... next bullet
5) Taking the statin at night on an intermittent regimen means the daytimes on the days you take the statin are “trough” or nadir levels of statin in your body and may be the ideal days for your higher intensity exercise sessions. For example, if you are due to take your statin Monday night, Monday morning could be you higher intensity or longer training session day.
6) Preface—this is REALLY anecdotal and NOT evidence-based: but for really big exercise days, eg a triathlon race, you might consider pausing your statin for 3 or more days before (which is >3 elimination half-lives). Big races result in CK releases (or muscle injury pattern) in even healthy people without medical conditions, and people on statins are shown to have even higher CK releases. SInce you are in the primary prevention category, you might consider this since races are few and far in between and should not unduly affect your overall “time under the curve” on LDL-C reduction.

Take care and good luck!





My response in the that thread quotes the studies proving importance of statin Rx.


In answer to the question, most active patients tolerate needed statin medicine just fine. I have quite a lot of patients who have known CAD/with or without revascularization, or risk equivalents like abnormal coronary calcium scores who are on drug therapy and continue to train and race without any issues at all. This list includes: people who do every aerobic sport, including lots of triathletes.

Depending on why you are taking a statin, the path to achieving the desired LDL level can be fast or slow. My patients with ACS (acute coronary syndromes) or AMI (acute MI) have no choice but to begin high intensity statin immediately and we deal with side effects and taper the med as able, when able. Most people placed on a statin take it for primary prevention-not secondary prevention: ie to prevent the first cardiac event. There is often less urgency and additional non-drug Rx can help lower the need for medication. Eating better, exercising regularly (*less of an issue with most, but not all, triathletes) and losing weight helps lower lipid numbers. I usually start low and titrate up to the needed dose to achieve an LDL goal of 40-70 for patients with known CAD or risk equivalents *(this includes any abnormal coronary calcium score or having a CT scan with vascular/coronary calcification). There is no evidence that CoQ10 works via studies, but I do encourage those with myalgia to try it.

Also, since this always comes up and people want to know what the real risk is about competing in triathlon once diagnosed with heart disease...so to be complete, I'll throw in this one
'Sudden death in triathlon'
https://forum.slowtwitch.com/...riathlon_P6427784-2/

I do wish you the best!

Please discuss options and any concerns with your MD, and be honest about side effects. Sometimes there is a perceived association with a med that may or may not be valid. Cardiac health is almost always most important for all, although the better we get at treating heart disease, the longer the patients are living and now getting CA...


edited this thread to add these LDL-C studies:

Bigger, broader and better 'Evidence Based Medicine' clearly shows that lowering LDL-C is associated with risk reduction and statins are a very useful mechanism for achieving this.


The Cholesterol Treatment Trialists Collaboration-CTT (dec LDL-C 22% less CV events --90,056 pts)
Heart Protection Study-HPS (same benefit in each tertile of baseline LDL--20,536 pts)

PROVE IT, TNT, FOURNIER (more intensive treatment=lower LDL, even fewer events)

above from PROVE IT

MIRACL (Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering), PROVE-IT (PRavastatin Or atorVastatin Evaluation and Infection Therapy) and IDEAL-ACS (Acute Coronary Syndromes) studies outline the benefits of high-dosage atorvastatin therapy started within 24-96 hours, 10 days or 2 months, respectively, of an acute coronary syndrome. Relative to placebo, pravastatin and simvastatin, atorvastatin reduced the risk of death or major cardiovascular events by 16-18%

ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm), revealed that atorvastatin reduced the relative risk of primary coronary heart disease (CHD) events by 36% (p = 0.0005) compared with placebo in patients with hypertension.

followed by NCEP (National Cholesterol Education Program) committee update-new goal for high risk pts=LDL<70

followed by ACC/AHA Guidelines change in 2013 (tried to be fully evidence based)

ALLIANCE (Aggressive Lipid-Lowering Initiation Abates New Cardiac Events) and GREACE (GREek Atorvastatin and Coronary-heart-disease Evaluation) trials highlight the benefits of atorvastatin in the 'real world' setting in patients with stable CHD. Compared with 'usual' care, atorvastatin reduced the risk of nonfatal MI by 47-59%
IMPROVE IT Among 18,144 patients, there were 9,545 total PEP events (56% were first events and 44% subsequent events). Total PEP events were significantly reduced by 9% with ezetimibe/simvastatin vs placebo/simvastatin
IDEAL- TNT (Incremental Decrease in End Points Through Aggressive Lipid Lowering) and TNT (Treating to New Targets) trials demonstrate the preventive efficacy of atorvastatin in patients with stable CHD. Relative to simvastatin (in the IDEAL trial) and low-dosage atorvastatin (in the TNT trial), intensive atorvastatin therapy (80 mg/day) reduced the risk of nonfatal myocardial infarction (MI) by 17-22% (p < or = 0.02).

more statin decreasing stroke data
SPARCL (16% reduction in CVA in group without carotid stenosis and in the group with carotid artery stenosis, treatment with atorvastatin was associated with a 33% reduction in the risk of any stroke)

2018 ACC/AHA Guidelines states "This confirms the general principle that 'lower is better' for LDL-C".
2019 European Sociaty of Cardiology Guidelines states "Throughout the range of LDL-C levels, lower is better".











Table 1
Randomized cardiovascular outcomes study with high intensity LDL-lowering therapy in patients with coronary artery disease.
TrialMean Reduction in LDL Cholesterol; mmol/L (mg/dL)OutcomeRR (95% CI) (per mmol/L)CTT meta-analysis (high-intensity vs. standard statin; subgroup < 2.0 mmol/L) [17]1.71 (66) vs. 1.32 (50)MI, CHD death, stroke, coronary revascularisation0.71 (0.56–0.91)IMPROVE-IT (ezetimibe plus simvastain vs. simvastatin) [12]1.55 (70) vs. 1.40 (54)CV death, MI, stroke, UA, coronary revascularisation0.94 (0.89–0.99)FOURIER (evolocumab plus high-dose statin ± ezetimibe vs. high-dose statin ± ezetimibe) [19]2.37 (92) vs. 0.78 (30)CV death, MI, stroke, UA, coronary revascularisation0.85 (0.79–0.92)ODYSSEY OUTCOMES (alirocumab plus high-dose statin ± ezetimibe vs. high-dose statin ± ezetimibe) [20]2.37 (92) vs. 1.37 (53)MI, CHD death, stroke, UA0.85 (0.78–0.93)
Open in a separate window
CHD, coronary heart disease; CV, cardiovascular; MI, myocardial infarction; UA, unstable angina.



Last edited by: dtoce: Sep 20, 23 9:56



I have PM'd you for your latest question-
Dale

great news of the follow-up. Also, some incredible info from dtoce and the slowtwitch community on these threads.

Looks like we have a similar path. After getting in to see the cardiologist in September we agreed to follow up with the CT angiogram which I had early this month. The results:

CAD-RADS 2 - (25-49%) Mild non-obstructive coronary artery
atherosclerosis.There are no significant luminal stenoses

This was a huge relief and after going through the entire summer being told to avoid max HR my cardiologist told me I was good to go for racing and to continue leading a heart healthy lifestyle and follow up in a year.


So, after "worrying" all summer a heart attack was imminent, it turns out I'm ok. I think I now understand why the medical community doesn't want us all rushing out to test ourselves. The high score from the coronary calcium test led me down the path to a stress test which, according to my cardiologist, produced a false positive, which then warranted a CT angiogram which showed I was "ok" which is what I thought I was until I had the high coronary calcium score. I never presented with any of the typical heart related symptoms.


I'm sure the coronary calcium score has helped a lot of people but in my case, I believe it led to unnecessary testing, a poor summer of racing (<max HR), and a lot of unnecessary worrying. YMMV!

I'm not an expert by any means, but I guess my takeaway would be different. 25-49% atherosclerosis means you do have heart disease -- again I'm not an expert but my guess is this puts you at least in the worst 10% of people, which means you are at very real risk of a future heart attack. And by finding that out now you can both keep an eye on it, and also take actions to prevent it. The coronary calcium score was a fairly cheap way of finding out that you might be at risk, then the CT angiogram was a more expensive way of verifying that you didn't need a more drastic approach *yet*. But even the CT angiogram is very cheap compared to treating you for a heart attack, let alone the associated possible loss of life and quality of life. In my case I kind of wish I'd known I was at higher risk 10-20 years ago, as I might have acted a bit differently had I known.

Lanier

Those are extremely wise words. I couldn’t have said it better myself…

I didn't know what CAD stood for before this summer. Now I know a little bit more and yes, it's not the best thing to have but it also sounds like it is very common for people eating a western diet. At almost 70 I'll take a CAD-RADS 2 score vs something higher. Out of all of this I am now on a statin and baby aspirin so hopefully that and a healthy lifestyle will keep the CAD under control.

I'm still conflicted on the statin because since starting it there have been a few occasions (maybe once a month) where I feel horrible post workout. But on the plus side, lately I feel like I can breathe so much easier during intense workouts. Something with my body has changed.

Now what I really want to know is if I race a guy in my AG who has no CAD does he have a performance advantage :)

I was wondering if anyone responded to you about best way to get these tests done in or travelling from Canada.
I’ve only found a couple private labs in Canada that do as part of expensive overall packages including body scans etc.
My 50-year old brother passed away suddenly last week in BC. The only thing they were able to find on autopsy was 60% blockage in left anterior descending artery. He was deemed cancer free after a colorectal tumour was found earlier this year and was on a last days of very optional precautionary chemo to help prevent anything from coming back.
We have no known heart disease in my family besides my 90 year old dad finally passing of a heart attack (hardened valves). So we are pretty shocked and the rest of us would like to see where we are at.
He was active, thin, good diet.
I don’t know if side effects from chemo can increase any risks of having such a blockage, but I am pretty sure my brother would have opted out of the chemo to concentrate on his heart if he’d known.
So, super massive cautionary tale both on doing earlier cancer screening for colorectal cancer and any testing on heart health. When you are youngish, thin, active and don’t have family history, it seems extremely hard to have things taken seriously. When my brother started passing blood over two years ago, his GP just told him it was likely hemorrhoids and my brother had to advocate strongly for himself to be tested further 18 months later.

Not really, no.
I don't live far from Maine, but even after lots of googling it wasn't clear where/how I could have it done there.
I have a brother who lives in Florida, so may look into it again if I get down there to visit him sometime.

I got my first CAD diagnosis this summer from a simple back x-ray looking for source of lower back pain. I wasn't aware that they could see calcification in your aorta from what seems like such a simple test.

It was a shocker for me that led me down the path of the coronary calcium score, stress test, and then CT angiogram and finally a CAD 2 diagnosis and a lifetime (hopefully longer) on statin and baby aspirin.

I know it won't be popular with the medical community here but why not complain of lower back pain to your primary care, whether you have it or not, to get a picture of the condition of your lower aorta?

Someone with more knowledge of CT scans can correct me if I am wrong but it seems almost any facility with a CT scanner should be able to do this test for you. Call any of the larger medical centers, in Maine, and ask for the radiology department. Someone there should be able to tell you if they do this test or not. I paid $80US for mine but I've heard prices vary from $80US to $160US

Sadly-you need an order from an md

Recently had mine done as part of heart health screening. I paid $99 and it included the scan, ekg, and lipid panel. Wasn’t having any symptoms but had just turned 50 and wanted to get a baseline. Thankfully score came back 0. Only remarks on report were marked bradycardia (which I expected as my rhr is low 30’s) and incidental note of aortic valve calcification, consider bicuspid aortic valve and/or aortic valve stenosis.

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Let food be thy medicine...

I’m so sorry for your loss-

Thanks.