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Coronary Calcium Score (update)
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Just had this done and was shocked to receive a 433. Now my cardiologist wants to do either a CT angiogram of my coronary arteries or cardiac catheterization (with angiogram).

Back in May 2023, I had sudden onset of terrible vertigo and pulsatile tinnitus (sounded like ocean waves in my ear that corresponded with my heart beat). It was definite vertigo, and not dizziness. I mentioned I did have occasional dizziness but it would come about with rest or activity and seemed to be more related to work related anxiety/stress than anything else. I mentioned I thought the vertigo could be instigated by my anxiety as well.........one episode hit me when I was sitting in my car waiting to return to work after lunch. Because of all of this, the cardiologist/ENT requested multiple different scans (hearing test, MRI brain, CT angiography of brain, EKG, holter monitor, and the coronary calcium scan). They believe I may have Meniere's Disease (except I don't have hearing loss yet) but wanted to be safe on the cardiac part.

I ride with a group of 20-30 year old guys (I am 53yo) so my heart rate is maxed out on multiple occasions (and without any chest pain or new excess fatigue or any other adverse cardiac signs). Now that I have this calcium score, and after reading about other's heart "misadventures" on here, I am paranoid about being the "fit looking" guy with hidden heart disease. Genetics may have doomed me as everyone on my father's side has had stents placed and/or open heart surgery (none of them were healthy eaters or active).

I've read papers that endurance athletes can have calcium scores over 300 without the associated cardiac risk percentages as inactive adults but I am not going to put weight to that until I get further testing.

Sorry, I am rambling here and just concerned.
Last edited by: EyeRunMD: Sep 15, 23 15:19
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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Mine is 780 but 0 in RT Main. So other 5 arteries have a bit of calcium. I would ask for proper stress test. I have had all the tests but Contrast CT to determine amount of soft plaque which is the most important.

My contrast cardiac MRI showed heart wise everything is perfect. The fact that I ran both stress tests 5 min beyond level 3 protocol with no EKG, BP or lung gas anomalies gave me and my cardiologist a bit of comfort. My blood work has been excellent until we looked into the makeup of my LDL which showed LPa to be off the chart. So after 6 month of Statins and PCSK9 inhibitor it has come down to just a little higher than normal. So for me at age 60 it is about arresting any more artery damage.

Hopefully for me if I have soft plaque and throw it causing a heart attack - I am lucky like some folks on the forum to be near an ER and just get a stint. So I am hypersensitive to any strange pain that typically we dismiss as… oh must be the swim workout I did yesterday that is causing chest pain.
Last edited by: scca_ita: Aug 23, 23 19:33
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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Great thing about this community, you read things and they light a spark, and sometimes we act on those sparks. Good for you after all these years of us talking about those scores, making the effort to finally go get one.

SO now you know, which is what dotce, myself and many others have been saying for a long time. Knowledge is power, and with your family history, you can now be proactive. I only found out about calcium scores about 6 years ago, chastised my heart doc a little on why he had never told me about them, until I had badgered him into other metrics I could use to see how I was doing. Too many healthy friends just dropped dead in workouts or races, I need more of an explanation of what that would be.

So for sure you are going to be given statin advice, and likely a pretty good dose with your score. I'm of course no doctor, just a 23 year heart patient who is trying his best to be able to continue to train, and even compete once in awhile when the stars align. This is good timing as there is a thread on the front page now with someone else asking about this, and dtoce linked several sites that you just plug in your numbers, and it gives you some therapies to look at. I know you must be really shocked to see that number, but just remember others see 2 to 3 times that number, and are still walking around, so dont panic.

You got it early, no doubt part of your family history, and now you get to mitigate and keep doing what you are doing. I will leave it to the real experts here to point you in the right direction, you are going to be fine once you get on the program. Just watch your anxiety in the meantime, that is the real killer...
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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Sorry to hear what you are going through

As for vertigo I had it to where it was a bit of a chore to walk a straight line.

This helped me with my vertigo tremendously

I can feel when I need a ‘time up’ and do the simple exercise. And am good to go foie a couple months




Best of luck with all of it
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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If you use the search function you will see a lot of great questions and answers from DTOCE on the subject of calcium scores etc. He is a great cardiologist and you will likely find many answers to any questions that are ticking over in the numerous threads on here.
I appreciate how anxiety provoking having a test come back like this can be. I often tell my patients that these sorts of processes are really like a journey and you are just at the beginning of this one at the moment and there are numerous things that will follow from here, but the end of that journey will hopefully have you in a better place than if you had not embarked on it at all.
In terms of the dizziness versus vertigo, it is too early to tell from the information you have provided whether this could be secondary to any cardiac issues and at the moment I would not give it much additional thought, the tests you will go through will provide more clarity on whether this may have been secondary to something cardiac related.
I hope all the tests etc go well from here.
Last edited by: Amnesia: Aug 24, 23 5:13
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Re: Coronary Calcium Score [scca_ita] [ In reply to ]
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scca_ita wrote:
Mine is 780 but 0 in RT Main. So other 5 arteries have a bit of calcium. I would ask for proper stress test. I have had all the tests but Contrast CT to determine amount of soft plaque which is the most important.

My contrast cardiac MRI showed heart wise everything is perfect. The fact that I ran both stress tests 5 min beyond level 3 protocol with no EKG, BP or lung gas anomalies gave me and my cardiologist a bit of comfort. My blood work has been excellent until we looked into the makeup of my LDL which showed LPa to be off the chart. So after 6 month of Statins and PCSK9 inhibitor it has come down to just a little higher than normal. So for me at age 60 it is about arresting any more artery damage.

Hopefully for me if I have soft plaque and throw it causing a heart attack - I am lucky like some folks on the forum to be near an ER and just get a stint. So I am hypersensitive to any strange pain that typically we dismiss as… oh must be the swim workout I did yesterday that is causing chest pain.

My calcium scan showed mine to be in my LAD and right coronary artery. The LAD is my biggest concern (though they both are concerning). I do have a stress test coming up soon, along with an echo.
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Re: Coronary Calcium Score [monty] [ In reply to ]
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monty wrote:
Great thing about this community, you read things and they light a spark, and sometimes we act on those sparks. Good for you after all these years of us talking about those scores, making the effort to finally go get one.

SO now you know, which is what dotce, myself and many others have been saying for a long time. Knowledge is power, and with your family history, you can now be proactive. I only found out about calcium scores about 6 years ago, chastised my heart doc a little on why he had never told me about them, until I had badgered him into other metrics I could use to see how I was doing. Too many healthy friends just dropped dead in workouts or races, I need more of an explanation of what that would be.

So for sure you are going to be given statin advice, and likely a pretty good dose with your score. I'm of course no doctor, just a 23 year heart patient who is trying his best to be able to continue to train, and even compete once in awhile when the stars align. This is good timing as there is a thread on the front page now with someone else asking about this, and dtoce linked several sites that you just plug in your numbers, and it gives you some therapies to look at. I know you must be really shocked to see that number, but just remember others see 2 to 3 times that number, and are still walking around, so dont panic.

You got it early, no doubt part of your family history, and now you get to mitigate and keep doing what you are doing. I will leave it to the real experts here to point you in the right direction, you are going to be fine once you get on the program. Just watch your anxiety in the meantime, that is the real killer...

Bad part, on my end, is I’ve usually scrolled right past any posts here on Slowtwitch about heart issues because I (naively) thought “nah, that’ll never happen to me”. Now, I’ve been going back and reading past posts about this (and other) heart related issues. I’m now in a statin and aspirin. More testing is coming up.
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Re: Coronary Calcium Score [MrTri123] [ In reply to ]
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Thanks for posting that video. I’d seen it previously when desperately searching YouTube trying to find something to help with my vertigo. So far, I cannot find anything to make mine go away except time and lying in bed. When the vertigo hits, it can last 2 hours to 24 hours, and I look like a drunk person if I try to walk. Have been on a few different meds as well, but no relief. The only treatment that helped, so far, was a steroid injection into my ear. I went from having 1-2 vertigo attacks per week to one vertigo attack over a 4 week period.
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Re: Coronary Calcium Score [Amnesia] [ In reply to ]
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Amnesia wrote:
If you use the search function you will see a lot of great questions and answers from DTOCE on the subject of calcium scores etc. He is a great cardiologist and you will likely find many answers to any questions that are ticking over in the numerous threads on here.
I appreciate how anxiety provoking having a rest come back like this can be. I often tell my patients that these sorts of processes are really like a journey and you are just at the beginning of this one at the moment and there are numerous things that will follow from here, but the end of that journey will hopefully have you in a better place than if you had not embarked on it at all.
In terms of the dizziness versus vertigo, it is too early to tell from the information you have provided whether this could be secondary to any cardiac issues and at the moment I would not give it much additional thought, the tests you will go through will provide more clarity on whether this may have been secondary to something cardiac related.
I hope all the tests etc go well from here.

Yes, the search function and DTOCE have been great resources.

This has certainly been an eye opener. It may sound strange to say but I was a bit embarrassed by my score. No one in my family is physically fit, they are smokers or obese, and most like to tease me with “why do you do all of that running/cycling?” After I received my calcium score, I told my wife “great, I’m the only person in my family who works at being healthy and now I may be the one with coronary disease”. But, more testing is to come and I’ll find out if it’s the changes seen by some endurance athletes, or more ominous.
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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EyeRunMD wrote:
Just had this done and was shocked to receive a 433. Now my cardiologist wants to do either a CT angiogram of my coronary arteries or cardiac catheterization (with angiogram).


I ride with a group of 20-30 year old guys (I am 53yo) so my heart rate is maxed out on multiple occasions (and without any chest pain or new excess fatigue or any other adverse cardiac signs). Now that I have this calcium score, and after reading about other's heart "misadventures" on here, I am paranoid about being the "fit looking" guy with hidden heart disease. Genetics may have doomed me as everyone on my father's side has had stents placed and/or open heart surgery (none of them were healthy eaters or active).

I've read papers that endurance athletes can have calcium scores over 300 without the associated cardiac risk percentages as inactive adults but I am not going to put weight to that until I get further testing.



As you know, since I've PM'd you earlier, you are doing the right things to check things out from a cardiac risk standpoint and you will work with your providers to do the right things to mitigate long term risk.

There have been lots of threads that I've commented on after several athletes in the community had cardiac issues and posed so I'm not going to pull them all up. But here are a few threads that may be worth a read.


Here's a link to an article I wrote for ST a while back
What Endurance Athletes Need to Know about Heart Health
https://www.slowtwitch.com/...art_Health_7911.html

'Statins and training'
https://forum.slowtwitch.com/...st=last-6643505#last

'Worried about my heart'
https://forum.slowtwitch.com/...tring=dtoce#p6619853

'Heart health screening thread'
https://forum.slowtwitch.com/...st=last-7150717#last

plus, Tom's thread
I'm 51, and just had a 5x coronary artery bypass graft (cabg) surgery with no prior symptoms : Triathlon Forum: Slowtwitch Forums

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/

Information about coronary artery calcium scoring
https://www.acc.org/...-cardiovascular-risk


You might like the article that Aaron wrote regarding athletes.
https://www.ahajournals.org/...LATIONAHA.117.028750

Good luck with your upcoming tests.
Last edited by: dtoce: Aug 24, 23 4:41
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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EyeRunMD wrote:

This has certainly been an eye opener. It may sound strange to say but I was a bit embarrassed by my score. No one in my family is physically fit, they are smokers or obese, and most like to tease me with “why do you do all of that running/cycling?” After I received my calcium score, I told my wife “great, I’m the only person in my family who works at being healthy and now I may be the one with coronary disease”. .

you are likely the only one who has yet bothered to get themselves checked out and others in your family certainly likely have CAD but do not know it....

as stated by monty: 'Knowledge is power'
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Re: Coronary Calcium Score [dtoce] [ In reply to ]
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dtoce wrote:
EyeRunMD wrote:
Just had this done and was shocked to receive a 433. Now my cardiologist wants to do either a CT angiogram of my coronary arteries or cardiac catheterization (with angiogram).


I ride with a group of 20-30 year old guys (I am 53yo) so my heart rate is maxed out on multiple occasions (and without any chest pain or new excess fatigue or any other adverse cardiac signs). Now that I have this calcium score, and after reading about other's heart "misadventures" on here, I am paranoid about being the "fit looking" guy with hidden heart disease. Genetics may have doomed me as everyone on my father's side has had stents placed and/or open heart surgery (none of them were healthy eaters or active).

I've read papers that endurance athletes can have calcium scores over 300 without the associated cardiac risk percentages as inactive adults but I am not going to put weight to that until I get further testing.



As you know, since I've PM'd you earlier, you are doing the right things to check things out from a cardiac risk standpoint and you will work with your providers to do the right things to mitigate long term risk.

There have been lots of threads that I've commented on after several athletes in the community had cardiac issues and posed so I'm not going to pull them all up. But here are a few threads that may be worth a read.


Here's a link to an article I wrote for ST a while back
What Endurance Athletes Need to Know about Heart Health
https://www.slowtwitch.com/...art_Health_7911.html

'Statins and training'
https://forum.slowtwitch.com/...st=last-6643505#last

'Worried about my heart'
https://forum.slowtwitch.com/...tring=dtoce#p6619853

'Heart health screening thread'
https://forum.slowtwitch.com/...st=last-7150717#last

plus, Tom's thread
I'm 51, and just had a 5x coronary artery bypass graft (cabg) surgery with no prior symptoms : Triathlon Forum: Slowtwitch Forums

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/

Information about coronary artery calcium scoring
https://www.acc.org/...-cardiovascular-risk


You might like the article that Aaron wrote regarding athletes.
https://www.ahajournals.org/...LATIONAHA.117.028750

Good luck with your upcoming tests.


Thank you so much for sharing these.
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Re: Coronary Calcium Score [dtoce] [ In reply to ]
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dtoce wrote:
EyeRunMD wrote:


This has certainly been an eye opener. It may sound strange to say but I was a bit embarrassed by my score. No one in my family is physically fit, they are smokers or obese, and most like to tease me with “why do you do all of that running/cycling?” After I received my calcium score, I told my wife “great, I’m the only person in my family who works at being healthy and now I may be the one with coronary disease”. .


you are likely the only one who has yet bothered to get themselves checked out and others in your family certainly likely have CAD but do not know it....

as stated by monty: 'Knowledge is power'

You are certainly correct. I believe a lot of them do have coronary disease (as well as the other maladies associated with poor life choices).

Because of my fitness level, I felt "immortal" for the longest time. Well, life has a way of humbling us and it has definitely done that to me.
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Re: Coronary Calcium Score [dtoce] [ In reply to ]
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Following this thread and have followed most of the recent threads on cardiac issues. I have a CCS scheduled for October although I have no issues (that I am aware of) and my GP hasn’t mentioned it because my lab values have been great. I turn 50 in September so figured it would be a good time to get a baseline score. My health system does a screening that includes CT scan of heart, EKG, glucose and cholesterol panel for 100 bucks. Pretty much a no brainer as far as I am concerned.

Let food be thy medicine...
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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EyeRunMD wrote:
"I am paranoid about being the "fit looking" guy with hidden heart disease"


Me too! Unfortunately, I'm right there with you. I scored a 429 last month. Not happy with it at all as I always "assumed" my arteries were clear because I've always been around 180 cholesterol and have followed a fairly healthy diet the last 20 years.


Things started unraveling for me back in June when I got a lower lumbar x-ray for back pain. Not surprisingly the x-ray showed some mild degenerative discs but what was surprising was the finding of severe aortic atherosclerosis. That was a WTF moment. I didn't even know they could diagnose that with a back x-ray. So that got me to schedule the CT coronary calcium score. After getting those results my primary care doctor put me on a statin and baby aspirin and ordered an echo stress test. The statin lowered my cholesterol to 150.


I do believe I felt some of the side effects from the statin of muscle soreness and started taking COQ10 as has been discussed here. It seemed to help but verdict is still out on that. I did ask my primary care if I had any restrictions and she said no so I did Nationals in Milwaukee earlier this month. I had a panic attack about 200 yds into the swim and stopped because I felt the normal, out of breath, chest tightness, that I've felt for 20 years in wetsuit cold water swims but this time I had something concrete to worry about :) After what seemed like several minutes I didn't die and started swimming again and completed the Olympic distance biking and running at max heart rate.

I finally got my stress test completed last week and initially I was told I passed it but then they later updated the results to say there was a suggestion (?) of stress induced ischemia. My primary care said to see a cardiologist (which I had already scheduled) and now she said to try to keep heart rate below max while exercising. So now I'm waiting for that appointment which isn't for another month.

I did a 110 mile gravel race this past weekend up in Iowa which just about destroyed me but I did try to keep the heart rate down. I also plan on doing another OLY this weekend (keeping the heart rate down).

I wonder if I would have had the calcium score 10 years ago if it would have been the same or near as I don't believe this just started this year. I'm anxious to see what the cardiologist says about my condition.


Oh yeah, concerning genetics, I told my older brother about my score and he scheduled a CT test. He scored a big fat 0. WTF? We both grew up on the same diet. He is moderately active and maintains a good BMI. Go figure!
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Re: Coronary Calcium Score [TJ56] [ In reply to ]
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"I am paranoid about being the "fit looking" guy with hidden heart disease"

Me three. These threads, with the expertise and experiences shared have been extraordinarily valuable.


I had the CACS test done earlier this year - 57yo. My score was very low, but not zero. It was well worth it the understand if my actual risk classification was higher than expected, or in line.
Last edited by: Math Drifter: Aug 24, 23 15:18
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Re: Coronary Calcium Score [Math Drifter] [ In reply to ]
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I'm with you Math Drifter. I've been very active most of my life, currently 62. I'm 6-2 158, so I'm not carrying much fat. I moved into endurance training in the late 90's and ran my first marathon in 2000. I am a regular at the Dr's office and have had my cholesterol checked many times and it has always been low. I'm not going to say I have great diet and a great lifestyle, but I will say it is better than most. My Dr, who is a beast of a Triathlete recommended getting a calcium scan score in May. I got a call from the Dr's office a week later saying the Dr wanted to see me about my score. Ooops! It was 280, which after I have done some research is not terrible, but it is not great. I guess the bad thing is 275 of that score is in my widow maker artery, LAD. I was shocked and the Dr. definitely was surprised, but he says it happens. I was really worried at first but have since, tightened up my diet and just being very aware of any symptoms. I'm trying not to worry about it. The glamorous life of an aging athlete.
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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Here are some interesting videos. My sister is same parents and has high LDL. But 0 CCS! CCS will not tell you the extent of soft plaques. Which I intend to quantify this year once my family’s out of pocket deductibles are reached.



And for PCSK9


Last edited by: scca_ita: Aug 24, 23 12:07
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Re: Coronary Calcium Score [TJ56] [ In reply to ]
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TJ56 wrote:
EyeRunMD wrote:
"I am paranoid about being the "fit looking" guy with hidden heart disease"


Me too! Unfortunately, I'm right there with you. I scored a 429 last month. Not happy with it at all as I always "assumed" my arteries were clear because I've always been around 180 cholesterol and have followed a fairly healthy diet the last 20 years.


Things started unraveling for me back in June when I got a lower lumbar x-ray for back pain. Not surprisingly the x-ray showed some mild degenerative discs but what was surprising was the finding of severe aortic atherosclerosis. That was a WTF moment. I didn't even know they could diagnose that with a back x-ray. So that got me to schedule the CT coronary calcium score. After getting those results my primary care doctor put me on a statin and baby aspirin and ordered an echo stress test. The statin lowered my cholesterol to 150.


I do believe I felt some of the side effects from the statin of muscle soreness and started taking COQ10 as has been discussed here. It seemed to help but verdict is still out on that. I did ask my primary care if I had any restrictions and she said no so I did Nationals in Milwaukee earlier this month. I had a panic attack about 200 yds into the swim and stopped because I felt the normal, out of breath, chest tightness, that I've felt for 20 years in wetsuit cold water swims but this time I had something concrete to worry about :) After what seemed like several minutes I didn't die and started swimming again and completed the Olympic distance biking and running at max heart rate.

I finally got my stress test completed last week and initially I was told I passed it but then they later updated the results to say there was a suggestion (?) of stress induced ischemia. My primary care said to see a cardiologist (which I had already scheduled) and now she said to try to keep heart rate below max while exercising. So now I'm waiting for that appointment which isn't for another month.

I did a 110 mile gravel race this past weekend up in Iowa which just about destroyed me but I did try to keep the heart rate down. I also plan on doing another OLY this weekend (keeping the heart rate down).

I wonder if I would have had the calcium score 10 years ago if it would have been the same or near as I don't believe this just started this year. I'm anxious to see what the cardiologist says about my condition.


Oh yeah, concerning genetics, I told my older brother about my score and he scheduled a CT test. He scored a big fat 0. WTF? We both grew up on the same diet. He is moderately active and maintains a good BMI. Go figure!



For both of us, I hope we fall into the category of endurance athletes who have high calcium scores secondary to our years of running/cycling rather than the same cardiac risk as a non-active individual with a score over 400. I'm no expert but I read a paper saying something like 11% of endurance athletes have CAC scores greater than 300 (and without the same cardiac risks as sedentary individuals). Like you, I am anxiously awaiting further evaluation with my cardiologist and am hoping I don't need aggressive interventional treatment. But, I'll do whatever I have to do to stay alive.

Yeah I am surprised talking to other people who have low CAC scores. It's also interesting to read the histories of others (FB group called Cardiac Athletes....IIRC) who had CAC scores of zero and then were surprised to have an MI and need stents/CABG. It's a screening tool to help us evaluate our risks, and take the appropriate steps.
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Re: Coronary Calcium Score [scca_ita] [ In reply to ]
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Thank you for sharing these videos.
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Re: Coronary Calcium Score [dtoce] [ In reply to ]
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At what age should one start to check calcium score? I have no significant family Hx of CAD. Just a couple parents with obesity and DM and HTN.
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Re: Coronary Calcium Score [AchillesHeal] [ In reply to ]
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At what age should one start to check calcium score? I have no significant family Hx of CAD. Just a couple parents with obesity and DM and HTN.//

Usually insurance tells you when you are eligible for certain tests, mammograms, colonoscopy, etc, but since they dont actually pay for this one, it is our choice. Like I said before, I have had many friends die in workouts, the youngest 39 and 44, both high level athletes. One running and one in the pool. I wish I had started my testing in my early 30's, if nothing else, just to see that 0 score and put it out of my mind(but probably not 0 in my case). I sure bet my friends had known their scores in their mid 30's too, but of course that was the last thing on their minds, and no doubt had never even heard of this test.


So since you have to pay anyways(about $100 to $200 bucks most places) just go ahead and get it done. I see a lot of guys in these latest threads in their 40's/early 50's with scores from 400 to over a 1000, so no doubt it would have been picked up in their 30's as something to look out for. IF nothing, then you can relax and wait for 5 or 10 years before another one. That is my non medical/non doctor advice as a long term heart patient who had his near fatal accident at 46...But mine was not related to a high CAD score, but same logic applies..
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Re: Coronary Calcium Score [EyeRunMD] [ In reply to ]
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EyeRunMD wrote:
Thank you for sharing these videos.

x2 That first video provided me with a much better understanding of statins that what my doctor did. I thought they just lowered cholesterol. I didn't realize that they could modify the plaque. Good stuff!
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Re: Coronary Calcium Score [dtoce] [ In reply to ]
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Apologies for the question and to the OP. I have just done a cholesterol test and my ldl is 3.2 (120) and the doc isn’t happy. Has given me 3 months to improve this number, otherwise I rekon he will be waiving statins in my face.

My questions is rather simple - those on statins and don’t get any sides of muscle soreness etc , I read that paper and it mentions reduction of mitochondria ? Does this means as a triathlete, we would find improvements in our peformance to swim bike run is diminished ?
Surely people have gotten faster even on statins ?
Last edited by: IamSpartacus: Aug 25, 23 1:35
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Re: Coronary Calcium Score [AchillesHeal] [ In reply to ]
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AchillesHeal wrote:
At what age should one start to check calcium score? I have no significant family Hx of CAD. Just a couple parents with obesity and DM and HTN.


Timing of cardiac screening is an individual thing. I never send my patients for ischemic testing of any sort at age 35 or less. I have, on occasion, done CACS on some patients in their 30's to show their risk is truly low and that they have time *(as I expect it will be normal/0) to take better care of themselves.

I often say to patients that this is the only body you get, so take good care of it.

There are no guidelines for specifically what age to start screening of 'low risk' individuals but I did read an NIH paper saying 42 yo for M and 58 for F. I generally think ~45 yo for men an ~50-55 yo for women *(protected by hormones longer compared to M). You'd like it early enough to intervene meaningfully and not so early to cause anxiety for years.

It is still likely best for clinicians to use the ACC risk estimator and MESA calculators *(using CACS) to help assess risk.
https://tools.acc.org/.../calculate/estimate/

https://www.mesa-nhlbi.org/...Score/RiskScore.aspx

Here's the article on 'hardening of the arteries' in athletes by Dr. Aaron Baggish of MGH.

https://www.ahajournals.org/...LATIONAHA.117.028750

The MESA %ile calculator using the CACS
https://www.mesa-nhlbi.org/Calcium/input.aspx


It is my belief that there will be a shift towards CTA and ultimately CTA with AI *(from coronary artery calcium scoring) to evaluate for soft plaques in the coronary arteries eventually. We'll see. It's been talked about for a long time but much closer to reality now.


IamSpartacus wrote:
Apologies for the question and to the OP. I have just done a cholesterol test and my ldl is 3.2 (120) and the doc isn’t happy. Has given me 3 months to improve this number, otherwise I reckon he will be waiving statins in my face.

My questions is rather simple - those on statins and don’t get any sides of muscle soreness etc , I read that paper and it mentions reduction of mitochondria ? Does this means as a triathlete, we would find improvements in our performance to swim bike run is diminished ?
Surely people have gotten faster even on statins ?


This is the downside of Rx with statins-issues with the muscles aka SAMS *(statin associated muscle symptoms)--- pain/achiness/muscle inflammation-myopathy/myalgia/concern about performance... It is real and varies in studies. Probably 5-25% of patients have some issue related to the muscles but it is still risk vs benefit and the discussion about an individual's personal risk and best plan to optimally treat needs to be shared decision making with the patient and the provider. The actual % of patients that have very significant issues may be as low as 1%, but that is not 0. There has never been any paper saying statins truly reduce muscle function but if they hurt, you will not be training appropriately. Some of the statins seem to affect the muscles more than others and there have been papers also suggesting that CoQ offsets this and that is why it is suggested-even though there is no hard clinical data to prove a benefit. Many of these studies are small so hopefully over time there will be better information to make informed choices. *edited to add: the meta analysis of all co Q 10 studies was only about 6 or 8 studies of ~240 participants. That muscle biopsy study you cited only had 48 patients...

It is suggested that diagnosis should be based on the triad of (i) temporal relationship of symptoms and/or CK elevation to initiation of statin therapy; (ii) disappearance of symptoms on withdrawal; and (iii) re-appearance on re-challenge with statin therapy
SAMS can be further classified based on muscle symptoms, the presence and degree of CK elevation. Muscle symptoms with no elevation in CK, often referred to as myalgia, is regarded as the mildest form. The term myositis is sometimes used to describe symptoms associated with significant CK elevation (>10 times upper limit of normal range). Rhabdomyolysis is the most severe form, and may result in myoglobinuria and renal impairment. CK levels in rhabdomyolysis may rise to >40 times upper limit of normal range.
The pathophysiology of and mechanisms leading to SAMS is yet to be fully understood.

Going 'low and slow' and finding a statin that is tolerated can be a challenge and take some time and effort. Multiple with-drawl trials are usually needed and re-challenging to find out if symptoms are truly related and to assess severity. It is still best to do whatever is necessary to optimally treat patients despite how difficult the effort.

It always starts with assessing risk...

While scrolling around, I did see a nice summary from the ACC about Primary Prevention and Reclassification of Risk using CACS so I copied those below.
Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease

  1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

  2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

  3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

  4. 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.

  5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

  6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

  7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

  8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

  9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

  10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

Utility of CAC in Reclassifying ASCVD Risk
For individuals with intermediate predicted risk (≥7.5% to <20%) or for select adults with borderline (5% to <7.5%) predicted risk, CAC measurement can be a useful tool in refining risk assessment for preventive interventions (e.g., statin therapy). In these groups, CAC measurement can reclassify risk upward (particularly if CAC score is ≥100 Agatston units or ≥75th age/sex/race percentile) or downward (if CAC is zero) in a significant proportion of individuals.
In adults at intermediate risk, CAC measurement can be effective for meaningfully reclassifying risk in a large proportion of individuals. In such intermediate-risk adults, those with CAC ≥100 Agatston units or CAC ≥75th percentile have ASCVD event rates for which initiation of statin therapy is reasonable. Those with CAC scores of zero appear to have 10-year event rates in a lower range for which statin therapy may be of limited value. Therefore, for patients with CAC scores of 1-99, it is reasonable to repeat the risk discussion. If these patients remain untreated, repeat CAC measurement in 5 years may have some value, but data are limited. It is important to note that the absence of CAC does not rule out noncalcified plaque, and clinical judgment about risk should prevail. Clinicians should not down-classify risk in patients who have CAC scores of zero but who are persistent cigarette smokers, have diabetes, have a family history of ASCVD, or, possibly, have chronic inflammatory conditions. In the presence of these conditions, a CAC score of zero may not rule out risk from noncalcified plaque or increased risk of thrombosis.
CAC might also be considered in refining risk for selected low-risk adults (<5%), such as those with a strong family history of premature coronary heart disease. CAC measurement is not intended as a screening test for all but rather may be used as a decision aid in select adults to facilitate the clinician-patient risk discussion. The following candidates for CAC measurement may benefit from knowing that their CAC score is zero:
  • Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely
  • Patients concerned about the need to reinstitute statin therapy after discontinuation for statin-associated symptoms
  • Older patients (men 55-80 years of age; women 60-80 years of age) with low burden of risk factors who question whether they would benefit from statin therapy
  • Middle-aged adults (40-55 years of age) with pooled cohort equations-calculated 10-year risk of ASCVD 5% to <7.5% with factors that increase their ASCVD risk.

I hope this helps...
Last edited by: dtoce: Aug 25, 23 8:31
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