Coronary Calcium Score (update)

[EyeRunMD]

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

[dtoce]

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.

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)
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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

[Nerd]

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

[TJ56]

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

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!

[lanierb]

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

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!

[dtoce]

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

[TJ56]

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

[imsquared]

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.

[SBRcanuck]

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.

[TJ56]

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?

[EyeRunMD]

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.

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

[dtoce]

Sadly-you need an order from an md
.

[JackStraw13]

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.

[dtoce]

I’m so sorry for your loss-
.

[imsquared]

Thanks.

[EyeRunMD]

Sadly-you need an order from an md

Yes. My bad for not pointing this out. Thank you

[MeggieB]

Following up on my score–while I got the test done weeks ago, they did not release my score until today, when I met with my doc. 62.5. I’ll be starting aspirin and re-evaluating in five years to see if I need to add a statin.

Again, thank you so much to everyone who has contributed here. There is so much helpful information, and I appreciated it.

[monty]

Following up on my score–while I got the test done weeks ago, they did not release my score until today, when I met with my doc. 62.5. I’ll be starting aspirin and re-evaluating in five years to see if I need to add a statin.//

I’m no doctor, just a couple decade heart patient now with a lot of first hand experience and those of many others who have posted here over the years. I got a fairly low score first time out about 6 years ago(half your score), but I then did one each year to see if I could discern any patterns. Each year it went up a bit until it was around your score, and that is when I got recommended to start my statin. Super low dose and I do it every other day for the lowest possible chance at side effects. So far so good, and last score was only up 3 points. Doc is pushing to up the dose last visit, but I’m resisting and cleaning up my diet to try and get the same result.

I suppose all of this is to ask you why wait? You have heart disease now, I think many would recommend a very light regime like I have been doing. Not sure how old you are, suppose that could make a difference, but just something to think about. If I had waited 5 years for my 2nd test, it would have tripled in that time and I wouldn’t have arrested it as quickly. But understand a lot of regular docs just aren’t as aggressive with folks, but as athletes we want the most our of our bodies, not the average…

[MeggieB]

This is a fair question. He gave me two options: aspirin and wait and see, and low-dose statin. He felt comfortable with both as my LDL is under 100. I will have blood panels again in a year and if the LDL is over 100, I would likely go on the statin. He stated the 62 was extremely low risk for heart attack, which was my main concern. If my next CAC is over 100, I would also go on the statin.

Your point is something to think about–although I thought the aspirin would arrest my CAC score, in theory.

Well, geez now I have something to think about–I didn’t think scores would go up that quickly. Hmmmm

[monty]

Well hopefully Dr Dale will see this and chime in. I consider him to be the foremost expert in this area for athletes, a category that most doctors dont consider as any different from their couch potatoes…