5 ms·

> How would you tease that apart? CAD requires some amount of inflammation ... This was my point. On one hand, statin supporters use these studies to say "cho

> How would you tease that apart? CAD requires some amount of inflammation ... This was my point. On one hand, statin supporters use these studies to say "cholesterol lowering" is warranted, but there's no quantification on how much protective effect is from its anti-inflammatory properties vs the cholesterol lowering aspects. The anti-inflammatory effect is also not tied to reducing LDL alone, but has separate mechanisms (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3394171/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3394171/). Rather than try to isolate the cholesterol lowering aspect, I'd be interested in studies that compared a range of anti-inflammatory drugs (other than just low-dose aspirin) to a variety of statins that also differ in the degree of their anti-inflammatory effects. But as far as I know (and I'm definitely no expert in this field), such studies have not been done. > Coronary calcium scoring can be a good tiebreaker when someone's risk factors suggest that they should be on a statin, but they don't want to take a statin. I know a healthy guy who has sky high LDL-P, didn't want to take a statin, and then got CAC imaging with a score of zero. If he hadn't talked his cardiologist into that scan, he'd be on a statin with all the side-effects it entails. That to me seems at odds with the "do no harm" mantra, especially when the CAC imaging seems more directly indicative of underlying CVD in asymptomatic individuals. There are many examples of people with low cholesterol (not on statins) who have underlying CVD as well as people with high cholesterol who have no CVD. > There are many primary prevention statin trials. They all involve people with at least one risk factor (high blood pressure, etc). I consider them trials in "healthy" people, since they don't yet have coronary artery disease Similar to your critique of the OP research paper, I am troubled with studies that treat all asymptomatic individuals the same and don't assess state of atherosclerosis (i.e., a CAC score) and differentiate types of risks (high blood pressure vs high cholesterol). The question is whether high cholesterol itself _in the absence of underlying pathology_ leads to worse outcome. If we have no idea whether the starting population has underlying pathology to begin with, IMHO there's a problem with extrapolating those results to asymptomatic people with those risk factors. Other risk factors like HBP may actually be causal.

carbocation 7y ago
What you're describing sounds like exactly what the CAC score is good for. Most people don't mind taking a statin if guidelines indicate that they should. But if they really want to avoid a statin, then a CAC of zero is reassuring.
- DocSavage 7y ago
  I'm suggesting that the reliance on a very fallible test (LDL Cholesterol) for asymptomatic individuals is bad. People could be started on statin treatment and yet have no underlying pathology. I understand CAC imaging is expensive, but so is decades of statin treatments and potential side effect issues.
  - carbocation 7y ago
    CAC imaging is expensive and exposes people to (a very small amount of) radiation. Statins are safe and well tolerated. Side effects are treated by temporarily stopping the medication. In people with an appropriately elevated risk, they are cost effective for risk reduction. I.e., they keep people alive longer. So, I don't agree that CAC screening is necessary or helpful prior to initiating therapy in most cases. CAC imaging is a good choice when there is equipoise or disagreement.
    - DocSavage 7y ago
      > In people with an appropriately elevated risk, they are cost effective for risk reduction. And this is where this is disagreement. What is appropriately elevated risk? In the case of asymptomatic high cholesterol individuals, especially those without additional risk factors beyond cholesterol, (1) there are flawed studies that include people with underlying pathology together with people who have none to assess statin "benefit", and (2) there are flawed studies that show statins might actually be detrimental with regard to overall mortality. Mainstream medicine currently is fine with #1 (your "they keep people alive longer") and disregard #2 ("they are inversely associated with mortality"). I completely disagree with your dismissal of statin side effects and definite overplaying of the radiation dose of CAC scanning. Nobody has complete understanding of the full side-effect profile of long-term statin treatment let alone all the different types of statins. You have a point with expense, but lets not kid ourselves about the relative side effect profile of long-term statins vs a CAC scan. There's also the management advantages knowing CAC score vs just using LDL. http://imaging.onlinejacc.org/content/10/3/304 http://imaging.onlinejacc.org/content/10/3/304 "The presence of CAC is both a sensitive and specific indicator of atherosclerosis, while the total CAC score is a strong predictor of both short- and long-term clinical outcomes. A zero CAC score has become the most definitive predictor of low risk, mild CAC score elevations are indicators for initiating optimal prevention strategies, and high CAC scores may indicate the need for more aggressive management and follow-up. Furthermore, the test has become inexpensive and, with current imaging technologies, is associated with radiation exposure that has decreased to 1.0 to 1.5 mSv per study and to even lower radiation exposure with the newer low-dose imaging protocols (34)." Average person receives about 3 mSv per year from natural sources. The annual dose for flight attendants is 1.5-1.7 mSv. Mammograms and CAC imaging is similar and less than what flight attendants get in a year.

carbocation 7y ago

What you're describing sounds like exactly what the CAC score is good for. Most people don't mind taking a statin if guidelines indicate that they should. But if they really want to avoid a statin, then a CAC of zero is reassuring.

DocSavage 7y ago
I'm suggesting that the reliance on a very fallible test (LDL Cholesterol) for asymptomatic individuals is bad. People could be started on statin treatment and yet have no underlying pathology. I understand CAC imaging is expensive, but so is decades of statin treatments and potential side effect issues.
- carbocation 7y ago
  CAC imaging is expensive and exposes people to (a very small amount of) radiation. Statins are safe and well tolerated. Side effects are treated by temporarily stopping the medication. In people with an appropriately elevated risk, they are cost effective for risk reduction. I.e., they keep people alive longer. So, I don't agree that CAC screening is necessary or helpful prior to initiating therapy in most cases. CAC imaging is a good choice when there is equipoise or disagreement.
  - DocSavage 7y ago
    > In people with an appropriately elevated risk, they are cost effective for risk reduction. And this is where this is disagreement. What is appropriately elevated risk? In the case of asymptomatic high cholesterol individuals, especially those without additional risk factors beyond cholesterol, (1) there are flawed studies that include people with underlying pathology together with people who have none to assess statin "benefit", and (2) there are flawed studies that show statins might actually be detrimental with regard to overall mortality. Mainstream medicine currently is fine with #1 (your "they keep people alive longer") and disregard #2 ("they are inversely associated with mortality"). I completely disagree with your dismissal of statin side effects and definite overplaying of the radiation dose of CAC scanning. Nobody has complete understanding of the full side-effect profile of long-term statin treatment let alone all the different types of statins. You have a point with expense, but lets not kid ourselves about the relative side effect profile of long-term statins vs a CAC scan. There's also the management advantages knowing CAC score vs just using LDL. http://imaging.onlinejacc.org/content/10/3/304 http://imaging.onlinejacc.org/content/10/3/304 "The presence of CAC is both a sensitive and specific indicator of atherosclerosis, while the total CAC score is a strong predictor of both short- and long-term clinical outcomes. A zero CAC score has become the most definitive predictor of low risk, mild CAC score elevations are indicators for initiating optimal prevention strategies, and high CAC scores may indicate the need for more aggressive management and follow-up. Furthermore, the test has become inexpensive and, with current imaging technologies, is associated with radiation exposure that has decreased to 1.0 to 1.5 mSv per study and to even lower radiation exposure with the newer low-dose imaging protocols (34)." Average person receives about 3 mSv per year from natural sources. The annual dose for flight attendants is 1.5-1.7 mSv. Mammograms and CAC imaging is similar and less than what flight attendants get in a year.