More On Calcium Scores

My last blog concerned the use of calcium scores to determine whether a patient did or did not have coronary artery disease.  An article has been published that I would like to share with you because it compares the Framingham risk calculator and the use of calcium scoring to determine which is better in defining patient illness.

This article titled “The detection of any coronary calcium outperforms Framingham risk score as a first step in screening for coronary atherosclerosis” was published in the Am J Roentgenol 2010: 194:1235-1243.  The study details that 1416 men and 707 women were included.  The mean age of the men equaled 51.4 years, and the mean age of the women equaled 56.9 years.

In those patients who had a presence of a segment plague score of 4 or higher, any calcium was 98% sensitive in men and 97% sensitive in women.  In the same population if you had a Framingham risk score of 10% or higher, it correlated with the findings only 74% of the time in men and 36% of the time in women.

If your plague segment score was 3 or higher, the presence of calcium was 97% sensitive in men and 92% sensitive in women.  In contrast, the Framingham score of 10% or greater was found in 88% of men and 35% in women.

This is not really surprising as I explained before that the presence of any calcium infers that the patient has the illness and needs to be treated.  It does not mean that they have symptomatic disease but the data can be used to propel the patient to “make the right decision” and stop smoking, control their blood pressure and take statins.  In much the same way the Framingham calculator does that because you input the blood pressure, the smoking status and the LDL level as some of the information to achieve a score.  By “manipulating” the data, one can point out that lowering numbers or stopping smoking reduces risk considerably.

Why the disparity in women and men scores is so great, I do not know.  It is widely understood that the diagnosis of coronary disease in women lags behind men, although equal numbers of men and women die each year.  Perhaps women should have scoring and men the Framingham test and then the numbers would be more reflective of need. 

Technology may help us lead the way to better patient care in both men and women.

Tags: blood pressure, calcium scoring, coronary atherosclerosis, Framingham Risk Calculator
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Novel Future Treatments for Cholesterol

There are other novel and promising agents, which are being tested for the treatment of elevated cholesterol.  One of the challenges I face on a weekly basis is that of patients who have coronary atherosclerosis and are on the maximum dose of statin and still have serious elevations of LDL cholesterol.  We have no good treatment options at this time.  These individuals try even strict diets to no avail.  Many have a genetic condition referred to as heterozygous familial hypercholesterolemia which produces exceptionally high levels of LDL cholesterol.

One novel agent almost finished with testing is Mipomersen.  This is a compound in development by Genzyme.  Genzyme purchased the drug from ISIS Pharmaceuticals for $325 million and will pay a further $825 million if the annual revenue tops $5 billion in two consecutive years.  To put that in perspective Lipitor had revenue of $16 billion last year and Plavix provides $11 billion in revenue to Bristol-Myers and Sanofi combined.

This compound is an antisense therapeutic agent.  It is administered as a weekly injection and concentrates in the liver where the action occurs.  It competes with the patient’s native compound and fools the messenger RNA which then decreases the production of apolipoprotein B thereby decreasing the level of LDL cholesterol.

Several studies have been performed and the pivotal trials are done.  It is expecting approval late this year.  It has been tested alone and in combination with statins and has been shown to be safe and effective.  It is not clear whether the FDA will require clinical efficacy testing before release or after.

If effective this would become a useful compound in those patients who have not achieved goal with statins and in those patients who cannot take statins at all because of side effects.  Novel treatments like this and ApoA-1 Milano may become the treatment of atherosclerosis in this decade.

Tags: Cholesterol, coronary atherosclerosis
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