How to Proceed?

If you fall into the age groups that I discussed in my last blog, what should you do?  First, remember that this discussion is only about asymptomatic patients. Those that do not have a history of heart attack, stroke or do not suffer from claudication, which is pain in the legs on exertion. 

First and foremost, if you are smoking stop, and after you stop, stay stopped.  Believe me it is not so simple if you judge from what my patients tell me.  Cholesterol levels are not the whole answer.  There is no such thing as a normal cholesterol level.  Each patient’s level is a number and then an atherogenicity potential. Although these can be determined by particle testing and such, our knowledge remains incomplete and our methods crude.

What has been proposed is finding a simple and reliable method to identify which patients have evidence of atherosclerotic changes in their vessels and then try to prevent the furtherance of the disease process by medical i.e. lipid lowering treatment.  We have these methods available to us now and the article cited in my previous blog provides the background for these methods.  One is calcium scoring by electron beam imaging. 

It is fast, simple and accurate.  However, it provides individuals with a small dose of radiation (median 2.3 mSv).  If negative, it virtually excludes significant atherosclerosis and the chance of a cardiovascular event in 5-10 years is .6% at the greatest.

Another modality is carotid ultrasound which is done slightly differently than normal and looks at the intima- media and measures the thickness of it.  This measurement has been shown to correlate with the disease process.  It is not as predictive as calcium scoring but does not use radiation.  It is not clear whether both tests are additive.

Imaging in this manner and using the SHAPE guidelines, it is estimated that almost 50% of the patients screened would be in a higher class and eligible for lipid lowering therapy.  The cost of this screening varies, but some institutions offer it at around $150.

All of the information we have to date supports screening for all patients who have intermediate risk based on Framingham Risk Scores in addition to those patients with low HDLs.  It is very unlikely that a large randomized study will ever be done.  Who wants to be in the placebo group?  We just have to manage with common sense.

Is it true that lipid lowering therapy saves lives?  In my next blog I will explore that.

Tags: calcium scoring, Carotid Ultrasound, Framingham Risk Scores, SHAPE Guidelines
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