My approach is to
Subsequently most people would not treat this patient with statins.
The estimated 10-year risk of a CHD event for a person with this risk factor profile including coronary calcium is 3.9%. The estimated 10-year risk of a CHD event for a person with this risk factor profile if we did not factor in their coronary calcium score would be 8.7%
Pooled co-hort calculator:
|Lifetime risk of atherosclerotic cardiovascular disease :||
(95% CI 62% to 73%)
|Lifetime risk for a 50-year-old with optimal risk factors :|
(95% CI 0% to 12%)
Discordance between particles numbers and non-HDLc is possible in a diabetic.
Treatment to Goals over Long term with Low dose Combination treatment:
1-Atorvastain 10 mg/d
2- Wax matrix niacin 1,000 mg/d
3- If still not to goal add one half ezetimibe a day
4- Still not to goal, now is time to go to maximum statin dose.
My philosophy is to avoid the maximum doses for lifelong treatments to avoid unforeseen side-effects and improve efficacy with multiple actions of multiple drugs at low doses.
LDLp 750 to 1,000
Non-HDL cholesterol 80 to 100
An option is to repeat CAC in 10 years or get CIMT now and serially.
It is generally accepted that lowering LDLp will initially raise CAC calcium score.
However, in 10 years a complex atheroma may develop which has a residual risk that a high dose statin cannot resolve while early treatment can prevent.
Thus the idea behind the multiplier effect is to prevent the plaque from growing to that complex state which carries a build-in residual risk (30%) that statins have not been able to treat.
Treating a 40 year old diabetic man with CAC 50 and his LDLp has been kept around 800.
However his CIMT shows his atheroma is getting thicker.
This is a good candidate to treat more aggressively and keep his:
LDLp below 750 always.
non-HDLc below 80 always.
Naturally, this is assuming his other risk factors are kept under control.