Part one
Treatment of new positive CAC in Topeka vs Dallas
The other disturbing part of John’s CAC report is that all the calcium is at one spot in the left main stem. Should John have had an angiogram and a stent as President Bush did in Dallas?
My 62 yo friend,John visited me from NYC.
He has Cadillac medical insurance from his Union
but unlike President Bush he does not get an Executive Check Up each year.
Like the President, John is asymptomatic.
Unlike the President, John is 50 pounds overweight with type ll Diabetes
and only walks a mile a day.
They both take statins?
“Although the team of specialists at the National Naval Center in Bethesda, Md., declared President George W. Bush “fit for duty” after his annual physical exam on Saturday, they still recommended that he take a daily aspirin and a statin to help prevent heart disease.”
My note: below 2 years later it is reported he is only on vitamins despite a POSITIVE CAC as noted in item six below.
“During his (President Bush) second year in office during a yearly physical at Bethesda his physician did a routine coronary calcium level which was 4 (trivial).
I wonder if Dr Dayspring would still think a positive CAC score is trivial?
Even though his LDL-C was fine (approx 100 mg/dL superb by 2001 standards) they started him on a statin and as one would suspect, a low fat diet”
My note: Despite Dr Dayspring’s note above in Aug 2013, the hx. below states he was not on statin in Aug 2006.
President Bush's medical history Aug 2006
“There is no past medical history of hypertension, diabetes, tuberculosis, sexually transmitted disease, or stroke.
The President benefits from a "low" to "very low" (favorable) coronary artery disease risk profile with
1-favorable family medical history,
2-absence of modifiable risk factors;
3-superior fitness,
4-favorable CAD markers (e.g. CRP, lipids) and
5- functional studies ("stress echocardiogram"), and
6-"minimal/mild" coronary artery calcification noted on anatomic study (coronary artery computed tomography, 2004).”
“Cardiology: Physical examination of the circulatory system was normal. The resting EKG revealed sinus bradycardia consistent with previous exams and aerobic conditioning.
Fasting lipid panel:
(I calculate non-HDLc at 174-60= 114.
I think this is high and the President should have had apoB or LDLc.
Remants: 174 -60=114 then minus 101= 13 Very good. )
total cholesterol: 174 (last year 178; “desirable”<200 span="">
HDL: 60 (last year 56; and 40);
LDL: 101 (last year 100; “optimal”<100 desirable="" nbsp="" near="" optimal="" span="">
total cholesterol/HDL ratio 2.9 (last year 3.2);
Triglycerides: 61 (last year 71; <150 nbsp="" span="">
hsCRP: 0.029 (range 0.0-0.5).
Homocysteine: 11.5 (range 7.6-20.8). Ankle-brachial index 1.27 (r), 1.25 (l) (normal 0.96 or greater).
The President underwent Balke protocol exercise treadmill testing (ETT) with echocardiogram. He exercised for a total of 26:02 minutes achieving a maximum heart rate of 179 bpm with a 1-minute recovery of 148 bpm (31 beat differential). No signs or symptoms of cardiovascular pathology were noted. Stress echocardiogram was normal. Screening ultrasound of the abdominal aorta was normal.”
Okay, enough with President Bush, what about my friend John?
John’s older brother died at 56 yo of sudden coronary death at his dinner table.
The brother had no known heart disease or symptoms before his death. He did manual labor without difficulty.
About 15 years ago, John had an abnormal nuclear stress test. He then underwent an angiogram that was ultimately normal however he went into ventricular fibrillation became unconscious and had to defibrillated back to life while on the table for his angio.
John’s lab in Aug 2013
Total Cholesterol 137
Triglycerides 139
HDL-C direct 49
Non-HDL cholesterol 88
Chol /HDL ratio 1.22 (should be less than 3.56)
LDL-C 60
VLDL calculated 28
Hgb A1c 8.7
John’s medications:
Atorvastatin 10 mg
Wax matrix Niacin 1,000 mg OTC Endur-acin
Diabetes medications but no insulin
Lisinopril low dose
Aspirin low dose
Lovaza 1,000 mg a day
John did not go to the Cooper Clinic in Dallas, he came to Topeka, Kansas and received the Tubby Theory Approach.
Five years ago I had him get a CAC which was zero and a Liposcience panel which he says showed an LDL-P of 750?
On Tues he had a CIMT with a 0.08 mm thickness which is greater than 75% of other males age 62. Cost $100.
On Thurs. he had a repeat CAC of 45, all of it at the left main stem. Cost $50.
We are waiting for John’s liposcience report.
However what do we know now we did not know before?
We know John has the disease of atherosclerosis. (CAC 45, CIMT 0.08 mm) PRICELESS INFORMATION.
How does that change John’s treatment?
John’s triglycerides are around 135. The lab says that is normal but I am telling him it should be less than 100.
Thus John should increase his Lovaza (fish oil) from one tablet a day to four tablets a day.
If John’s LDL-P is greater than 1,000, then he has discordance with his LDL-C and he needs to double his atorvastatin to 20 mg.
When John gets home he needs additional testing:
1- Lp a
2- CRPhs
3- Lp-PLA2
The puzzle is that he went from CAC of zero to 45 in five years. Why did that happen if his LDL-C has been less than 70. His last non HDL-C was 88 which is excellent while his LDL-C was 60. (This might suggest discordance as I would not lower the LDL-C but I might increase his statin to get non-HDL-C to less than 80.)
The possible answer to the puzzle:
1-DM and central obesity (Rx with weight loss, Atkins)
2-High triglycerides (Rx with Fish oil and Atkins)
3-Inflammation (Rx with more fish oil, exercise and weight loss)
4- Elevated Lp a (get LDL-P less than 750 with statin and zetia)
5- Discordance with LDL-C, with LDL-P greater than 1,000 (wait for this weeks result)
Since his present good treatment has failed to prevent atherosclerosis and since any plaque is prone to rupture especially with his brothers history of sudden death at 57 yo, he needs more aggressive treatment as outlined above and then to determine if that Rx is working he needs to follow his progress with:
1- Liposcience lipid panel at least every 4 months (apo B with Berkley lab or Boston Heart Lab is acceptable) apo B should be less than 60.
2- Get CIMT every two years to see if there is progression or hopefully regression of atheroma.
Low fat diet is definitely not the answer.
Losing weight in short term will help no matter how he does it but maintaining weight almost impossible if he doesn’t continue low calorie diet for rest of life.
To my mind, a diabetic with central obesity should be on Atkins diet. He doesn’t have to be hungry, he just has to deprive himself of carbohydrates. Atkins is still restrictive but the best of choices for the long run.
  | |||
In addition his HDL-C is "normal" in the 40's. That again is a test that is not as significant as HDL-P in liposcience NMR lipopanel. “HDL” in general is still a puzzle in the science of lipidology.
The other disturbing part of John’s CAC report is that all the calcium is at one spot in the left main stem. 15 years ago he had a abnormal nuclear stress test which led to an angiogram. He had a normal "lumenogram" but he went into ventricular fibrillation on the table and had to be paddled(electric shock) back to life.
John has no symptoms now but his brother may not have had any symptoms before his sudden death. If the atheroma in John’s left main stem coronary artery were to rupture, he might have no warnings before hand. 50% of sudden coronary death has death as the first sign of the disease.
Scary situation. Thus someone may want John to get further testing as President Bush did. The Courage and Bari ll trials show Left Main Stem disease does better with bypass than medicine or stents. But disease without symptoms, should be treated with aggressive medicine, not invasive procedures.
I think four tablets of lovaza and making certain John’s LDL-P is less than 750 by increasing statin (and adding zetia if necessary)and getting particle number count blood test every three to four months is an aggressive medical approach better than getting an angiogram and a stent or bypass. However if John ever has symptoms then of course do the angiogram.
Thus start the 4 lovaza right away.
Go on atkins.
Walk 10 minutes after each meal.
Check Liposcience again in two months to see how John responds to the 60% fat diet.
If LDL-P greater than 750 double the atorvastatin.
If the Lp (a) is high then double the atorvastin.
If inflammatory markers are high get serious about Atkins and slowly increase walking to one hour a day.
Get a CIMT again in two years.
If President Bush had come to Topeka instead of Dallas his testing and treatment would have been different and cheaper and his treatment much cheaper. Atorvastatin and Wax Matrix Niacin costs $100 a year. Statin and Niacin much safer that Plavix which is often given with the stent.
As with John if President Bush ever had symptoms he could always then get an angiogram.
This is part two of President on Statins
If someone knows he was taking statins in 2012, it would be nice to be know. I write this blog to the health reporters to show that this is an important fact that they need to ascertain.
My friend responded with this:
"Brian: I have no idea what Bush was on after he left office -- Whatever he was on since he was asymptomatic he certainly did not need a stress test, CT-angiogram, coronary angiogram or a stent"
My viewpoint:
If in 2006 President Bush's doctors did take him off statin when they knew he had a positive CAC of 4 (which I believe elevates him from low CV risk to Intermediate CV risk),
how do they know when to put him back on a statin and to what goal?
The answer is obvious, they use stress testing.
Apparently the stress test last year was normal so his Doctors missed the opportunity to get President Bush back on statins.
A follow-up CAC without contrast might have been enough. CAC only costs $100 while a Angio CAC is much more expensive and more radiation.
I have not seen a LDL-C result of less than 100 for President Bush. Traditional teaching says atheroma build up continues with LDL-C greater than 100. In fact I don’t know what his LDL-C in Aug 2013 was? To not use the metric LDL-P seems incredible from a major health center in Dallas. Again I hope reporters have access to this information.
As lipidologists we are not surprised that off a statin President Bush increased his CAC score from 4 in 2004 to an actual plaque that showed up on Angio CAC in 2013. Would be nice to know how high the CAC score went up to and did it happen off statins?
What is the best way to screen results of treatment?
Not with a exercise stress test. Especially with women.
Cardiologists don't hesitate to do nuclear stress tests periodically after a stent is put in.
(I don't think this expense of President Bush’s procedure has been discussed)
Repeat imaging with radiation exposure is a concern. Repeat CIMT has no radiation and if there is no thickening of the wall with treatment, there is a reassurance that the plaque is not building up.
No studies for this except in various trials looking for CIMT change with drugs. Use of CIMT with Drug trials.
However, instead of a nuclear stress test, I sure wish asymptomatic Tim Russert had had less radiation with a repeat CAC (10 yr before his death Mr. Russert had CAC of 200) rather than a false negative nuclear stress test, a cheaper and safer repeat CAC might have shown a significant jump in calcium score that might then have driven Mr Russert to get a particle count.
Of course he probably would have gone for an angio which is what happened to President Bush. We believe more is always better in medicine. Just kidding.
CAC and CIMT are not perfect but they are cheap and safe. Of course because no one makes money on them, they are the red-headed step child of medicine.
Instead Cardiologists jump to Nuclear stress tests, Echocardiograms and Angio CAC or Angiograms.
All of them very expensive and much more radiation.
No one discusses Glagov Remodeling of Coronary Artery. Lumenograms or angiograms are often called normal when the lumen is only the tip of the iceberg in plaque formation. Picture of the coronary iceberg The large subclinical atheroma can rupture without prior symptoms in 50,000 to 100,000 people a year.
So back to John.
If I had not done a CAC and CIMT, no one would have done a Lp (a).
No one would get his Triglycerides under 100 by increasing Lovaza.
He may now be motivated to lose weight because his good present therapy that results in worse CAC of 45, failed.
We await his LDL-P next week but he remembers he had a good one.
I feel sad when President Bush's CAC 4 is minimized as insignificant. How can anyone say that if you don't know how much hidden atheroma he has? Get a CIMT to get some idea of what is going on at the wall level, then follow it every two to three years to determine efficacy of treatment.
John, had one lump of calcium at the Left Main Stem. Even with a low score of 45, the location should make us much more vigilant in his treatment and followup and CIMT is the cheapest and safest way to do that.
Jimmie Moore has a false sense of security because he has a CAC Zero.
The only way to break through his denial is for him to get a CIMT.
I have followed my CIMT over the years with good results despite being on 60% fat. Here are my results
I wish Jimmie had done the same with serial CIMT's.
Jimmie says he wants a CIMT. I told him don't go to Dallas, come to Topeka.
No comments:
Post a Comment