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The Skeptical Cardiologist's avatar

I've noticed that there are many comments on my post which take the viewpoint that either

1) LDL/apo B is not important in the development of ASCVD

2) Statins don't reduce the risk of ASCVD

Clearly, if you believe these 2 points, there is no point in doing CAC

When I became the skeptical cardiologist in 2013 I systematically challenged all that I had been taught about ASCVD. At that time, the hypothesis that lowering LDL would invariably lead to reduced ASCVD in my mind was not fully established. Since then it has been. Basic scientific investigation, prospective longitudinal cohorts, mendelian randomization and randomized clinical trials have all established that apo B is the particle that triggers atherosclerosis and that drugs that lower apo B reduce or eliminate atherosclerotic plaque formation and its consequences including heart attack and stroke.

As Peter Toth has as written recently (https://www.sciencedirect.com/science/article/pii/S2666667722000551)

"despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs"

We have the ability to eliminate ASCVD, the biggest killer of humans in the world.

CAC is how we identify subclinical atherosclerosis.

We now have multiple very safe and effective medications beyond statins that lower apo B/LDL and reduce the devastation of ASCVD.

The only serious scientific question at this point is how aggressive to be without pharmacologic treatment in the individual sitting in front of us in the office

Dr P

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Steve roedde's avatar

Interesting perspective. Except for the part about “lack of RCT’s”! This retired EBM teacher and medical generalist has heard this argument about every single screening test in existence. The CAC score is indeed a “screening test”. Regardless of baseline risk, it is attempting to “find” a disease in patient who may or may lt have it. The results do change probabilities, it does not make the diagnosis! It is not a credible gold standard, merely another thing to plug into risk calculations. The results trigger another therapeutic and investigational cascade that have their own risks and benefits.

One can “believe” it changes meaningful outcomes, and that the harms are trivial. The same occurred with every other medical intervention… where RCT’s demonstrated reality. In many cases it was only the RCT data that allowed physicians to communicate risks and benefits to patients … so that THEY could decide what to do with their lives. That is true “personalized medicine”.

This 70 year old retired doc, with 12% body fat, lifelong endurance exercise, parents and well into their 90’s, BP of 90/60 and strikingly high LDL and non-reassuring Apo B, will give this a miss! It’s my one precious life, and only data from RCT’s will allow me to decide what to do.

I remain dismayed how we keep making the same errors over and over again.

That said, heterodox viewpoints are critical, and this was important reading. We must all leave our opinion silos, and you both demonstrate how it is done.

Thank you both.

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