Patient Mentoring 01

A new patient said: “My friend told me that she read that cholesterol in the diet is not bad for you and she stopped taking her Lipitor. She persuaded me to stop taking my Lipitor two months ago. My father and brother, who are your patients, said to me that I should resume taking my statin and that is why I am consulting you."

This case is a 55 year old white female, a high school science teacher with family history of heart attack. Her father and older brother are my patients who had stents before they were my patients. She consulted me to find out if she needs to resume taking her statin which she was taking for three years. 

During her first visit, I ordered a Coronary Calcium Scan to get her calcium score. Just as mammography is for the breasts and colonoscopy is for the colon, coronary calcium scan is for the heart. But unlike the first two tests, coronary calcium scan is done only once in many cases and if the score is 0, a repeat scan in 5 years may be needed. 

Coronary calcium scan is best way to determine the presence or absence of atherosclerosis in the coronary arteries. It also quantifies the amount of plaques present. The calcium score can range from 0 to over 4,000. A calcium score of 0 signifies the lowest possible risk of heart attack, stroke and sudden cardiac death in the next 5 to 10 years. It is as close to 0 risk as one can get. If the calcium score is 0, many will not need to take statin but focus primarily on healthier diet, exercise and weight control, and the test is repeated after 5 years. If the score is 300 or higher, the risk of having a heart attack, stroke or sudden cardiac death within the next 10 years is high - over 20% or more than 1 in 5 chances. The higher the score, the greater the risk. I have many patients with scores over 1,000 and a few over 4,000, and they are successfully treated medically - not with stents, not heart bypass. Optimal medical therapy, which includes a statin, is needed to halt disease progression, prevent plaque rupture and even induce disease regression.   

Unfortunately her calcium score is not 0 but 522. She has plaques in all her coronary arteries.

Like most people, she did not understand the difference between cholesterol and LDL-cholesterol. Cholesterol is essential for life and every cell in our body can synthesize all the cholesterol it needs. This is not the same as the cholesterol measured in the blood which is inside LDL particles. Cholesterol and triglycerides are fats in the blood and are manufactured mostly by the liver. Because they are fats, the liver can not secrete them directly into the blood. They need a carrier to carry them in the form of VLDL particles. VLDL is eventually degraded to LDL particles. Both are carriers of cholesterol. 

When we test for LDL cholesterol in the blood, we are quantifying the amount of cholesterol carried by the LDL particles. The higher the blood cholesterol, the more LDL particles are present but until recently, we can't easily determine the number of LDL particles present in the blood, so LDL cholesterol level measurement is a cheap and readily available surrogate for LDL particles. Why is this an important distinction? It is the LDL particle that causes atherosclerosis, not the cholesterol that it carries. But for practical purposes, measuring the LDL cholesterol level is a good enough indicator of the LDL particle number. 

Every year, more women than men die from heart attack. The likelihood of a women dying from heart disease is 14 times greater than breast cancer. While women are concerned about breast cancer, they are less so with heart attack. While heart attack is preventable, breast cancer is not.

Her medical treatment includes a statin and the goal is to prevent heart attack, stroke, sudden cardiac death and reduce the future need for stents and heart bypass surgery. Lowering LDL cholesterol to less than 70 mg/dL stabilizes her plaques, prevents plaque rupture and induces plaque regression.

She had a choice - without optimal therapy, all her plaques will progress. She chose plaque regression, not progression. 

Most patients are not given that choice - because they don’t know they have many plaques in their coronary arteries or they don’t know there is choice other than wait until they have a  heart attack, stroke, need a stent or heart bypass or they are not offered medical treatment or they are misinformed.

Is a healthy diet still important? Only 5% to 10% of cholesterol in the blood comes from what we eat and from the bile, the rest is manufactured by the liver. Eliminate trans fat, moderation in the rest. Yes, a healthy diet, keeping physically active and controlling weight are still important.

If someone has high coronary calcium score, without optimal medical therapy, these are the other random choices. 

During the first 20 years of my practice, I saw too many of these but nothing more could be done at that time. That all changed by 2001. Medical science had progressed to the point that we can prevent most of them. So for the next 20 years, that is what we did. What used to be common occurrences became rare events. A large cardiovascular healthcare industry has grown and prospered by catering to what are now largely preventable events - they want the revenue stream to continue. A major problem in healthcare.

Watch an award-winning Netflix documentary - The Widowmaker.

© Rolando L. deGoma MD  2019     www.deGomaMD.com     Capital Cardiology Associates     Princeton Physicians' Organization