What role cholesterol medication?

10. April 2006 William Davis (0)
A frequent conversation point among my patients, as well as participants in the www.cureality.com program, is "Are cholesterol medications really necessary?"

No, they are not. What IS necessary is to correct all manifest and hidden causes of coronary plaque. Among these causes, in my view, is LDL cholesterol of 60 mg/dl or greater. There are many other causes of coronary plaque--e.g., small LDL particles, unrecognized hypertension, Lp(a), hidden diabetic patterns, etc.--but reducing LDL to 60 mg is still an important part of a plaque-reversing effort.

Insofar as we wish to get LDL to this goal, the statin cholesterol drugs like Lipitor, Zocor, Crestor, etc. may play a role. However, they should only be considered after a full effort dietary program is pursued. Don't follow the American Heart Association's diet unless you want to fail. It's nonsense.

For a more detailed discussion of how to use nutrition and nutritional supplements to reduce LDL cholesterol, go to www.lef.org, the website for the Life Extension Foundation. I wrote an article for their magazine called "Cholesterol and Statin Drugs: Separating Hype from Reality". You'll find the article at http://search.lef.org/cgi-src-bin/MsmGo.exe?grab_id=0&page_id=1295&query=davis%20cholesterol%20natural&hiword=CHOLESTEROLA%20CHOLESTEROLS%20DAVI%20DAVID%20DAVIE%20DAVIES%20DAVIN%20DAVIO%20DAVISON%20DAVISS%20DAVIT%20NATURALBASED%20NATURALES%20NATURALIZED%20NATURALLY%20NATURALS%20NATURE%20NATURES%20cholesterol%20davis%20natural%20.)

Can your plaque-reversal efforts succeed without statin drugs? It depends on your causes. For instance, someone with small LDL and Lp(a) only may do great on our basic program and then add niacin. Unfortunately, another person with a starting LDL cholesterol of 240 mg/dl--sky high--will have more success with these drugs.

Believe me, I am no blind supporter of drug companies and their flagrantly profit-seeking practices which, in my view, are cut-throat, shoving anyone and anything out of their way to increase profits and market share. I share many of Dr. Dave Warnarowski's views on how vicious their tactics can be; see his recent Blog post at http://www.drdavesbest.com/blog/ called "I smell a rat".

Nonetheless, the deep and well-funded research of the pharmaceutical industry does yield some useful tools. You don't have to love the insect exterminator, but if your house is being eaten by termites, his services can be useful. Same thing with these drugs. Useful--not the complete answer, not even close, but nonetheless useful in the right situations. Sometimes antibiotics are necessary, even life saving. That's how cholesterol drugs are, too.

Take it all in the proper perspective. Your goal is not cholesterol reduction, per se, but plaque control, preferably reversal.

Supplement Mania!

9. April 2006 William Davis (3)
Ever hear of "polypharmacy"? That's when someone takes too many medicines. People will have lists of 15-20 prescription medicines, for instance, with crazy interactions and oodles of side-effects.

Well, how about "poly-supplments"? That's when someone takes a large number of nutritional supplements.

Let me tell you about a 45 year old man I met.

In an effort to rid himself of risk for heart disease that he felt was likely shared with his family (brother and father diagnosed with heart attacks in their late 40s), Steve followed a program of nutritional supplementation. You name it, he took it: hawthorne, anti-oxidant mixtures, vitamins C, E, B-complex, saw palmetto, 7-keto DHEA, velvet deer antler, gingko biloba, policosanol, chronium picolinate, green tea, pine bark extract, St. John's Wort, CoEnzyme Q10, papain and other digestive enzymes...He became a distributor for a nutritional supplement company to allow him to afford his own extraordinary program.

To satisfy himself that he had indeed "cured" himself of heart disease, he got himself a CT heart scan. His score: 470, in th 99th percentile. Steve's heart attack risk based on this score was around 10% per year. High risk, no question.

For weeks after his scan, Steve admitted walking around in a daze, not knowing what to do. Years of telling himself that he had effectively dealt with his heart disease risk, now all down the drain.

When we met, I persuaded him that to think that this collection of supplements would reverse heart disease was magical thinking. We trimmed his list down to the essentials and got him on the right track.

Heart disease is controllable and reversible, but not this way. Don't fool yourself into thinking that some collection of supplements will be enough to stamp out your heart disease risk. Just like taking an antibiotic when you don't have an infection achieves nothing, so does taking the wrong supplements.

What does heart scanning mean to you?

8. April 2006 William Davis (0)
CT heart scans can mean different things to different people.


What does a heart scan mean to you? There are several possibilities:

1) A way of reducing uncertainty in your future.

2) A tool to crystallize your commitment to health.

3) A device to help you track how successful your heart disease prevention program is.

4) A trick to get you in the hospital.

5) A moneymaking tool for unscrupulous physicians hoping to profit from "downstream" testing, particularly heart catheterizations.


Like anything, heart scans can be used for both good and evil. How can you be sure that your heart scan is put to proper use--for your benefit and not someone else's profit?

Simple: Get educated. Understand the issues, be armed with informed questions.

If, for instance, you're a 55-year old female with a heart scan score of 90, active without symptoms, and you're told to have a heart catheterization right off the bat---run the other way. This is bad advice. A heart procedure like catheterization at this score in an asymptomatic woman is very rarely necessary. That decision can only be made after a step-by-step series of decisions are made by a truly interested, unbiased party. (A stress test is almost always required in this situation before the decision can be made to proceed with a catheterization.)

Unfortunately, in 2006, getting unbiased advice from your doctor is still a struggle. That's why we started Track Your Plaque---unbiased information, uncolored by drug or device company support, with an interest in the truth.

Coronary disease is drying up!

7. April 2006 William Davis (1)
I had an interesting conversation with a device representative this morning. He was a sales representative for a major medical manufacturer of stents, defibrillators, and other such devices for heart disease.

Since I'm still involved with hospital heart care and cardiac catheterization laboratories, this representative asked me if I was interested in getting involved with some of the new cardiac devices making it to market over the next year or two. "The coronary market is drying up, what with coated stents and such. We've got to find new profit sources."

Well, doesn't that sum it up? If you haven't already had this epiphany, here it is:

HEART DISEASE IS A PROFITABLE BUSINESS!

Why else can hospitals afford billboards, $10 million dollar annual ad campaigns, etc.? They do it for PROFIT. Likewise, device and drug manufacturers see the tremendous profit in heart disease.

The representative's comments about the market "drying up" simply means that the use of coated stents has cut back on the need for repeat procedures. It does NOT mean that coronary disease is on the way out. On the contrary, for the people and institutions who stand to profit from heart care, there's lots of opportunity.

Track Your Plaque is trying to battle this trend. Heart disease should NOT be profitable. For the vast majority of us, it is a preventable process, much like house fires and dental cavities.

Mammogram for your heart

6. April 2006 William Davis (0)
With the booming popularity of "64-slice CT scans", there's a lot of mis-information about what these tests provide.

These tests are essentially heart scans with added x-ray dye injected to see the insides of the arteries. However, to accomplish this, a large quantity of radiation is required. In addition, the test is not quantitative, that is, it is not a precise measure that can be repeated year after year.

It is okay to have a 64-slice CT coronary angiogram. It is NOT okay to have one every year. That's too much radiation. However, a heart scan can be repeated every year, if necessary, to track progression or regression. Once stabilization (zero change) or reduction is achieved, then you're done (unless your life takes a major change, like a 20 lb weight gain).

The tried-and-true CT heart scan is the gold standard--easy, inexpensive, precise, and repeatable. Not true for 64-slice angiograms.

Is your doctor using "leeches"?

4. April 2006 William Davis (0)
What if you went to your doctor for a problem and he/she promptly placed leeches on your body?

Yeccchhhh! Would you go back? I'd bet that you'd run the other way as fast as your bleeding legs could take you. Outdated health practices like "bleeding" are outdated for good reason.

Then why would you allow your doctor to approach your heart disease prevention program by checking cholesterol and then waiting for symptoms to appear? That miserable approach leads to tragedy and death all too often--ask Bill Clinton! He might as well have had leeches!

Don't allow your doctor's ignorance or disinterest impede your prevention program. Get your coronary plaque measured, then attack it from all sides by knowing all causes, hidden and obvious. That's why Track Your Plaque is such an effective program.

I often wonder why more doctors aren't using this unbelievably powerful approach to deal with heart disease. But when I see colleagues implanting stents, defibrillators, and the like for many thousands of dollars per patient, the answers are obvious. Given a choice of a rational, effective program of prevention that pays the doctor a few hundred dollars for his time, versus $2000 to $10,000 for a procedure, you can see that the temptation is irresistible for many physicians.

All in the family--What to do if there's heart disease in your family

3. April 2006 William Davis (0)
What should you do if a close relative of yours is diagnosed with coronary disease?
This question came up recently with a patient of mine. The patient--a strapping, 47 year old businessman who looked the absolute picture of health--was undergoing bypass surgery. Although I'd met him for the purposes of plaque reversal, he was already having symptoms and his stress test was flagrantly abnormal, all discovered after a heart scan score of 765. On the day after the patient's bypass, the patient's brother came to me. Understandably concerned about his own health, he asked what he should do. The answer: get a heart scan.
Measure the disease with the easiest test available. If his heart scan score is zero, great--he's at exceptionally low (near zero) risk for heart attack. A modest program of long-term prevention is all that's necessary. What if his score is like his brother, should he get in line for his bypass? No, absolutely not! But he will need two things: 1) a stress test to ascertain whether or not he's safe (60% likelihood a stress test would be normal), and 2) an effort to determine how the heck he got so much plaque. (We favor lipoprotein testing, of course, for greatest diagnostic certainty.)
Message: Learn from the lessons your own family provides. Don't let this valuable information go to waste.
"Heart scans are experimental"

"Heart scans are experimental"

18. December 2007 William Davis (25)
Let me warn you: This is a rant.

It is prompted by a 44-year old woman. She has a very serious lipoprotein disorder. Her family experiences heart attacks in their 40s and 50s. I asked for a heart scan. Her insurance companied denied it.

This is nothing new: heart scans, like mammograms, have not enjoyed reimbursement from most insurers despite the wealth of data and growing acceptance of this "mammogram" of the heart.

However, 10 minutes on the phone, and the "physician" (what well-meaning physician can do this kind of work for an insurance company is beyond me) advised me that, while CT heart scans for coronary calcium scoring are not covered, CT coronary angiograms are.

Now, I've been witnessing this trend ever since the big players in CT got involved in the game, namely Philips, Siemens, Toshiba, and GE. These are enormous companies with hundreds of billions of dollars in combined annual revenues. They, along with the lobbying power of cardiology organizations like the American College of Cardiology, have gotten behind CT coronary angiograms. This is most likely the explanation of why CT coronary angiograms have rather handily obtaining insurance reimbursement. Interestingly, the insurance company I was speaking to is known (notorious?) for very poor reimbursement practices.

A CT heart scan, when properly used, generates little revenue, a few hundred dollars to a scan center, barely enough to pay for a device that costs up to $2 million. However, CT coronary angiograms, in contrast, yield around $2000 per test. More importantly, they yield downstream revenues, since CT angiograms are performed as preludes to conventional heart catheterizations, angioplasty, stents, bypass surgery, etc. Now we're talking tens or hundreds of thousands of dollars revenue per test.

What puzzles me is that much of that increased cost comes out of the insurance company. Why would they support such tests if it exposes them to more costs? I'm not certain. It could be the greater pressures exerted by the big CT companies and powerful physician organizations. I seriously doubt that the insurance companies truly believe that heart scans for coronary calcium scoring are "experimental" while CT coronary angiograms are "proven." If all we did was compare the number of clinical studies that validate both tests, we'd find that the number of studies validating heart scans eclipses that of coronary angiograms several fold. Experimental? Hardly.

The smell of money by physicians eager to jump on the bandwagon of a new revenue-producing procedure is probably enough to have them lobby insurers successfully. In contrast, plain old heart scans just never garnered the kind of vigorous and vocal support, since nobody gets rich off of them.

If CT coronary angiograms are sufficiently revenue producing that my colleagues and the CT scanner manufacturers have managed to successfully lobby the health insurers, even one as financially "tight" as the one I spoke to today, well then I take that as testimony that money drives testing, as it does the behavior of hospitals, many of my colleagues, and can even force the hand of insurers.
Tags :

Comments (25) -

  • Cindy Moore

    12/19/2007 12:51:00 AM |

    It seems like everything medical is profit driven!!  One of my biggest irritants with insurance companies is the unwillingness to act pro-actively and approve preventative procedures, treatments, etc.

    They spend a fortune each year on statins, but won't cover heart scans. They spend millions on coronary bypass, PTCA, etc but they won't pay for inpatient smoking cessation programs, and many still have no coverage for lifestyle change programs!!

  • Peter

    12/19/2007 6:14:00 AM |

    Nice post this one. Just keep telling yourself; there is no conspiracy. The depth of complexity generated by billions of often quite small acts of personal greed, when combined together, does behave like a coherent plan. Eventually there may be studies looking at this as a phenomenon in its own right. The further out of the mainstream that you live, the more interesting it becomes to consider the hows and whys. No conspiracy, just human greed. Some small quanta of greed, some enormous. You even get personal greed combined with the will to do general good. Very complex.

    Peter

  • Anonymous

    12/19/2007 9:35:00 AM |

    Years ago, my baby was in NICU with a condition that seriously affected his immune system; the drs wanted him on breast milk to help boost the immune system, and since I wasn't always at the hospital anymore (I had returned to work by then), the drs wrote an order for a breast pump.

    Since I worked in that field, I asked the lactation specialist for a catalog of pumps from the same company the insurance company used, and found out the pump I *wanted* cost $300, but the pump the insurance comp wanted me to have cost $1000. I asked the lacto nurse about the pumps, and the cheaper one (shaped like a large purse with a shoulder strap) worked just as good as the more expensive pump (a boxy machine attached to a wheeled pole, like a short IV pole) was better if there were going to be many women pumping.

    Since it was just going to be me pumping, and the cheaper pump was so much easier to transport to work, I asked the insurance company if I could have the $300 version. They denied it, and I had to contest it with my lacto-specialist coworker's written letter that the cheaper one would work just as well.

    The insurance company's nurse told me she was glad I contested it with a letter from a lacto-specialist, because now the company would save money on pumps.

    WOW! It took somebody that had experience in that field with access to a specialist just to get an insurance company to change to a much cheaper, but just-as-effective, medical device. So your story doesn't surprise me at all. Insurance companies are either getting kickbacks, have too many layers of bureaucracy to approve anything different, or might just be dumb sometimes.

    S

  • Anonymous

    12/19/2007 12:43:00 PM |

    How did we get to this point that revenue generation overrides the care of patients?  Can we blame Hollywood for creating a myth of the health care provider that knows it all and worries endlessly over the health of patients, government and insurance companies not giving enough oversight over hospital practices, and/or patients not questioning enough the motives of health care providers?  What ever the answer, I imagine future generations will read about these times and cringe over the health care practices of today.

  • keith

    12/19/2007 1:21:00 PM |

    I asked my cardiologist to order a scan for me in a big boston hospital. My insurance wouldn't cover it until enough "risk factors" were documented on the claim form. The test was $270, money very well spent.

    What is sad is that most people believe patients' health is the medical community's primary concern. Also, interestingly, those with marginal insurance are forced to advocate for themselves and as such can, perversely, end up with better care.

    keith

  • Dr. Davis

    12/19/2007 1:24:00 PM |

    I truly get the sense that there are factors present that we are not privy to: behind-the-scenes maneuvering, closed-door politics, etc. It's surely not always in a health insurer's best interests to follow the policies often in place. So we can only conclude that something fishy is going on.

  • Dr. Davis

    12/19/2007 1:25:00 PM |

    You could be right.

    An inadvertent, collective evil?

  • Dr. Davis

    12/19/2007 1:37:00 PM |

    Yes, Keith. You make a crucial point.

    Caveat emptor, whether it's in the doctor's office, hospital, or used car lot. Watch your wallet and recognize that they all share one thing: they are profit-seeking operations with your welfare second.

  • Thomas

    12/19/2007 3:05:00 PM |

    This is NOT a defense of insurance cos, just an attempt to explain their possible thinking. One reason for an objection to CT heart scans is because there could be potentially very many ordered, relative to CT/angiograms. It is like a pyramid, with a much greater number of lower cost procedures resulting in a higher amount of claims submitted, and higher overall cost experience. So, they say no.

    I don't think insurance cos. engage in collusion with equipment makers or doctors. They just use a logic that isn't necessarily in my or your best interests.

  • Mike

    12/19/2007 3:36:00 PM |

    That is one reason that I am against mandatory medical insurance. The patient and doctor should decide what medical care is appropriate, not an insurance company.

  • Dr. Davis

    12/19/2007 4:55:00 PM |

    It may indeed be as simple as that. And, in fact, that is what I told many people who were frustrated by their insurer's failure to reimburse heart scans. However, more recently, I have begun to wonder if there is more to this question. I've just witnessed this phenomenon too often: When big money is involved, things happen. Heart scans do not make big money for anybody. CT angiograms provide potential for lots of big money.

  • Michael

    12/19/2007 7:54:00 PM |

    Out of curiosity, do insurance companies ever pay for heart scans, if they are considered high risk? That is, have had a heart attack, extremely high lipids, or some other heart disorder?

    The only rationale I can imagine for declining calcium scans, while paying for full CT scans, is what Thomas suggested -- it's a numbers game. Since generally speaking, only high risk people get CT scans, the numbers are relatively low. If everyone got calcium tests (although in the long run it'd pay off for them), insurance companies would have to pay a lot out of pocket now.

    But... if insurance companies paid for calcium scans for high risk people, it'd make sense both in the short and long term for them, I'd think. Then again, in my own experience, I find the behavior of my health insurance company bizarre. They'll gladly pay for physician visits/testing even when I tell them the doctor never actually did those things... yet decline certain tests I need just because less reliable (and cheaper) alternatives exist.

  • Thomas

    12/19/2007 11:52:00 PM |

    The evolution of the marketing and ins. coverage will be interesting to watch. For example, a hospital in the Chicago suburbs markets a 64 slice CT scan direct to the public for $99. No doctor referral needed. You can bet they figure stress tests and angios will follow. Nonetheless, you can get the scan about as cheap as possible.

    In my town far away, cardiologists won a turf war with radiologists to be the exclusive readers of these tests, and they aren't being marketed. And, the tests aren't on sale either. Local politics, and the ability to control patient flow, is probably the most important driver, but if you live in a large metro area, you may find what you're looking for at a decent cost.

  • Dr. Davis

    12/20/2007 4:54:00 AM |

    Some insurers do try and distinguish who is "high risk" or not, depending on conventional risk factors.

    Of course, the difficulty is that conventional risk factors fail to identify many people truly at high risk for heart disease and heart attack. In effect, health insurers have legislated who can or cannot obtain reimbursement for a heart scan.

  • MAC

    12/20/2007 8:11:00 AM |

    I have heard it expressed that insurance companies have no interest in preventative medicine. The benefits are too long term for them to see the results. People change jobs, change insurance carriers, etc.

  • Dr. Davis

    12/20/2007 12:37:00 PM |

    Yes, I believe that is true. From their perspective, better to pay lots for the occasional catastrophe rather than pay for the many more who would use preventive services. Insurance is not in our best interests, but of the collective financial good.

  • Anonymous

    12/20/2007 5:36:00 PM |

    Three years ago I had a stress test done due to chest pains and triglycerides as a risk factor.  I ended having an area of concern and my doctor wanted to do a CTA.  The insurance company approved it and I was all set up to go when I mentioned the test to my allergist.  She was concerned that I may have a reaction to the contrast dye, so the CTA was canceled and they sent me for a calcium score test.  The insurance company wouldn't pay the $195 for the test even though they were ready to pay a few thousand for the CTA!  Anyhow I came back with a big fat 0 for the test so the money was worth the piece of mind.

  • Dr. Davis

    12/21/2007 2:40:00 AM |

    What a great example of how useful cheap, simple heart scans can be. You also spared yourself over 90 chest x-rays of radiation.

  • g

    12/21/2007 4:26:00 AM |

    The latest Oprah mag Jan 2008 has this article about the first sign of heart disease/obstruction is 'fatigue' and reports that the MD may order a heart 'CT scan'... (this health writer is on TOP OF HER GAME -- unlike DR. Oz!!)

    Don't read the proposed 'treatment' -- the writer is not apparently informed on TYP yet!

    http://www.oprah.com/health/omag/health_omag_200801_fatigue_102.jhtml
    Most Often Overlooked Causes of Fatigue (2 or 4)

    Heart Trouble

    Fatigue is a distinct characteristic of cardiovascular disease in women, according to recent research. In one study of 515 female heart attack survivors, 70 percent reported unusual fatigue in the weeks before; just 57 percent had acute chest pain. In another study, fatigue was a symptom for women with dangerously clogged arteries that escaped notice on heart scans.

    Why it's overlooked: Only one in ten women realizes that heart disease is her biggest health threat. And emergency room doctors are six times more likely to give women with serious heart problems (as opposed to men) a clean bill of health.

    Other Symptoms: Shortness of breath. Indigestion. Pain in your shoulder, arm, or jaw. But for many women, nothing at all.

    Tests: Your doctor will order an exercise stress test or angiogram if she suspects clogged arteries in your heart. Because that test isn't always accurate in women, she may order a CT scan or echocardiogram as well. She'll also test your cholesterol, blood pressure, and blood sugar—diabetes can quadruple a woman's heart risk.

    Treatment: You may get a cholesterol-lowering statin and medicines to treat blood pressure, such as diuretics. You'll also be advised to follow a heart-healthy diet and get regular exercise.

    From Why Am I So Tired? in the January 2008 issue of O, The Oprah Magazine.

    THANK YOU! g

  • g

    12/22/2007 4:30:00 PM |

    FYI... Recent pubs -- 12/1/2007 and 12/15/2007 respectively

    Merry Xmas Dr. Davis! You have many buddies in more progressive countries! Regards, g

    (1) Non-invasive screening for coronary artery disease: calcium scoring
    Raimund Erbel1, Stefan Möhlenkamp1, Gert Kerkhoff2, Thomas Budde2, Axel Schmermund3
    http://heart.bmj.com/cgi/content/
    extract/93/12/1620

    Despite the decrease in overall mortality from coronary artery disease, the number of out-of-hospital deaths from myocardial infarction is in the range of 60% of all infarct related case fatalities.1 In patients with known risk of sudden cardiac death (SCD), such as survived resuscitation, left ventricular aneurysm or low left ventricular ejection fraction, the incidence of SCD is in the region of 30% per year. In the general population, it is only 0.5% per year.2 However, the absolute number in this group is 10 times higher than in the patient population with known SCD risk, reaching more than 300 000 case fatalities per year in the USA.2 Even renowned cardiologists such as Ronald W Campbellw1 and Jeffry M Isnerw2, who were experts on the topic of arrhythmias and myocardial infarction, suffered SCD. The MONICA (Monitoring trends and determinants in Cardiovascular disease) study reported that of all coronary . . . [Full text of this article]

    (2) Cardiac computed tomography: indications, applications, limitations, and training requirements

    Report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology
    http://eurheartj.oxfordjournals.org
    /cgi/content/abstract/ehm544v1

    As a consequence of improved technology, there is growing clinical interest in the use of multi-detector row computed tomography (MDCT) for non-invasive coronary angiography. Indeed, the accuracy of MDCT to detect or exclude coronary artery stenoses has been high in many published studies. This report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT (WG 5) of the European Society of Cardiology and the European Council of Nuclear Cardiology summarizes the present state of cardiac CT technology, as well as the currently available data concerning its accuracy and applicability in certain clinical situations. Besides coronary CT angiography, the use of CT for the assessment of cardiac morphology and function, evaluation of perfusion and viability, and analysis of heart valves is discussed. In addition, recommendations for clinical applications of cardiac CT imaging are given and limitations of the technique are described.

  • g

    12/22/2007 4:42:00 PM |

    Another FYI...  HOLY MOLY This is why the lame Framingham misses the entire picture --- failure to take into acct that 70-80% of the population are on the Metabolic spectrum is like trying to see thru gauze blindfolds. very holey... (I guess it's good I can't access TYP right now... I'm spending my time otherwise well spent *ha*).  I LOVE the first line...'Coronary artery calcification is pathognomonic of coronary atherosclerosis.'  Hope you and your familia have a great holiday season -- full of wishes fulfilled and hope re-ignited!  Thanks for letting me loose *ha ha* Take care, g

    http://content.onlinejacc.org/cgi/
    content/abstract/50/23/2218

    J Am Coll Cardiol, 2007; 50:2218-2225(Published online 14 November 2007).

    CLINICAL RESEARCH: CORONARY ARTERY DISEASE
    Determinants of Progression of Coronary Artery Calcification in Type 2 Diabetes
    Role of Glycemic Control and Inflammatory/Vascular Calcification Markers
    Dhakshinamurthy Vijay Anand, MBBS, MRCP*,,*, Eric Lim, MBChB, MA, MRCP*, Daniel Darko, MD, MRCP, Paul Bassett, MSc, David Hopkins, BSc, MBChB, FRCP||, David Lipkin, BSc, MD, FRCP*,¶, Roger Corder, PhD, MRPharmS and Avijit Lahiri, MBBS, MSc, MRCP, FACC, FESC*
    * Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom

    Objectives: This study prospectively evaluated the relationship between cardiovascular risk factors, selected biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, and osteoprotegerin [OPG]), and the progression of coronary artery calcification (CAC) in type 2 diabetic subjects.

    Background: Coronary artery calcification is pathognomonic of coronary atherosclerosis. Osteoprotegerin is a signaling molecule involved in bone remodeling that has been implicated in the regulation of vascular calcification and atherogenesis.

    Methods: Three hundred ninety-eight type 2 diabetic subjects without prior coronary disease or symptoms (age 52 ± 8 years, 61% male, glycated hemoglobin [HbA1c] 8 ± 1.5) were evaluated serially by CAC imaging (mean follow-up 2.5 ± 0.4 years). Progression/regression of CAC was defined as a change 2.5 between the square root transformed values of baseline and follow-up volumetric CAC scores. Demographic data, risk factors, glycemic control, medication use, serum hs-CRP, IL-6, and plasma OPG levels were measured at baseline and follow-up.

    Results: Two hundred eleven patients (53%) had CAC at baseline. One hundred eighteen patients (29.6%) had CAC progression, whereas 3 patients (0.8%) had regression. Age, male gender, hypertension, baseline CAC, HbA1c >7, waist-hip ratio, IL-6, OPG, use of beta-blockers, calcium channel antagonists, angiotensin-converting enzyme (ACE) inhibitors, statins, and Framingham/UKPDS (United Kingdom Prospective Diabetes Study) risk scores were univariable predictors of CAC progression. In the multivariate model, baseline CAC (odds ratio [OR] for CAC >400 = 6.38, 95% confidence interval [CI] 2.63 to 15.5, p < 0.001), HbA1c >7 (OR 1.95, CI 1.08 to 3.52, p = 0.03), and statin use (OR 2.27, CI 1.38 to 3.73, p = 0.001) were independent predictors of CAC progression.

    Conclusions: Baseline CAC severity and suboptimal glycemic control are strong risk factors for CAC progression in type 2 diabetic subjects.

    Why did they NOT look at 25(OH)D when they were looking at the osteo- whatever thingy. *uurrgghh*

  • g

    12/22/2007 5:03:00 PM |

    I like this guy... he proposes heart CTs for all T2DM to screen for silent MIs. just like colon CA screening... and breast CA screening... wow ya think?

    CAD in most people esp T2DM is diffuse and systemic (maybe someday we can CAC someone's wrist like we do for Bone Mineral Density testing for osteopenia/porosis screening at the local drugstore?)... and very accelerated when glucose and insulin are elevated (without a good mod/high healthy MUFA PUFA diet and systemic TYP strategies).
    http://content.onlinejacc.org/cgi/
    content/abstract/49/19/1918

    Noninvasive Screening for Coronary Atherosclerosis and Silent Ischemia in Asymptomatic Type 2 Diabetic Patients
    Is it Appropriate and Cost-Effective?
    George A. Beller, MD, MACC*
    Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.

    Coronary artery disease (CAD) accounts for 65% to 80% of deaths in diabetic patients. The merits of screening asymptomatic type 2 diabetic patients for either Innocent the presence of coronary atherosclerosis by imaging of coronary calcification using cardiac computed tomography or (B) silent ischemia by stress myocardial perfusion imaging (MPI) remain controversial. Some observers have advocated for such noninvasive screening in at least the subset of the diabetic population who have significant clinical CAD risk factors, so that the highest risk patients for future cardiac events can be identified and offered more aggressive intensive medical therapy or coronary revascularization and optimum medical therapy. Computed tomography coronary calcium scanning could be the first noninvasive screening test in these clinically high-risk diabetic patients, followed by stress MPI to detect silent ischemia in those who exhibit high coronary calcium scores.

  • Dr. Davis

    12/23/2007 12:36:00 AM |

    Hi, G-

    As you see, some people in the medical community are waking up to the great usefulness of heart scans to detect hidden coronary plaque.

    However, it's going to be another five or more years before they also wake up to the idea of using it to TRACK the disease.

  • g

    12/23/2007 4:56:00 AM |

    Not unless you win global recognition for your achievements and TYP ...  Smile

    Can u imagine a world where the failure to offer TYP would be malpractice...for someone with diabetes? pre-diabetic? with Lp(a) or Homocysteinemia?  I do... and  who knows sooner than u might think.

    I think behind every genius-man, there stands a genius-woman. Once when I couldn't log on, couldn't access 'chat' and couldn't find reports when they were right in front of my *darn* NOSE... a wise woman told me 'you can't know everything.'  *ha ha* give her a hug for me Smile
    g

  • Anonymous

    1/2/2008 1:55:00 AM |

    Just a note to g regarding screening for osteoporosis at the wrist.  These are very ineffectual tests.  It is best to use the spine +/or hip as osteoporosis starts at the center of the body.  By the time it is detected in the distal extremities, you would already have significant bone loss. At least this is my understanding as a technologist. Could this also apply to artery disease?

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