Coronary Artery Calcium

To the Editor,

The goal of interventional lipidology is the treatment of at-risk individuals to prevent atherothrombotic disease (ATD), or if ATD is extant, then stabilization/regression of the ATD plaque.
A targeted approach aimed at higher-risk individuals, sparing lower-risk patients immediate treatment that is not necessary, would appear to be the prudent approach.

Use of coronary artery calcium (CAC) has been advocated, most recently based on the MESA study. (1) CAC is not a good method of assessing ATD for the following reasons:

1) CAC is absent in early vulnerable plaques, which can and do lead to acute myocardial infarction (2),

2) CAC increases with age, irrespective of ATD risk factors, and may be seen in elderly patients who are free of clinical ATD (3),

3) Chelation therapy was once used to treat CAC, but has no effect on ATD (4),

4) Statin therapy shrinks ATD plaque but does not influence CAC, which progresses despite statin therapy (5).

Hence CAC can not be recommended. Perhaps what is needed is a better screening tool to predict the population at risk of ATD.
W.E. Feeman,Jr,MD

1. Blaha MJ, Budoff MJ, DeFilippis AP, Blankstein R, Rivera JJ, Agatston A, O’Leary DH, Lima J, Blumenthal RS, Nasir K. Associations Between C-Reactive Protein, Coronary Artery Calcium. And Cardiovascular Events: Implications for the JUPITER Population from MESA, a Population-Based Cohort Study. Lancet. 2011; 378: 684-92.
2. Schmidt HHJ, Hill S, Makariou EV, Feuerstein IM, Dugi KA, Hoeg JM. Relation of Cholesterol-Year Score to Severity of Calcific Atherosclerosis and Tissue Deposition in Homozygous Familial Hypercholesterolemia. Am J Cardiol. 1996; 77:575-580.
3. Newman AB, Naydeck BL, Sutton-Tyrrell K, Feldman A, Edmundowicz D, Kuller LH. Coronary Artery Calcification in Older Adults to Age 99 Prevalence and Risk Factors. Circulation. 2001; 104: 2679-2684.
4. Ernst, J.Commentary . Chelation Therapy Does Not Benefit Heart Patients. Focus on Alternative and Complementary Therapies. 2002; 7153.
5. Terry JG, Carr JJ, Kouba EO, Davis DH, Menin L, Bender K, Chandler ET, Morgan T, Crouse JR. Effect of Simvastatin (80 mg) on Coronary and Abdominal Aortic Arterial Calcium (from the Coronary Artery Calcification Treatment with Zocor [CATZ] Study). Am J Cardiol. 2007; 99: 1714-1717.

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