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Significance of high calcium CAC score
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Significance of high calcium CAC score

Thanks for taking my question.

I recently had a CT-Angiogram that revealed a high calcium (CAC) score of 739. My cardiologist has been somewhat evasive as to how bad this is but he did immediately prescribe a statin which lowered my total cholesterol from 220 to 131 and he urged me to make lifestyle changes. I'm a 65 year old male with a history of chronic afib and an enlarged left atrium (5.4 cm). My ventricles appear normal (EF= 60). I'm otherwise asymptomatic and fairly active physically, working out several times a week at a gym. I'm over weight (6'5" 270 lbs)but muscular.

Here is the calcium scoring by artery: Left Main 36, LAD 193, Left Circumflex 21, Right Coronary 489, Posterior Descending 0. The CT-A images showed 3 blocks of less than 30% but also a fair degree of non-obstructing noncalcified plaque. Of note, is that "the RCA is poorly visualized because of motion".

My questions are:

1. What's the prognosis with a CAC of 739? Am I due for a heart attack in the near future?

2. Will lowering cholesterol and losing weight reverse calcification? Or is the best I can expect is to slow CAD progression?

3. Is it likely the 489 RCA score is correct? I've read that motion leads to anomolously high estimates.

4. Would my total CAC score still be considered dangerously high even if the RAC score were actually substantially lower?

5. Any advice?

Thanks again for providing this wonderful service.

Tony
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1.  It is difficult to predict whether you'll have a heart in the future with a high CAC score.  There is some evidence that higher CAC scores are associated with increased rate of events.  At the same time any elderly person would have increased CAC scores yet their risk of events may not be different from the age matched controls.  

2.  Lowering cholesterol and losing weight have been shown to prevent future events in patients who are both symptomatic and asymptomatic from CAD stand point.  Therefore, starting you on a statin and encouraging weight loss and exercise are the best things your cardiologist could have done.  There is no reason for you to have a catheterization as you have no symptoms.  There is some new evidence that   not only do statins prevent events and slow down progression, but they also reverse the process as well.  That evidence is not that strong but there are ongoing trials that will evaluate that further.  

3.  The RCA score is likely to be correct, however, the test is not perfect and there are some false positive results.  I would not pay too much attention to the details.  The more important issue is to focus on how to prevent future events and the therapy that you are on now is the best thing you can do.

4.  Your score would be in the moderate risk zone otherwise, however, that would not change the current management.  You are on the right track.  Make sure that you take the statin and that you are on a daily ASA.  Besides lowering cholesterol, losing some weight and exercising you should also make sure that your blood pressure is well controlled, that you have no exposure to second hand smoking and that you are not a diabetic.  Is your atrial fibrillation related to hypertension?

5.  I would again advise you to limit all the risk factors to the minimum, become a health nut, watch what you eat, stay away from heavy meats and high fat diets, stay away from cigarettes, exercise (very important), lose weight, keep taking the statin and start taking daily baby aspirin.  You are probably already on it due to atrial fibrillation.  If you do take coumadin for atrial fibrillation, adding aspirin may cause some minor bleeding.  Discuss that with your cardiologist.
2 Comments
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Doctor

Thanks so much for taking the time to answer my question(s). I realize how busy you are and so greatly appreciate your clear & insightful answers and advice.

I don't expect you to reply again but I wanted to address some of the issues you raised in answers 4 and 5:

Yes, my AF is likely due to previously untreated high BP.  But my BP is now well controlled (110/75) with cardizem, altace and HCTZ. The AF is somewhat controlled with rythmol.

I have been on coumadin for several years and have now added a daily baby aspirin since the CT-A. I religiously take all meds including the statin, supplements (fish oil, vitamins and folic acid) and have monthly PT/INR measurements to avoid over anticoagulation.

I don't smoke and avoid second hand smoke. I am not a diabetic.

I'm used to a regular exercise program and so don't anticipate slacking off in the future.

The only part of the advice that I expect to have difficulty with is maintaining a good diet and proper weight. I have a weakness for high calorie foods, large portions and the occasional steak and beer. But I do realize that a chance for a long life and staying healthy depend on making real sacrifices. Thanks for providing some motivation in that direction.

Regards

Tony
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