Hello, you have posted a very interesting question. As 21st century physicians we are often having to absorb new technology and information very quickly, just to keep up with the new tests and diagnoses available to our patients. The coronary artery calcium score (CACS) and the VAP lipid panel are both relatively new comers in the cardiovascular risk prediction realm, so I had to verify my answers before posting them for you.
1. Your CACS of 2000 is indeed very high, at the 94th-99th percentile based on age, gender and race. According to the MESA study (Polonsky et al, JAMA 2010), there is indeed an elevated risk of cardiovascular events. More than 2-fold increased compared to someone with low CACS, but still a low number (in the range of 5% in 10 years or so).
2. Your cholesterol levels, as measured by the VAP test shows the LDL is in the normal range for someone treated with a statin. However, there is no true limit to how low the LDL should be, as there is a continued benefit towards lower and lower LDL, ie. 100 is better than 130, 70 is better than 100, etc). Your HDL is actually the "large bouyant" molecule, which is actually a protective factor (probably reflects your exercise program).
In summary -- you are asymptomatic and are taking good care of yourself. There is no need to do any further invasive study at this time such as a catheterization or repeat CT scan. Simply maximize your medical, diet and exercise regimens. First, stay lean and fit as you have done so far. Then I would discuss with your MD on switching back to atorvastatin/lipitor and even increase the dose to 40mg daily. Lastly, while there is no data on aspirin use, you could consider taking a baby dose (81mg) of aspirin daily. I would recommend this (aspirin + high dose statin) if you were a patient of mine in clinic.
IF you start to experience chest discomfort or shortness of breath and persistent fatigue, I would immediately think about a coronary angiogram, since you are in a higher risk category due to your CACS.
What always confuses me with regards to the fashion on LDL lipids, is the fact that this isn't the actual cause of artery disease. When arteries inflame (primary cause) then the immune system response causes white cells to be filled with fat and turn them into foam cells, making the beginnings of atherosclerosis, or at least the possibility. So surely, no matter how low the LDL, the white cells will always have the natural ability to turn into foam cells?
If these are damaged, such as oxidation, then they are unable to release their fats back into the lipid world. So why is lowering lipids so important, is there really a point? I've met lots of patients with normal cholesterol and having more disease than me and I have hypercholesterolemia.
From a teen (was 46 with first heart attack) I always had high blood pressure, but in those days Doctors just said "oh it's your chemical make up". If I was a teen now, I would be on medication because they know it would damage the arteries over years, causing foam cells.
Can anyone please help me with this confusion which has bewildered me since my first heart attack.
I think some of this might be psychological. I think the "normal" stress test would not be sufficient to rule out coronary blockages, since any non-invasive study would have some rate of false negative. I would say get a cath IF you are convinced that you have exertional symptoms which are getting longer and more severe.
THANKS, A few points;My VAP results showed the LDL as large bouyant. Ever since I received the calcium score I am feeling all sorts of neck and shoulder aches while excersizing. Could i have heart troubles now, right after that "Normal" thalium stress test?
Thanks for your reply. R u a cardiologist? My understanding is that a calcium score of over 400 indicates a probable heart attack within the next couple of years.
Nothing. Just keep doing what you are doing.