Calcium Score Paradigm Shift in Cardiology

Raggi 2004 calcium Score 15 per cent change Fig.2

Calcium Score, a Paradigm Shift in Cardiology

by Jeffrey Dach MD

A Cardiology “Paradigm Shift” occurred in 2004 with publication of the Paolo Raggi study on annual Calcium Score progression.(1)

This above left chart shows the MAJOR FINDING: Less than 15% annual increase in calcium score is associated with a good prognosis.(upper line), regardless of high starting score.   On the other hand, greater than 15% annual progression (lower line) shows poor prognosis with increasing myocardial Infarction rate.  Above Left Chart Fig2 Courtesy of Dr Raggi 2004 (1) 

According to Dr Phillip Greenland in a 2010 report in the Journal of the American College of Cardiology (10):

“studies have shown that an annual increase of ≥ 15% in the volume of coronary calcium would be related to a 17-fold increase in the risk of a cardiovascular event.” (10)

Cholesterol Levels Were the Same for Both Groups

When you see this chart for calcium score, let me remind you, there are no similar data charts for LDL cholesterol.  As a matter of fact, there was no difference in LDL levels for the 41 heart attack patients compared to 450 others free of heart attack.  There was no difference !!!   Dr Paoli Raggi says:

Mean LDL level did not differ between groups (118 mg/dL versus 122 mg/dL, MI versus no MI).(Dr Raggi 2004 (28)  (Note: MI = Myocardial Infarction)”(1)

Dr Paoli Raggi found that LDL cholesterol is a useless marker for predicting future heart attack.

The Patient is Failing the Statin Drug or is the Statin Drug Failing?

Dr Raggi’s study also showed that 41 of the 500 patients suffered heart attacks over the 6 years of follow up  in spite of treatment with statin drugs.  In these 41 patients, the calcium score progressed greater than 15% annually in spite of the statin drug treatment. This casts considerable doubt on ability of the statin drug to prevent myocardial infarction.  Here is a 2017 quote from Matthew Budoff, MD about repeating the calcium score for annual progression (7):

 “I want you to think that if someone is on a statin or not and  they are progressing (meaning the calcium score is progressing), they are failing their current therapy.”(7) Quote Dr Budoff.

Why is Calcium Score a Superior Predictor Over Cholesterol 

Cholesterol and subfractions are substances we measure in the blood stream, distant from the wall of the artery where the pathology is located. With calcium score, we are measuring the pathology directly in the wall of the artery.   Progression of calcium score indicates progression of pathological change in the wall of the artery.

Chronic Inflammatory Foci

The pathological change in the wall of the artery is discussed by Dr Abedin in 2004 who states:

“Vascular calcification is a clinical marker for atherosclerosis and may represent a special example of the general phenomenon of soft tissue calcification surrounding chronic inflammatory foci.(2)”

I would propose that the chronic inflammatory foci mentioned in the above quote from Dr Abedin is a polymicrobial infection with biofilm formation.  Soft tissue calcification in response to infection is well known and commonly seen with modern imaging techniques in human bacterial, fungal and parasitic infections .  Here is a good example of a CAT scan showing calcified pericardium caused by tuberculous pericarditis. Notice the white rim of calcification encasing the heart, typical for pericardial calcification.

Tuberculous Pericarditis Calcified Pericardium Jeffrey Dach MD

Above Image courtesy of: (3) Goel, Pravin K., and Nagaraja Moorthy. “Tubercular chronic calcific constrictive pericarditis.” (2011).

Notice the pattern of calcification in the pericardium is curvi-linear and visually similar to arterial calcification which is also curvi-linear.  If I told you this was caused by elevated cholesterol, you would call me crazy.  This is NOT CAUSED by elevated cholesterol !!!  Similarly, why on earth should anyone believe that elevated cholesterol can cause calcification like this in the wall of an artery?  Ladies and Gentlemen, a much more reasonable explanation is polymicrobial infected biofilm, already confirmed by modern 16s ribosome techniques as discussed in my previous article on this topic.

Cholesterol and Calcium Score – No Correlation

Dr Harvey Hecht reported in 2001, there is no correlation between serum cholesterol and the calcium score.(6)   Dr Ware reported multiple studies showing this same finding. (4)  This non-correlation proves that cholesterol does not cause calcification in the coronary arteries.  In addition, according to Dr. Gill in a 2010 reportfive randomized controlled studies show that statin drug treatment (which reduces cholesterol), does not reduce coronary calcium score or slow progression.(5)  Worse, the statin treatment showed progression of coronary calcium score indistinguishable from the non-treated placebo group.(5)

Calcification caused by Microbial Organisms

white_cliffs_dover chalk coccolithophoresIn case you have any lingering doubts about the ability of microbes to cause calcification, take a look at this beautiful photo of the “White cliffs of Dover” (courtesy of wikimedia commons).

Extending 10 miles along the coast of England, the white cliffs of Dover are composed of chalk from photosynthetic microbes called coccolithophores.  Their calcified shells accumulate on the ocean floor over thousands of years and eventually compacted into chalk, also called calcium carbonate.  Imagine this stuff in your coronary arteries !

Leaky Gut and Vascular Infection

We are currently witnessing an epidemic of Leaky Gut in our population, a syndrome in which antigenic food particles and gram negative organisms (called LPS) leaks through the gut barrier into the circulation.  The microbes may then set up house inside the walls of our arterial tree at site of stress shear injury such as bifurcations, or movement such as the coronaries imbedded on the surface of a beating heart.  Most commonly, leaky gut is caused by wheat gluten sensitivity in susceptible individuals and NSAIDS drug use.  Also consider Glyphosate ingestion, and there are many other causes.  Testing for anti-gliadin antibodies, and anti LPS antibodies can be useful here.

Conclusion: 

Left image: yellow arrow points to calcified coronary artery.

Dr Paoli Raggi’s study in 2004 showed superiority of calcium score over LDL cholesterol in predicting future heart attack.  As of 2004, the cholesterol panel has been replaced by the calcium score for routine management of heart disease.  This is the paradigm shift in Cardiology.  However, more than a decade later, mainstream cardiology is still in denial, having buried and ignored Dr Raggi’s 2004 study.  The financial stakes are too high to give up on the “Cholesterol Myth” and the billions from the cholesterol drugs.

As Upton Sinclair once said:

“You can’t get a Cardiologist to understand something if his salary depends on him not understanding it.”

The paradigm shift has occurred, coronary artery disease is a polymicrobial infected biofilm, seeded from the gut, and best managed with the Calcium Score.  The cholesterol myth is dead.

Its Time to Let Older Cholesterol Panel “Rest In Peace”

One cardiologist who has made the transition to Calcium Scoring is Khurram Nasir, MD, MPH of Baptist Health South Florida, Miami, who stated in a session at the 2017 Society of Cardiovascular Computed Tomography Annual Meeting (7):

“It’s time that we should let traditional risk scores and risk factor-based management rest in peace….They have served their “purpose” for the last 50 years and now in 2017, we have the ability to look at the actual disease with calcium testing, which only costs $75 to $100, takes a few minutes, and has a radiation dose almost equivalent to a mammogram…..CAC (Calcium Score) testing “provides the most precise insight of what your actual risk is so you can tailor the treatment.”(7)

Heart Book by Jeffrey dach MDFor more on this, see my new book on Amazon: Heart Book  (see cover – left image)

Jeffrey Dach MD
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References:

1)  Raggi, Paolo, Tracy Q. Callister, and Leslee J. Shaw. “Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy.” Arteriosclerosis, thrombosis, and vascular biology 24.7 (2004): 1272-1277.

Objective— Statins reduce cardiovascular risk and slow progression of coronary artery calcium (CAC). We investigated whether CAC progression and low-density lipoprotein (LDL) reduction have a complementary prognostic impact.

Methods and Results— We measured the change in CAC in 495 asymptomatic subjects submitted to sequential electron-beam tomography (EBT) scanning. Statins were started after the initial EBT scan. Myocardial infarction (MI) was recorded in 41 subjects during a follow-up of 3.2±0.7 yearsMean LDL level did not differ between groups (118±25 mg/dL versus 122±30 mg/dL, MI versus no MI).On average, MI subjects demonstrated a CAC change of 42%±23% yearly; event-free subjects showed a 17%±25% yearly change (P=0.0001). Relative risk of having an MI in the presence of CAC progression was 17.2-fold (95% CI: 4.1 to 71.2) higher than without CAC progression (P<0.0001). In a Cox proportional hazard model, the follow-up score (P=0.034) as well as a score change >15% per year (P<0.001) were independent predictors of time to MI.

Conclusions— Progression of CAC was significantly greater in patients receiving statins who had an MI compared with event-free subjects despite similar LDL control. Continued expansion of CAC may indicate failure of some patients to benefit from statin therapy and an increased risk of having cardiovascular events.

2) Abedin, Moeen, Yin Tintut, and Linda L. Demer. “Vascular calcification: mechanisms and clinical ramifications.” Arteriosclerosis, thrombosis, and vascular biology 24.7 (2004): 1161-1170.

Vascular calcification is a clinical marker for atherosclerosis and may represent a special example of the general phenomenon of soft tissue calcification surrounding chronic inflammatory foci.

3) Goel, Pravin K., and Nagaraja Moorthy. “Tubercular chronic calcific constrictive pericarditis.” (2011). Heart Views. 2011 Jan-Mar; 12(1): 40–41

4) Ware, William R. “The mainstream hypothesis that LDL cholesterol drives atherosclerosis may have been falsified by non-invasive imaging of coronary artery plaque burden and progression.” Medical hypotheses 73.4 (2009): 596-600. cholesterol atherosclerosis falsified coronary artery plaque Ware Medical Hypotheses 2009

5) Gill, Edward A. “Does statin therapy affect the progression of atherosclerosis measured by a coronary calcium score?.” Current atherosclerosis reports 12.2 (2010): 83-87.

6) Hecht, Harvey S., et al. “Relation of coronary artery calcium identified by electron beam tomography to serum lipoprotein levels and implications for treatment.American Journal of Cardiology 87.4 (2001): 406-412.

7)  SCCT 2017 Coronary Calcium Scores in 2017: Useful, Yes, but Hard Outcomes Data Still Lacking
Experts agree on the value of CAC scoring for statin therapy decisions, but disagree on when and why the test might need to be repeated.
By Yael L. Maxwell July 13, 2017

Society of Cardiovascular Computed Tomography (SCCT) 2017 Annual Scientific Meeting… “It’s time that we should let [traditional] risk scores and risk factor-based management rest in peace,” said Khurram Nasir, MD, MPH (Baptist Health South Florida, Miami), who presented in a session on prevention last Friday.
They have served their “purpose” for the last 50 years “and now in 2017, we have the ability to look at the actual disease” with calcium testing, which only costs $75 to $100, takes a few minutes, and “has a radiation dose almost equivalent to a mammogram,” he told TCTMD. CAC testing “provides the most precise insight of what your actual risk is so you can tailor the treatment.”

8)  Coronary calcium scans: NYT article highlights value and minimizes limitations  Posted By Michael Joyce is a writer-producer with HealthNewsReview.org

9)  Journal of the American College of Cardiology Volume 71, Issue 11 Supplement, March 2018 RISK RECLASSIFICATION WITH ABSENCE OF CORONARY ARTERY CALCIUM AMONG STATIN CANDIDATES ACCORDING TO AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION (ACC/AHA) GUIDELINES: SYSTEMATIC REVIEW AND META-ANALYSIS
Gowtham Grandhi, Anshul Saxena, Tanuja Rajan, Emir Veledar, Amit Khera, Ron Blankstein, Roger Blumenthal, Leslee Shaw, Michael Blaha

10) Greenland, Philip, et al. “2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society ….” Journal of the American College of Cardiology 56.25 (2010): 2182-2199.

11) Ravnskov, Uffe, et al. “LDL-C does not cause cardiovascular disease: a comprehensive review of the current literature.” Expert review of clinical pharmacology 11.10 (2018): 959-970. LDL-C does not cause cardiovascular disease Ravnskov Uffe Expert rev clin pharm 2018

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Calcium Score Paradigm Shift in Cardiology
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Calcium Score Paradigm Shift in Cardiology
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The Calcium Score has Replaced the Cholesterol Panel
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