Dear Dr. Roach: I am 71. In November 2021, my cardiologist prescribed me 40 mg of atorvastatin in case of chest pain before any tests. I subsequently had a stress test with perfusion that came out negative, as did an echocardiogram (TTE). My coronary calcium score is 83. I rejected a recommended cardiac catheterization, as I wanted to avoid stents and the required blood thinners.
I had high cholesterol levels in the past (259 mg/dL in 2017), but I radically changed my diet long before my chest pain. I had a total cholesterol level of 154 mg/dL with an LDL of 90 mg/dL and an HDL of 49 mg/dL in 2022. I believe the change in diet reduced my cholesterol, and I asked the doctor if I could discontinue the two medications as a test. If my cholesterol rose as a result, I planned to go back on the meds. But if my scores remained low, I wanted to avoid the meds, given the side effects at my age. However, the cardiologist was adamant that I must continue the meds.
What would be the risk of discontinuing the meds temporarily to see if my cholesterol remains at a low level, as compared to the risk of the potential side effects of the meds at my age?
I respect my doctor’s impeccable credentials, but I feel he may be overprotective about cardiac risks and dismissive of the potential side effects of the medications. I believe my symptoms are a result of extreme job stress or something non-cardiac-related. I understand experts say the benefits of statins far outweigh any risks, but if my cholesterol remains low without the meds, do I want to accept those risks?
B.S.
Most importantly, it’s your body, and you have the choice to accept or reject your doctor’s recommendation. However, I’ll try to give you a better idea of what your risks are with and without medication.
If I input your information into a risk calculator based on your coronary calcium score and your cholesterol prior to changing your diet and starting on medication, the calculated risk of having a cardiac event (heart attack, stroke or death) in the next 10 years is 13%. With a better diet and atorvastatin (I don’t know your blood pressure level, so I am guessing you are about average), your risk of an event dropped to just below 10%. The medication reduced your risk of having a bad event by about 3%.
The negative stress test with perfusion is a good result, but it does not mean that you do not have blockages in the heart. A negative stress test means that if there are any blockages, they aren’t severe enough to block blood flow (blockages below 50% are rarely detectable by a stress test). Your calcium score is low, but not zero. So, there could well be some small cholesterol plaque, and atorvastatin is clearly indicated even in people with small blockages. An angiogram or CTA scan is best for evaluating small blockages.
There is clear evidence that people who go on and off of statins have better results than those who aren’t on statins at all, but stopping a statin completely does increase the risk of an event. You can expect your LDL level to increase by about 50% if you were to stop.
To be clear, an angiogram by itself doesn’t mean you will get a stent or medication. You need those if you have a blockage significant enough where opening that blockage (with a balloon) and keeping it open (with meds and a stent) outweighs the risk.
Email questions to [email protected].
