An Anxious Man With Coronary Plaque

John Roe has plaque but no symptoms. He ended up getting an angiogram a few years ago for chest pain that ultimately turned out to be acid reflux. But somebody put him on 80 mg of atorvastatin.

He had wanted to know what his lipid numbers were, so we checked them. They were quite low. His LDL was 42. For people who believe in target numbers, under 70 is the desired target for patients with known heart disease. Would John qualify as a member of that population?

“My daughter thinks that’s too high a dose for me”, he said. Amanda, his forty something daughter, is a psychiatric nurse practitioner. “I’m worried about my liver and my kidney numbers were off last year and what if they get worse again?”

This is a conversation I find myself in very often.

“It’s all a question of how much risk you tolerate, how worried you are about having a heart attack. How much insurance, or assurance, you want. The more you take, the more protected you are. And atorvastatin does more than lower cholesterol – I’m sure we have talked about that before. It stabilizes plaque and prevents plaque rupture. And 85% of all heart attacks happen not because of plaque growth but because of plaque rupture – sometimes of plaque that are too small to make you flunk a stress test.”

“I remember you saying that”, he admitted.

“It also prevents plaque buildup, and high doses can make plaque shrink – both in the carotid and coronary arteries, we have lots of proof of that. It also has a blood thinning effect that is different from aspirin, plus it relaxes the little muscles in the walls of the coronary arteries that clamp down when you get that letter from the IRS that you’re being audited (my standard joke..).”

I continued “I’ll print a couple of articles about all this for Amanda. And also, the FDA long ago stopped recommending routine checking of liver enzymes because liver damage from atorvastatin is very rare. And it has been shown to actually protect the kidneys.”

I clicked PRINT a couple of times and went back to my office for the printouts.

When I came back to the exam room, I undid everything I had said.

“But, some people have muscle aches or joint pains, some get higher blood sugars and some get brain fog or pseudo dementia. And there are other ways to avoid heart attacks. Without drugs.”

He looked up from the papers I had given him.

“I’ll print up one more thing for you. The Hale study, many years ago, showed that people aged 70-90 who followed a healthy lifestyle and a Mediterranean diet had half the heart attack and stroke rate, half the cancer rate and half the overall death rate of people with more typical western diets and habits. That’s the same reduction you can get with atorvastatin.”

John sighed. “So what am I supposed to do?”

“Only you can decide”, I answered. “It depends on how much risk you tolerate, how many hoops you are willing to jump through to avoid a heart attack. That’s a very personal choice.”

I know he wished I would tell him what to do. If he had had a heart attack, it would be simpler – there is a “party line” for that. But primary prevention isn’t that straightforward or universally agreed on. So I only provide the evidence and the options.

I don’t babysit. I want to empower.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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