Dr. Roach: Very high CAC score might require more aggressive treatment

Dear Dr. Roach: I am 68 and in good shape; I work out daily. I had a few episodes of angina two to three years ago and started going to a cardiologist as a result. I have had quite a few tests done, but the one that was really concerning was my coronary artery calcium score, which is over 4,800 (not a misprint).

He put me on 80 mg of atorvastatin, 10 mg of ezetimibe and 40 mg of valsartan. My blood pressure is good (generally around 110 over 65 mm Hg), and other than some shortness of breath, I feel fine. I’m wondering if my doctor should be more aggressive due to the extremely high CAC score (i.e., a stent). I would really like to hear your thoughts about this.

— C.B.

Dear C.B.: Your extremely high calcium score means you are at a very high risk for, and probably have, blockages in the arteries that provide blood to the heart muscle. This condition is called coronary artery disease (CAD).

There are several medications that have been proven to reduce the risk of heart attack and death in people with coronary artery disease: statins (80 mg of atorvastatin is the highest dose of one of the most effective statins); ezetimibe (which works along with the statin to stabilize blockages); and ACE inhibitors and angiotensin blockers (valsartan probably has benefits beyond lowering blood pressure to prevent heart disease), all of which you are on. If your doctor was sure that you really have CAD, you should probably be on aspirin and a beta blocker as well, unless there is an underlying reason not to be.

Although stents are commonly placed after cholesterol plaque blockages are opened through a balloon procedure, they have not been proven, despite many studies, to reduce the risk of heart attack and death in people who have stable coronary artery disease. (The story is different for people who experience an emergency like a heart attack.)

Angioplasties and stents are normally reserved for people who have symptoms of heart blockages that have not been treated successfully with medications. A recent and still controversial study cast doubt on how effective stents are at relieving symptoms.

I can’t tell if your shortness of breath is a symptom due to blockages of the heart. A cardiologist’s clinical judgment is necessary to determine whether a test, such as an angiogram, is appropriate to see how many blockages there are and their severity. Although a CT scan with dye can give excellent information, an angioplasty and stent placement can only be done during a cardiac angiogram.

In a few cases, the blockages are so severe that a decision is made to go directly into surgery, where one or more grafts can be placed to bypass the blockages found on the angiogram. There are specific indications for cardiac surgery. Medications are much more effective than they used to be, so there are far fewer coronary artery bypass graft surgeries (CABG, always pronounced “cabbage”) performed now than in decades prior.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.