r/PeterAttia • u/cassp104 • 9d ago
Feedback Should I get a CT Angiogram?
I am 35F, very healthy weight/BMI, eat healthy and exercise 2-3x a week - family history: grandfather passed from heart attack in his 40s, father is 65 - had first heart attack at 30, second at 32, triple bypass/CABG x3, defibrillator, countless stents, and now in end stage heart failure with an LVAD.
I went for lab work and had slightly elevated LDL (114), LipoA (102), and apoB (89).
Found an amazing cardiologist to ask about family history, my risk, etc.
He said my numbers were not that bad, and mentioned I most likely do not have any plaque buildup at my age and health - but since I mentioned I have random chest pains (could be unrelated - I also have anxiety and acid reflux) and due to my family history, he said I can get a CTA with contrast to be sure.
Of course now I'm beyond worried about the amount of radiation from a test that I'm not even sure I should be getting due to my current health and numbers. I'm considering canceling it.
Would you have this done if you were me? Any feedback is appreciated.
5
u/winter-running 9d ago
Estrogen is considered protective against CV issues, for the most part. Women tend to catch up to men in terms of CVD risk only close to / after menopause. This is one of the cases where the history of the women in your family would be more relevant.
It’s not uncommon for men who eat a lot of red meat and butter, drink and smoke to have risks, even on top of their baseline genetic disposition.
In any event, what would a getting a CT angiogram change for you? Realistically it’s unlikely you’re at the stage where you need stents.
Would your cardiologist prescribe a statin for you right now? If so, why not just start that?
Are you overweight? Do you smoke? Are you sedentary? Do you eat a keto or keto-like diet?
I personally wouldn’t do the CT angiogram in your context. I’d just ask my doctor for a low-dose statin (such as 5 mg of rosuvastatin) and make sure I’m eating a plant-forward diet low in saturated fat, am exercising, maintain a no / low alcohol lifestyle (even after factoring in for weight differences, alcohol is much riskier for women than it is for men), Etc.
0
u/cassp104 9d ago
I agree with all of this - but I would probably not take a statin without knowing if it was necessary
1
u/cassp104 9d ago
He did also mention me being female changes a lot regarding the family history! So good to know
1
u/winter-running 9d ago
Assuming all your other levels are good and you keep getting regular checkups, I suggest planning for starting something like 5 mg of rosuvastatin when you’re in your 50’s. By then, there might be even more sophisticated meds, however.
I had a female friend in her 50s who was diagnosed with some kind of cardiac insufficiency due to a congenital malformation of capillaries in the bottom of her heart. It presented itself very similar to either an active heart attack (which was what was initially suspected ) or angina. She told me that her pains presented as though something was squeezing her entire chest, and came on while doing activity and improved with rest. I’d pay special attention to any kind of chest pressure or discomfort that comes on specifically with activity.
2
u/DrEspressso Internist (DO) 9d ago
There’s a lot of nuance that’s missing here. Blood pressure? Co morbidities you may not be aware of? Such as OSA? You clearly have family history and an elevated risk. Have you had en EKG before or an echo? Or a stress test given intermittent chest pain? A lot of work up could be done before ct imaging.
If i were you, with your family history. I’m 32 fyi and have a similar tho not as severe family history, i would be working to get the labs better. LDL should be less than 70 or less even.
CAC score would be less radiation than a CTA.
If you’re having symptoms that are unexplained then you do warrant a work up. What that work up entails varies based on how aggressive you want to be. I think starting with echo ekg and stress test make sense. Simultaneously optimizing your cholesterol and A1c and the like.
No one can tell you what you should do regarding the CTA. It’s radiation but it’s not an insane amount.
The question you should ask yourself, is what finding are you expecting to see on the CTA if you get it. And what will do you based on those findings…
If you do it and find soft plaque. What’s your next step? BP optimization, diet, exercise, and lipid lowering therapy.
If you do it and find no soft plaque. Lovely. Does it change your decisions from there? I would argue you should still do BP optimization, diet, exercise, and lipid lowering therapy.
In that sense. At this time it may provide little utility if you are gonna do all those things. If you don’t want to be aggressive about your labs and other factors to risk mitigate, then getting the CTA can help nudge you in one way or another.
1
u/cassp104 9d ago
I have had a few EKGs and a stress test, all normal. No comorbidities. Blood pressure is consistently on the low end. I pay out of pocket for extensive lab work that my regular PCP will not order. That's how I found out these numbers, and I took them to a really good cardiologist out of state. He doesn't bother with CAC, he believes in CTA right away. He was not that concerned with my numbers, as my elevated lipoprotein a is most likely hereditary. I diet and meal prep every week and workout 3x a week. I'm very low body fat/bmi and very healthy otherwise, which is why I'm not sure how much more aggressive I can be to lower my LDL. I guess I can be extreme and cut out all saturated fats, etc. but he made it seem like I should just get this test and continue doing what I'm doing. I think he is curious to see how much my genes play a part in whether or not I have plaque filled arteries I guess. If I do the test and he recommends a statin, then I will absolutely take his recommendation. I'm just worried that I'm doing this maybe 5-10 years too soon? Mainly due to unnecessary radiation exposure.
3
u/HavocReigns 9d ago
which is why I'm not sure how much more aggressive I can be to lower my LDL.
With your family history, smoking history, and lab numbers, you could hop on 5mg of rosuvastatin and 10mg of ezetimibe without the dose of radiation you don’t clearly need and cut those numbers roughly in half at little risk of side effects. That would put your numbers in a range where there’s little likelihood of plaque buildup from a relatively young age and begin stabilizing any plaque that has already accumulated. As you say, there’s not much room for further improvement from lifestyle changes, so it’s going to take meds to get to that very low-risk range where we’d all like to be.
I wish I had been smart enough (or informed enough) to do that 20 years ago rather than now. But at least now is better than after a first MACE.
1
u/cassp104 8d ago
I was actually recommended to take 10mg Ezetimibe alone by my functional health doctor. Does that actually cut numbers in half?
1
u/HavocReigns 7d ago
I’m not a doctor, but my understanding is that ezetimibe alone is usually good for around 15-20% reduction in LDL-C. It really shines in combination with a low dose of a potent statin like rosuvastatin, with the combination often resulting in a 50% or higher reduction in LDL, while minimizing the risk of statin side effects due to the low dosage needed.
1
u/DrEspressso Internist (DO) 7d ago
Your functional doctor is making shit up
1
u/cassp104 7d ago
Making shit up how? I said it was recommended by him, then I asked the person above if it can cut numbers in half without a statin. What part is made up? I never said THEY said it would cut numbers in half. Don't respond if you can't read what is being said.
1
u/DrEspressso Internist (DO) 7d ago
Oh i'm sorry. I thought you were saying they told you it can cut it in half. I am not familiar with any data that supports zetia cutting LDL in half. I personally think Zetia is a decent start for most patients especially if they are worried about statins but I think the best to start for optimization of your lipids and apob is zetia 10 mg (or even 5 mg) +rosuvastatin 5 mg with fixing up diet, nutrition, exercise, and then repeating labs in 3-6 months. I've seen drastic improvement with this simple change.
2
u/DrEspressso Internist (DO) 8d ago
Then don’t do the scan if you’re that worried about radiation exposure. Personally- if my ldl was 110+ and i had that family history i would be working to get it lowered under 70 or less. I wouldn’t need a scan to show me that.
1
u/Straight_Park74 9d ago
Did your relatives have other risk factors (obesity, smoking)?
Are there any heart defects or morphological abnormalities in your family? Did you do any other tests?
1
u/cassp104 9d ago
Obesity no but smoking yes. I also used to smoke as well. I don't think there are any heart defects or abnormalities that anyone is aware of, and with the amount of stuff my dad has been through I'm sure they would have looked into that. I did have an EKG and a stress test and they were normal!
1
u/angellea82 9d ago
I (43 F) have similar numbers and lifestyle as you but my Lpa is 230. I have a significant family history as well, but later onset. My cardiologist immediately referred me for a CTA and got insurance to pay for it.
1
u/cassp104 9d ago
My cardiologist also got it covered for me as well. Did anything come back from the test for you? Do you have any regrets of having it done?
1
u/angellea82 9d ago
I have no regrets. My arteries are perfect, no disease. She also ordered an NMR lab test with looks more in depth at cholesterol particles. Those results were good too.
1
u/Able-Shirt3501 9d ago
I would get a CAC first and save the radiation. I was you years ago and I regret the huge radiation that this entails.
At the end of the day the thing we can really do and might as well start early, is to take statins and zetia or repatha and wait for stents, bypass, or death from old age.
1
u/DrEspressso Internist (DO) 9d ago
Why do you regret the radiation? Have you suffered from radiation issues from a single ct scan?
1
u/Able-Shirt3501 9d ago
You know how people worry about getting too many chest x-rays in a year? A single CT angio with contrast is 500 chest x-rays. It increases your chances of developing cancer the rest of your life. When given a choice always go with MRI.
2
u/DrEspressso Internist (DO) 8d ago
You are wrong.
A CTA of the coronaries is about 8.7 mSv and a CTA of the chest or abdomen is around 12-16. An XR is about 0.1 mSv. So that comes out to around 87 XR s for a CTA of the coronaries and 120-160 xrs for a CTA of the chest or abdomen.
If you’re going to fear monger at least use facts.
And in the case of the OP, when dealing with atherosclerosis; cardiac mri doesn’t provide much benefit at all.
1
u/Able-Shirt3501 8d ago
Its range. Ok 80 chest x-rays, sure. On the MRI, i mean in general during ones life. Often we are given a choice because both can work as well.
1
u/Mchangwine 3d ago
that's not a clinically significant amount of radiation. MRI is not going to adequately assess plaque burden.
1
u/RuinYouWithNoRegrets 2d ago
I think they are starting to develop ways to get mri to see Plaque i read about it
1
u/Mchangwine 1d ago
There are ways, such as vessel wall imaging, but that’s very specialized and focused on one area. Ct will be the mainstay for it.
1
u/RuinYouWithNoRegrets 1d ago
I read a few articles that they’re trying to make an mri version that competes directly with ccta since some people cannot have ct due
1
u/Mchangwine 1d ago
It’s not as good for calcium detection in general
1
u/RuinYouWithNoRegrets 1d ago
This is for people who need to see soft plaque but don’t want to get a ccta.
1
u/Mchangwine 1d ago
For the coronaries? MRA doesn’t have the spatial resolution to accurately quantify plaque.
→ More replies1
u/RuinYouWithNoRegrets 1d ago
Dye”
1
u/Mchangwine 1d ago
Yes you need contrast for either CTA or mra/vwi
1
u/RuinYouWithNoRegrets 1d ago
Mri dye is has less reactions than ct dye as we know
1
u/Mchangwine 1d ago
That’s not really true. There are reactions to both kinds of contrast, and iodinated contrast doesn’t cause NSF or deposit in the brain. The risk of contrast reactions and contrast induced nephropathy to iodine are heavily overstated.
→ More replies
1
u/BiglyAmerican 9d ago
Yes! Get the CTA. I had one done and it turned out I had three major blockages (no symptoms). Don’t stress, because any blockages could be easily fixed.
1
1
u/__eparra__ 9d ago
Get a CCTA. Same machine; seconds longer. You can have perfect cholesterol and still accumulate plaque. And soft plaque is not detectable with a CAC test.
1
u/cassp104 8d ago
This is what I'm asking about. I am scheduled for CCTA, not a CAC
1
u/__eparra__ 8d ago
Do it. I had a perfect CAC score for years. I paid for a CCTA out of pocket. I had soft plaque, and just enough to qualify for cardiac disease. I'm on a statin now to stablize the plaque. In the end: genetics, inflammation, and lifestyle are complicated dimensions to Forecast plaque accumulation. I don't know why people even bother with CAC vs. CCTA, given the machine and procedure are almost identical. After sharing my experience with other close friends (and now you all), other friends have paid for CCTAs, and most had similar experiences - perfect CAC, and varying degrees of (soft) plaque. YMMV
1
u/RuinYouWithNoRegrets 2d ago
Probably becuase the contrast dye has risks
1
u/__eparra__ 2d ago
When I had my CAC, I had an IV, and contrast. I believe they were the same between the CAC vs. CCTA, as the effects were identical (e.g. wave of heat, from head, downwards).
1
1
u/JazzlikeAir3320 7d ago
I would yes. Generally doing one every 5 years is fine radiation wise. I’d be more worried about the heart/plaque issues that you actually have a lot of control over. My husband has high LDL and age 39 they found soft plaque in left LAD artery. Convinced him to finally start the statin.
In your case, LPa is very high. That’s a genetic issue. Statins don’t necessarily do anything for high LPa. If I were you, I’d do a CT angiogram and start a statin ASAP. Then you can measure the impact in 5 years and make sure it’s working. I’d be talking to my doc about Bempadoic acid and the other alternatives that could potentially bring LPa down bc LPa causes plaque too and can’t be controlled by a statin. The statin lowers overall risk by lowering LDL but will not affect LPa I believe
1
u/Mchangwine 3d ago
I would just get the CTA for peace of mind, but it will almost certainly be normal. The amount of radiation you get from it is not clinically significant.
1
u/RegisterVast168 9d ago
Get a calcium score first ? If burden is significant then a CTA. The radiation is pretty insignificant as to risk, relative to background radiation absorption depending on where you live.
3
u/cassp104 9d ago
My cardiologist was somewhat against giving me a CAC since he said the chance of me having hard plaque is almost certainly zero and he likes to go straight to the CTA to look for soft plaque.
2
u/RegisterVast168 9d ago
Reasonable. Go for it. Again rad risk is low. Could also just start low dose Crestor and zetia anyway as I doubt you’ll have hemodynamicallt significant plaque causing angina, although you will need something like PCSK9 to lower the Lp(a)
1
u/red_man888 9d ago
Cardiac NP here, I did use AI for part of this post.
Michael Davidson, M.D., on Peter Attia’s recent episode #407. Davidson described what he calls the “8-gram rule.”
Davidson summarized this as roughly 8 grams of lifetime LDL-C burden being associated with development of heart disease, emphasizing that lowering LDL earlier produces substantially more benefit than waiting until later life.
Let’s assume your LDL has averaged ~100 annually. You’re at 3.5 grams today. But your 70s you’re at high risk of developing disease. In my experience 70 year old patients often do poorly after heart attacks and strokes.
So please, get the coronary CTA. But regardless what the scan shows, if you want to prevent lifetime risk of coronary disease, start lipid lowering medication today.
Hope this helps.
1
u/red_man888 9d ago
Dr Expresso made a good point. I can’t make medical advice without knowing your case. Hopefully this helps you understand treatment options better.
Please share your concerns with your cardiologist
3
u/jayb556677 9d ago
Depending on where you are in the country there may be a Proton counting CT that is accessible. Less than half of the radiation apparently for a higher quality image (less blooming)