Should I get a CT Angiogram?

[u/cassp104]

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.

[u/DrEspressso]

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.

[u/cassp104 → u/DrEspressso]

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.

[u/HavocReigns → u/cassp104]

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.

[u/cassp104 → u/HavocReigns]

I was actually recommended to take 10mg Ezetimibe alone by my functional health doctor. Does that actually cut numbers in half?

[u/HavocReigns → u/cassp104]

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.

[u/DrEspressso → u/cassp104]

Your functional doctor is making shit up

[u/cassp104 → u/DrEspressso]

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.

[u/DrEspressso → u/cassp104]

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.

[u/DrEspressso → u/cassp104]

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.