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Welcome to Doctor Warrick's Podcast Channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick Believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.

Hi, my name is Dr. Warrick Bishop, and I'd like to welcome you to my podcast station, my videocast station, and of course to the Healthy Heart Network. Today, I'd like to share with you a patient experience, because it might be a question that you've had yourself. Just today, I was asked by a patient, "if my arteries look okay on C.T. imaging if I've got a zero calcium score, can I stop my cholesterol tablets?" What a great question.

So, this comes up a fair bit and I would like to take a moment to discuss it, and I'm sure that someone out there will have had this experience. There's a couple of things to remember here, I think. We know that zero calcium is a very good predictor of a low risk of event in average people with average sort of risk factors. That's because they're the group of people who are examined when they did this sort of work. The people who didn't get into these observational trials are people with really high blood pressure or really high cholesterols, or really bad family histories, perhaps. I can't answer that for sure, but what I'm sort of saying is that average people at average ages, went into the trials that informed us that low calcium scores are a very good reassurance.

Now that's important to think about, because, if for example, we took a 50-year-old male who had a high cholesterol. Let's say his total cholesterol was 7. 7 or even 8. Let's say his bad cholesterol is 4.5. Something like that. These are high numbers. If that 50-year-old male has a zero coronary calcium score, should we take him off his cholesterol-lowering tablet? To some degree, nobody really knows the answer for this, and so it warrants some discussion and consideration. The first thing that we know, is that if he's a 50-year-old male with nothing in these arteries, regardless of his cholesterol level, and regardless of anything else, if he has no calcification, then there's probably not any plaque in his arteries, and that's a pretty good sign.

It is possible to get plaque in the arteries that have no cholesterol, but it's pretty uncommon. But it can happen. Pretty uncommon. The other thing that we want to know, or the other thing that we want to bear in mind, is that when we looked at the data that informs how reassuring a zero calcium score is, it didn't look at people with super high cholesterols, because most of those people get put on therapy without a second thought. The other thing is this: all our research tells us that high cholesterol levels create an environment where plaque can form. That doesn't mean they always cause it. No. But they create an environment where it can occur. And the analogy I often use is, I live in a house that is near the sea, and my house is made out of steel. Now, if I walk around my house today, and there's no rust in the steel, does that mean I don't have to think about painting my house ever again? No. And that's because there is a powerful environment for rust formation because I live by the sea. And so, to some degree, I wonder if we need to think about cholesterol and arteries in a similar way.

If patients have a LOT of risk, perhaps from an elevated cholesterol level, then perhaps we need to think about that environment being something that could drive a problem in the future. It just hasn't to now. So how do we deal with these people with a zero calcium score and elevated cholesterol levels? Well, my experience is that plenty of people want to get off their statins, and I sort of understand that. It's nice to think you can get off medications because, well, taking medications is a bit of a pain in the backside, and psychologically, it gives you the impression that there's something wrong with you.

However, I think it's more complicated than that. We don't have data to guide us in that space. That's for sure. So, what I often say to patients is "look, in the ideal world, I would like to see your cholesterol kept down a bit, because I recognize that that high cholesterol level is likely to be an environment of plaque formation. And although you have nothing in your arteries at the moment - that's fantastic - but I want to keep it that way."

So, my stance is normally to say, "look, if your cholesterol levels are high, it's probably not a bad thing to be on a cholesterol-lowering agent, and that's fully in keeping with all current guidelines." Now, some people will say, "oh doc, I don't want to be on a tablet! I'll do anything to get off these tablets!" or, "I'm having lots of trouble with these tablets," that's possible as well. In that situation, then a specific strategy needs to be employed where we recognize that the environment for plaque formation or build-up of cholesterol in the arteries continues to exist, and we recognize that that process is dynamic. And so, for some patients, I will say, "I'm open to the possibility of you coming off your cholesterol therapy, but we have to continue to monitor you closely.".

We know that a zero calcium score in an average patient, say an average 50-year-old bloke, is pretty good for five years. It's pretty good for five years, but we don't know it's good for five years in someone whose cholesterol is elevated. So, I will often say to these people, "I'm happy for you to come off your statin, but we need to put in place a strategy of surveillance to make sure that we keep a very close eye on anything that may develop. If there is a spot of rust or spot of cholesterol in the pipes, we need to know straight away.".

So, I'll often say, "look, as long as you're able to keep off the cigarettes, keep your blood pressure down, keep your weight under control, keep regular exercise happening and eat well, then, come off the medication, but we need to repeat image in say two years. Or three years. But sooner than that regular five years, and I'll pick that time or discuss that time with the patient based on their age, their other risk factors, their potential family history, lipoprotein little A, gaining weight, exercise, etc.

There isn't a clear cut answer here. In general terms, I think keeping the cholesterol down makes sense. Certainly, if people are adamant they want to be off that medication if they can, then I'd like to check the carotid arteries as well, because although it's very uncommon, a zero calcium score generally suggests that the rest of the vasculature is clear, but very occasionally, you can have a zero coronary calcium score, yet still have plaque in the arteries of your neck. And so, I wouldn't think about stopping therapy for any lengthy period of time whatsoever unless I had clear information about what's going on in the carotid arteries of that individual.

"So, what's the answer to the question, doctor? If my calcium score is zero, can I come off my statins?"

Well, the answer is, "it depends." It requires a very detailed and considered discussion around the exact levels of the cholesterol, the age of the patient, the sex of the patient, the family history of the patient, the other risk factors the patient has, what other interventions they're going to put in place to mitigate their risk, and then figuring out a sensible repeat scanning interval to make sure that no plaque does develop in that individual.

I haven't given you a straight answer, but deliberately, I didn't give you a straight answer because there isn't one. But it's a really important conversation. In general terms, I think of that cholesterol, really in those higher levels, particularly if there's a whiff of family history, then my practice would be to make sure people remain on a cholesterol-lowering agent. If they want to back it off a little bit, sometimes I'm happy to do that as well, but gee whiz, what an interesting space where there's no precise guide to tell us exactly what to do, but there's plenty of stuff to think about.

I hope that makes a little bit of sense to you. If you have any questions, please let us know. If you have any ideas for future podcasts, we'd also like to hear from you. For now, I'm going to say goodbye and wish you the very best, and please, don't die from a heart attack. Goodbye. You've been listening to another podcast from Dr. Warrick. Visit his website at drwarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.

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