Dr. Keith Roach

DEAR DR. ROACH: I am a 61-year-old white woman who is 5’5″ tall and weighs 150 pounds. I walk two miles just about every day, and easily hit more than 10,000 steps almost every day. I have never smoked. I do not have high blood pressure.
However, I have very high cholesterol. Here are the numbers of my last reading in February: total cholesterol was 288; triglycerides was 119; HDL cholesterol was 69; VLDL cholesterol was 21; and LDL was 198. All other measurements of blood and urine factors are within normal ranges. I took atorvastatin and had a full-blown allergic reaction, and I had a reaction to pravastatin as well. Niacin caused severe muscle pain for me.
My doctor’s office referred me to a cardiologist. My calcium score was 0. I have no family history of heart issues. I am now taking fish oil and ezetimibe, but the cardiologist implied this is of almost no value. The cardiologist has suggested he may wish to prescribe Repatha or Praluent. When I asked him the risks of these medications, he said there were none, except the possibility of a tough, itchy spot at the injection site. I don’t believe this, and in fact, this cardiologist did not inspire confidence in me. Should I consider one of these drugs? — H.C.
ANSWER: Your cholesterol levels are high, and with an LDL above 190, most authorities do recommend treatment. However, you have a high to normal HDL cholesterol and no family history, which reduces your risk. You have a calcium score of 0, which also significantly reduces your risk.
The cardiologist is using his best judgment, but given your combination of risk factors and protective factors, I think it would be helpful to get some aid in doing a formal decision analysis, using an algorithm to estimate risk.
I used the MESA score to estimate yours based on your cholesterol numbers, family history, blood pressure and the results of your calcium score. Although these calculators do not take into consideration many less traditional risk factors, it is at least a starting place, and the result, which may surprise you, estimated your risk of having a CHD event (heart attack, death or need for surgery or stent) within the next 10 years is 1.6%. At this level, I would recommend against medication treatment of your cholesterol levels. Even though the CSK-9 inhibitors like Repatha and Praluent have low risk for side effects (pain and bruising at the injection site in 5-10% of people is the most common), these drugs are very, very expensive.
Unless there is more information you haven’t told me, I think the cardiologist may have experienced what we call an anchoring heuristic error, where he became so fixated on the different treatments available (which would be appropriate in a person with known blockages in the arteries) that he didn’t step back and consider how much benefit you might get from treatment. (It’s called “anchoring” because he became anchored to the idea that you need treatment.) In this case, because your estimated risk is so low, there is little potential benefit from medication treatment. The calcium score of 0 is a major reason that your estimated risk is so low. Continued exercise, a heart-healthy diet and stress management are much more likely to benefit you than medication.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.
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