At my insistence, my 77 yo father had a Coronary Artery Calcium (CAC) test done and his score is a worrisome 323. He is currently taking Bempedoic Acid + Ezetemibe which has lowered his LDL from 130 to 65 and his ApoB from 120 to 65. However, he only started doing this in February, so most of the damage was probably done before that.
His inflammation (HSCRP) has always been quite low (below 1.5 before and now at 0.5)
I am both happy and sad at this news. I am glad that we didn’t find out through a heart attack or stroke or instant death, but I am sad because it signifies that he has moderate heart disease and at a serious risk of death. We have an echo-cardiogram scheduled for next month and he is going to make an appointment with his cardiologist tomorrow. Should he stop going to the gym?
I am quite worried about him and I wonder what else he can do to prevent a heart attack or stroke? Add a statin? PCSK9i? Nattokinase?
I am considering having him at 20 mg atorvastatin which, according to this RCT led to a 63% reduction in LDL, which would bump his down from 65 to 45. However he takes GFJ with his Rapamycin so maybe he should take rosuvastatin, pravastatin, or pitavastatin that do not interact with grapefruit.
You can reverse atherosclerosis with one or more of the following supplements:
High dose Nattokinase : 12000 FU/day (2 capsules of 2000FU every 8 hours, for example) will reduce deposits by up to 36% per year (mentioned in another thread Anyone taking Nattokinase? Why not? - #7 by CTStan and here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9441630/). I prefer the NSK-SD Nattokinase used in those studies, though it is more expensive. I take half that amount prophylactically, even though my CAC score = 1.
Serrapeptase 160K-240K Units per day ( I take 100K units per day, consisting of 20K units from Serrapetase Natramedix, the top brand, + 80K units from Serra-RX, prophylactically, with a washout period of 3 weeks every 3months). Reportedly can dissolve the majority (50% ?) of plaque over a 12 month period, though the only well documented effect is to reduce fibrinogen levels, which is an independent predictor of CAD.
Lumbrokinase 600K-1200K LU/day, there is only one well studied brand (Boluoke). I take 300K LU (1 capsule) per day and it is expensive : the cheapest source I found is Femologist.com ($162 for 120 capsules, with 10% subscribe & save discount), amazon.com is $174.38 with subscribe and save. Reportedly dissolves plaque rapidly in 3 months, with an average 50% reduction over 12 months, (when taking 1-2 capsules every 8 hours) https://mednexus.org/doi/pdf/10.3760/cma.j.issn.0366-6999.20131332 (“After 1 year of therapy, the carotid plaque volume reduced falling by 41.84％ in the left side and 51.30％ in the right side in the treatment group．However, the carotid plaque volume increased by 103.38％ in the left side and 80.04％ in the right side in the control group”) . Such a rapid breakdown of plaque does come with a slight risk that pieces of plaque will break off and cause a stroke. This risk is reduced if the plaque is calcified (high CAC score) and risk is further reduced if also taking Nattokinase, since most of the stroke risk is from blood clots formed after the plaque tears away from the artery walls and Nattokinase acts as a clotbuster.
RemChol Cavadex to dissolve cholesterol plaque : $224/month (suppository) cholrem-cavadex.com. I have never used it, but some others here have reported using it. I would consider this as a last resort if Natto/Serrapeptase/Lumbrokinase are not effective.
Just using prescriptions to lower LDL Apo-B to below 50, also reduces plaque by up to 30% (cumulative), but reversal starts gradually taking 1-2 years to fully kick in : https://www.amjmed.com/article/S0002-9343(20)30945-1/fulltext ( " Stabilization of the atherosclerotic plaque occurs within 30 days of beginning antilipidemic therapy, and initial plaque reversal is demonstrable within 1 or 2 years thereafter.", though no specific rate of plaque reduction after 2 years is mentioned. Conversely, “…at an LDL of approximately 70 mg/dL, only 50% of high-risk patients reverse their atherosclerosis.”). Another article claims a total plaque reduction of 24% if LDL is maintained below 70 mg/dL (elsewhere it says at 60 mg/dL, but no mention how long that takes) : Can You Reverse Coronary Artery Disease?. With an LDL above 70mg/dL, plaque will continue to build up and use of Nattokinase, Lumbrokinase should be done conconcurrently with LDL Apo-B reduction, otherwise they willl probably not be as effective.
I also second taking colchicine : I got the 0.5mg dose from India and take 1 tablet per day prophylactically (start slow 1/4 then 1/2 tablet a day to avoid digestive upset).
This has been an ongoing discussion here… and I’d love to see any scientific references that support this (and I hope its true). I just haven’t seen anything on the specifics of reducing plaque.
@DeStrider I would also look at the Dean Ornish Programs for your father. He has books, online courses, etc. - and more. Check it out. The data seems reasonably good: https://www.ornish.com
@RapAdmin I got the Dean Ornish Program for my mother when she had a heart attack in March. I’m pretty sure my Dad is going to be digging into it as well.
Based on what I’ve read, I think we’re going to try a statin to get his LDL and ApoB down to about 40-50. We’ll see if his plaque reduces. If so, I’ll report it here.
We’ll also consider some other treatments as well!
Take a look at the book “Beat the Heart Attack Gene” by Bale and Doneen. It’s packed with lots of useful information. For starters, you want to know what’s contributing to the atherosclerosis. Also, consult with an endocrinologist and/or cardiologist, and consider ASA 81 mg.
As people get older it’s probably best to not do GFJ with rapamycin, because now it’s harder to introduce medicines that is affected by GFJ as I would guess older people have a harder time breaking or starting habits.
I think you are taking a sensible approach. There is no benefit to being more aggressive than medical management. Yes, events may occur, but getting more aggressive such as getting a CTCA or stents have not been shown to benefit outcomes.
If Lp(a) negative - I’d not goal any more aggressively, in general than an APOB anywhere in the 50’s.
There is some literature on Nattokinase in higher doses helping - there may be some excess bleeding risk there, as the literature isn’t as complete as I’d like it on the safety aspect. It is probably safe, but I’d talk with his doctor if thinking about this.
Getting something to non-invasively follow, such as carotid intimal thickness by U.S. might be a sensible approach to monitor yearly.
What shape is Dad in otherwise? This is really important in determining the longer plan - and naturally I can’t give advice specific to him - but in generalities - if someone isn’t likely to be alive 10 years from now due to non-vascular disease causes, the approach might be a little less aggressive than someone you think might otherwise make it to 100.
Irrespective, generally not a reason for panic. Also was the 300 CAC added diffusely through multiple vessels or focused all on a couple of vessels? I tend to be a little less excited if there is a bit in multiple places that add up to this versus almost all of it focused in one focal area. If so, then some might argue for a CTCA.
Anyway, hopefully this helps you contextualize a little on coming up with a plan with Dad’s doctors to most safely navigate through this.
@DrFraser Dad is in great shape except for the CAC results. He goes to the gym three times a week and is mentally tip top. He is a vegetarian. He did have a fight with prostate cancer that he won about 3 years ago. He had an LDL of 130 and ApoB of 120, but started Bempedoic Acid and Ezetemibe and it lowered to 65. All of his other blood biomarkers are optimal. That’s why we were so surprised by these results. We are hoping he can make it to 100 or beyond.
About 50% of the calcium is in the right coronary artery. So it appears to be concentrated.
If it gives you hope, I have been well over 400 for at least 15 years. Over 300 for well over 20. I also have elevated Lp(a)
My cardiologists are at UCSF and I can only share that they tell me not to worry about it (easy for them to say, right?!). For ME, they have told me there is nothing I can’t do and I’m perfectly healthy (aside from this one big thing). AKA, go run marathons if I so wish. I do know my plaque is not in the widow maker. As Dr F has said, they also told me they never do stents preventatively, and aside from medicine, diet, and exercise, there is nothing to do.
If there is shortness of breath or another sign, then you go and have the testing done… I did and went for all the testing but I was fine.
And glad he’s a vegetarian…. If he can give up all the sat fat he’s willing to give up, that would is what they would advise. Meaning, give up cheese/butter if he is willing.
I don’t tolerate statins so am on a pcsk9… i started ezetemibe recently … also on colchicine
Oh, and don’t forget baby aspirin… they advise me to take on 3x per week… I probably take a little extra
I’d expect those results with having an APOB of 120 … likely for many decades. The other usual focuses are making sure Dad is insulin sensitive and his BP is well controlled. Those would be the usual risk mitigation approaches that have reasonable evidence.
Sounds like Dad is lucky to have you looking after him … It’s a problem with the health system that, if the lipids were like this 30 years ago, that it wasn’t addressed and managed for the entire time.
@DrFraser Should we be worried that 50% of the calcification is in the right coronary artery?
As for BP, he just started Telmisartan 20 mg. He’s in the 120-130 SBP and 60-70 DBP range. He is also taking Empagliflozin and Metformin along with Rapamycin (4 mg + GFJ).
Fortunately, this is not particularly significant in an asymptomatic pt > 75. Some would go as far as to say it may often cause more harm than good for most in that age group to perform CAC. He’s at 52% percentile, so he’s just an average 77 yo man. I had a 48 yr old pt last week with a CAC of 930. All 77 yo men have +CAC, only 2% of 77 yo men have a CAC of 0.
Yes, I would pursue all tx as normal to hit targets. > 400 CAC your targets should be the same as those who have already had an event. By more harm than good, I meant many will be much higher than this at 77. Often into the 1000s, I’ve seen one 7000+ CAC personally. Then they have caths, leading to stents that they may or may not need. Many 77 yr olds esp w/ scores into the 1000s have multiple comorbidities and it is generally best to leave them alone if they have no symptoms. But people will freak out, it will cause mental issues and they’ll often demand everything be done, which can be a particularly slippery slope in this population.
