Statins may cause soft plaque to calcify

Insights and discussion from the cutting edge with reference to journal articles and other research papers.
Post Reply
User avatar
Stavia
Contributor
Contributor
Posts: 5255
Joined: Tue Apr 29, 2014 6:47 pm
Location: Middle Earth

Statins may cause soft plaque to calcify

Post by Stavia »

http://www.medscape.com/viewarticle/842499

Once a statin is commenced and taken for a significant period of time, it may cause soft plaque (that is more prone to rupture) to become calcified and thus converted to a stable state.
This has implications for using a coronary calcium score for monitoring effects of statin therapy. It may be misleading to consider that serial coronary calcium scores are useful once a statin is commenced.
apod
Senior Contributor
Senior Contributor
Posts: 971
Joined: Fri Mar 06, 2015 5:11 pm

Re: Statins may cause soft plaque to calcify

Post by apod »

I wonder what the mechanism is here and how this might relate to "statin-like" supplements and foods (eg. natural HMG-CoA reductase inhibitors or foods like oyster mushrooms.) I suppose this is protective and not an arterial calcification concern?
User avatar
Stavia
Contributor
Contributor
Posts: 5255
Joined: Tue Apr 29, 2014 6:47 pm
Location: Middle Earth

Re: Statins may cause soft plaque to calcify

Post by Stavia »

Good question apod.
I guess its possibly protective. We know statins are protective in ways beyond just LDL lowering. Perhaps this is one of them.
User avatar
KatieS
Senior Contributor
Senior Contributor
Posts: 1224
Joined: Wed Mar 05, 2014 1:45 pm

Re: Statins may cause soft plaque to calcify

Post by KatieS »

Apod, you have an amazing knowledge of the various food nutrients! Before statins, I used to eat oyster mushrooms regularly.

Thanks, Stavia for posting the Medscape article. If I have a coronary calcium score, I should do this before I'm on statins too long. Interesting how this plaque stability did not correlate with lipids. Also they mentioned the score interpretation: "The editorialists speculate that coronary calcification might be better thought of in patterns, such as spotty calcification vs more coalesced calcification, rather than as a "monolithic unit." The density of calcification might also provide more important information than one lone number, such as the Agatston CAC score." My husband & his brother have relatively low calcium, but all within the LAD.
User avatar
ru442
Contributor
Contributor
Posts: 706
Joined: Sun Mar 20, 2016 8:52 am

Re: Statins may cause soft plaque to calcify

Post by ru442 »

Maybe this explains my high CAC score??.... since I've been on statins for 12+ years.
Male 4/4 56 yrs., "Live, Laugh, Love"
User avatar
Stavia
Contributor
Contributor
Posts: 5255
Joined: Tue Apr 29, 2014 6:47 pm
Location: Middle Earth

Re: RE: Re: Statins may cause soft plaque to calcify

Post by Stavia »

ru442 wrote:Maybe this explains my high CAC score??.... since I've been on statins for 12+ years.
Could be RU. Its quite reassuring I think.
User avatar
ru442
Contributor
Contributor
Posts: 706
Joined: Sun Mar 20, 2016 8:52 am

Re: RE: Re: Statins may cause soft plaque to calcify

Post by ru442 »

Stavia wrote:
ru442 wrote:Maybe this explains my high CAC score??.... since I've been on statins for 12+ years.
Could be RU. Its quite reassuring I think.
Yes it is given my normal stress test results.... seems to correlate well I think.
Male 4/4 56 yrs., "Live, Laugh, Love"
User avatar
slacker
Contributor
Contributor
Posts: 2127
Joined: Wed Aug 03, 2016 6:20 pm
Location: Kentucky

Re: Statins may cause soft plaque to calcify

Post by slacker »

very interesting and helpful discussion. I've been off statins for over 5 years but was on them all sequentially and consistently at least that long prior to stopping. Maybe I should save my $$ and skip the coronary calcium imaging; this study may have pushed me off this particular fence I've been balancing on.
Slacker
E4/E4
GenePoole0304
Contributor
Contributor
Posts: 561
Joined: Mon Nov 10, 2014 7:20 pm

Re: Statins may cause soft plaque to calcify

Post by GenePoole0304 »

the value is reading the comments of some well known doctors..I picked the best in my opinion.

77 comments
Newest | Oldest
Dr. mostafa ahmed hussein| Internal Medicine May 19, 2015
This paradoxically relationship is curious but may I explain by tha;the intensive stating dose affectso the soft tissues of a the Roma and has no effect on calcium content so a sizero of a the Roma is less while calcium increased.
Like
Dr. RAJEEVE KUMAR| Cardiology, Interventional May 7, 2015
Very interesting and not unexpected : stable plaques on stain therapy : calcium score may increase but does not lead to increased events
1Like
Dr. William Blanchet| Internal Medicine May 4, 2015
First off, we are comparing plaque volume by IVUS with calcium change by IVUS, not by ultrafast CT. This technique limits the ability to look at the total calcium progression as we look at only specific segments of a percentage of the coronary vascular bed. In addition, IVUS detects calcium below the threshold for detection by CT. Prior statin studies have often found a small benefit in serial CAC by statin use and an even smaller incremental reduction in CAC progression with high dose statin vs low dose statin. This study suggests increased progression of calcified plaque with use of high dose statin therapy not seen in most prior statin studies.

I am not aware of any studies correlating serial IVUS calcium with serial CAC by ultrafast CT to see if the IVUS correlations have any validity.
I am also not aware of any studies that correlate serial IVUS studies with clinical outcomes. We assume that serial IVUS predicts coronary outcomes. In reality, the PERISCOPE trial found net regression by IVUS on those randomized to Pioglitazone. There was a nonsignificant 18% reduction in heart attacks in the Pioglitazone cohort. In the very large Proactive trial, there was a nonsignificant 10% reduction in the study's primary end point of all macrovascular events among those randomized to pioglitazone vs placebo but found a significant 16% reduction in the secondary composite end point of death, MI, and stroke with pioglitazone treatment. For a therapy associated with plaque regression by IVUS, this is a rather weak reduction in hard endpoints.
Compare the multiple studies of CAC by ultrafast CT where the event reduction is dramatic and proportional to the baseline risk. The greater the baseline risk, the greater the event reduction associated with plaque stability. In the Ragi study, there was a 17X reduction in MI across the board but with a 40X reduction among those with CAC>1,000. Other studies have shown a 5 to 10X reduction in events based upon calcium stability vs progression. In addition, calcium stability by EBCT correlated with plaque stability by serial quantitative angiography.
As this meta-analysis has adequate numbers of patients that hard outcomes could be reported, it does beg the question as to why they are not reported.
The Canadian studies of serial carotid ultrasound have found only a mild correlation between event reduction and carotid plaque regression but no difference in hard events between plaque progression and plaque stability by total plaque area analysis via ultrasound.

So we can conclude from this study that serial CAC by IVUS does not predict plaque regression by IVUS. We have no basis for assuming that these results correlate with coronary events. As no one should do screening serial IVUS studies, I am not sure the relevance of this study in clinical medicine. Perhaps for bench research.


Dr. William Feeman| Family Medicine Apr 8, 2015
@Dr. JOSE CASCO RAUDALES @Dr. William Feeman Just treat lipids to plaque stabilization/regression levels and get the patient off cigarette smoking, and treat hypertension too, and that's all you have to do. I have never ordered a CAC, which I regard as a useless waste of money.
Dr. david frisch| Internal Medicine Apr 4, 2015
I have managed several hundred patients with CAC scores in the 90-99th percentile of risk and thousands above average over a period of up to 15 years. My highest current patient score is 7200. I am so pleased to see this article. There is significant established data that indicate untreated/pretreatment high calcium scores in the absence of treatment are an indicator of CV event risk. I suspect that treating patients with elevated CAC scores takes that individual from a high (>75 %tile) risk to, most likely, below average risk. How exciting!! This has been my intuitive and experiential position on this issue and how I manage my thousands of high risk patients. It's reassuring to see some counter proposal to the idea that progressive calcium scores >15% per year or more are a greater danger. Obviously there is much more to learn, but the progress has been very encouraging thanks to the work of Dr. Nissen and his colleagues and many others using technologies like IVUS, NMR, the science of lipidology etc. etc. I think we now know that treatment with statins (and perhaps other lipid therapies -- i.e. the CLAS study and others) can stabilize the thinning "cap" of the plaque, reverse/resorb the soft unstable lipid core of the plaque, alter lipoprotein structure and function and stabilize the vulnerable plaques resulting in lower event rates. I'll be anxious to discuss this with my colleague and friend Dr. Matt Budoff (Professor UCLA) who has published data suggesting higher event risks with rising CAC scores. Dr. Budoff is one of the most acclaimed experts in the US on cardiac imaging technologies.

Dr. William Feeman| Family Medicine Apr 4, 2015
@Dr. Alan DeCarlo Statins were not released till 1987, if I recall correctly. If your lipids are at plaque stabilization/regression levels, you can ignore CAC. I remember the Arizona Heart Institute presenting a case of a 70 year old man with wonderful lipids but dense CAC. They hammered away at these already ideal lipids using statins and watched in horror as his CAC increased. The patient had no health problems; he simply had a screening CAC done because it was advertized as a good idea. I wonder what his parents, who were in their 90's and in good health, thought.

and we must not forget that statins can deplete Coq10 from 48-75% increasing with age.

Terry Lynch| Other Healthcare Provider Apr 4, 2015
@Dr. William Feeman @Dr. roberto massa A doctor friend had us over to dinner a few weeks ago. After 10 years of religious statin protocol with Lipitor he collapsed and could not move. Turned out he had Statin induced Rhabdomyolysis and needed a quadruple coronary bypass. He is still a true believer though...he says "it is in my genes" and has continued on with another Statin therapy? He also got hit with Mevcor from way back. I said nothing. Meanwhile his wife was developing Statin Diabetes. Of course it was not the magic bullet statin therapy her husband/doctor had her taking. A hole through the pancreas, heart, and brain with the same bullet?. Maybe JFK can help us on this mystery? I said nothing to my host. I remain a Statin atheist, but I sure believe you are a kind descent caring human being. I get a lot from your posts. aloha my friend

M J| Other Healthcare Provider Apr 3, 2015
Dear Medscape: Did you choose the picture of the concrete pipes to be sarcastic about your title question - maybe in a good way? Thanks JP Sands for pointing out that MERCK PAID MEDSCAPE $3,873,850 in just the last three quarters of fiscal year 2014. Medscape provides a great venue for us to share ideas; I like that it is free but it never occurred to me that the 'positive spin' in most titles might be contrived to appease the financial backers of the medical news/blog. I'm glad to see that other readers also questioned the wisdom of trading arteriosclerosis for atherosclerosis. Was the photo of the concrete pipes designed to make us laugh at the advantages of stiff vessels just to publish this amusing study about calcification of vessels without angering the financial backers? Pretty slick droll humor. It is gratifying to see that 9 people liked my scientific explanation below (the first comment submitted) which means that many of us are truly interested in honoring the science that allows us to critically think about these clinical studies with surprising outcomes.
24Like
Terry Lynch| Other Healthcare Provider Apr 4, 2015
@M J sad that real scince is hijacked by " thirty pieces of silver". Same with the American Diabetes Association "approval with reservations" of statin protocol that causes diabetes and statin induced peripoheral neuropathy. Oh well...at least the spin the writer for medscape cardiovascular is pretty apparent in his pro statin no matter what happens to you reporting. Perhaps intelligent study also provided in some opposing publications gives us a more balanced view? Thanks to Medscape for offering some oppositional evidence too.
Post Reply