High CVD Risk Advice

Medical Q&A [Moderated]
1

Hi Doctors,

I’m writing to ask if you have any advice for my 80+ year old father (see bloodwork below). I’ve read your articles and listened to podcasts on cholesterol. My father is relatively active for his age but lives in a very small town with limited access to doctors, specifically 1 doctor. He can get to my sister in Chicago who has some medical connections and might be able to get him more advanced assessment or procedures.

My concern came from him telling me he was refusing to take the statin that his Doc had prescribed. He said it was prescribed due to “some elevated Calcium score,” as he put it. That prompted my request for the data below. He told me he had been on a statin years before but stopped it due to the muscle aches. He is opting to take Vitamin K2 alternatively (???). I’ve heard of this having potential benefits but no idea if it is a worthwhile alternative to a statin, especially at this stage. I’m admittedly a bit confused about statins as well even though I’ve read your explanations of the science. My dad gives the impression that he is healthy because he walks, sometimes rides a stationary bike, is an avid gardener and eats tons of veggies, some lean meats and fish. But he also has a sweet tooth for ice cream and baked goods and isn’t doing a specific strength or conditioning program of any kind. I’m going to guess he is around 50 lbs overweight?

From my limited understanding of the data below I know he needs to focus on diet/exercise. Glucose control is possibly/likely an issue. I don’t think his doctor states the need for weight loss or exercise urgently enough, if at all.

I know this is very late in the game. Is there any deeper testing that should be done to see if there is any blood flow restriction that might cause eminent danger? He is still active and mobile and we really want to keep him that way as long as possible. We will continue to urgently press him to focus on strength and conditioning (trying to get him to go to the local YMCA) and will show him your general diet advice.

Thanks so much!
Sincerely,
Kathy

CAC = 663
Tri = 76
HDL =61
LDL = 134
Total chol = 210
Non-HDL = 149

Sodium Level 138 mEq/L 135-145 mEq/L
Potassium Level 4.4 mEq/L 3.5-5.1 mEq/L
Chloride Level 105 mEq/L 98-107 mEq/L
Carbon Dioxide Level 26 mEq/L 22-30 mEq/L
Anion Gap 11.4 mEq/L 6.0-16.0 mEq/L
Blood Urea Nitrogen 18 mg/dL 9-20 mg/dL
Creatinine 0.88 mg/dL 0.66-1.25 mg/dL
Estimat Glomerular Filtration Rate > 60.00 /1.73m^2 >60 mL/min /1.73m^2
BUN/Creatinine Ratio 20.5 3.0-33.0
Glucose Level 107 mg/dL 70-100 mg/dL H
Calcium Level 9.0 mg/dL 8.4-10.2 mg/dL
Hemoglobin A1c Percent 6.3 % 4.8-6.0 %

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2

Hi Kathy,

I understand your concern. However, these decisions always need to be individualized – even moreso for a patient who is well into their 80s. I have seen people in their 80s who have no interest in additional medical intervention and potential side effects, or who have relatively poor quality of life with little room for improvement from medicines, versus others who are otherwise very healthy, vigorous/active, and seeking to gain every bit of additional life they can.

I would not view K2 supplementation as an effective alternative to lipid-lowering therapy like statins. However, by the time someone is at this age, the majority of the “damage” from lifelong exposure to blood lipids is done (as evidenced by the calcium score, which is not surprising at this age). The potential benefits of starting lipid-lowering treatment diminishes at this point compared with starting it in a younger person earlier in life. However, if he wanted to absolutely maximally reduce his risk from this standpoint, there are other statin options that could be tried, alternative dosing strategies, or non-statin options altogether. These would require a consultation and detailed conversation to work through both his reservations and the available options.

I agree that the blood sugar (as evidenced by his HgbA1c) could be better, although this isn’t surprising either if you say he is carrying approximately 50 lbs of excess weight, and his waist circumference is presumably elevated. Similar to the above discussion, addressing these will come down to a conversation with him about his values/preferences, goals, etc. Of course, the other risk factor to check on is his blood pressure, too.

If he is moderately active without symptoms like chest pain or shortness of breath, there is not a role for advanced heart/coronary testing like stress tests, angiograms, stents, etc. at this time.

In short, I would not pursue a ton of advanced testing here. There are certainly some lifestyle interventions that can be discussed and recommended, and the question of medications is going to involve a conversation about what is “worth it” to him at this age, in terms of potential upsides balanced against potential downsides.

3

Thank you! That’s incredibly helpful, as much for me as for him. :slight_smile:

4

He did email me back this morning to say his last BP was 142/85. He definitely does have some issues with shortness of breath even with just walking at times. I’m not sure how severe that is.