2018.06.01 01:19
2018.06.01 05:37
2018.06.01 09:58
An expected but valuable information in the paper.
And more valuable informations from Dr.Lee, one of the true front line soldiers in this
long battle against atherosclerotic CV disease.
2018.06.01 11:15
Thank you, Dr. Choh, for you comment and support.
We cardiologists now truly believe that all in all
atherosclerotic CVD is preventable with latest addition
of PCSK9 to the therapeutic preventive armamentarium.
Going back to the point I made for the elderly in the above
and to illustrate the case further, I would like to quote
three examples.
First one of my few mentors, a Cardiologist, died a couple of months ago
at age 97. He had coronary arttery(LAD)PTCA before the era of coronary stent
in his late 60's. With intensive medical therapy he continued active life,
maintaining three homes, extensive traveling, etc, for decades until
just about one month before he died in the hospital.
He was experiencing recurrrent sudden onset pulmonary edema and chest pains
requiring visits to ER and admission. Cardiac cath showed severe cad and
reduced LVEF. There was a window of a couple of days when he could have
had CABG at a significant risk because of his age and elevated creatinine 2.5.
He elected not to undergo surgery. He called for Hospice care after saying good by
to his family and doctors. He died in sleep with IV morphine running.
The second example is the well known comedian, George Burns, who had had
CABG in his 70's lived actively to be over 100.
Henry Kissinger who had had CABG many yrs ago is still active in his 90's.
Dick Cheney who had his first MI in his 30's is still active after his heart transplant.
He indeed was a prototype who took advantage of every major advance in the
history of modern Cardiology with heart transplant being the latest.
He had defibrillator implanted when he was Vice President.
I started Cardiology practice in 1971 and vividly remember all the desperate patients
and doctors in trying to control cholesterol and to prevent CAD and recurrent MIs,
strokes, etc, until we had the first statin, Mevacor, came out decades ago.
The contribution of the statins in dealing with atherosclerosis is inestimable, I believe.
The above examples could not have happened without statins.
An average patient absolutely has no idea how important this readily available drug is.
So many patients and doctors get carried away because of some side effects and stop
or neglect to take the medicine regularly.
There is a conviction or belief among cardiologists that if you have hypertension,
you automatically need to take statins because hypertension injures endothelium,
which will automatically invite atherosclerosis even at what you call normal level
of LDL.
In short, I cannot overemphasize the importance of lowering LDL as low as possible
along with the close control of BP, even for the elderly as long as you want to lead
an active life like those examples above.
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The higher the coronary artery calcium score is, the higher the coronary event rate is
over a period of 10 some years, which is not surprising.
The coronary artery calcification(cac)is the evidence of coronary atherosclerosis, which
has been studied extensively as a screening tool for the population wihth risk factors over the years.
There is a high incidence of cac among the elderly over age 70, more so over 80 and older.
The important known fact is that the most common causes of death in people in 70's are the same
in 80's and 90's but not in those over 100, i.e. CVD and cancer.
I used to follow patients with CAD as long as 40 some years, enabling me to observe the progression
of the disease longitudinally for decades.
Typically a middle aged man suffered a coronary event followed by CABG for multivessel cad.
I follow this patient regularly for decades. As his age advances into 70's, 80's, 90's,
he often would develop carotid disease and other PVD.
I would have a series of serious discussions in regard to how to stop or slow down the advances of atherosclerosis.
Pretty soon my patient and I come to the realization that my patient is pushed against the wall in that one more cardiac
event or stroke would be the end of the rope.
Pretty soon I convince my patient that the only thing to do is to lower LDL as low as possible,
something like anywhere from 40 to 70 in spite of the fact that we did not have the published data
among the elderly.
Believe it or not, I witnessed some of my patients reaching 90's and 100+ of ages even though some have
only one coronary artery partially open, and some of them have severe bilateral carotid stenoses and other pad.
In other words, as latest data show (that the lower LDL is, the lower the incidence of cad is,)
lowering LDL as low as possible for the elderly, in my medical opinion,
is just as important as in the younger people especially when there is evidence of cac.