DEAR DR. ROACH: I’m a 76-year-old Caucasian male who’s in excellent health. (Or so I thought.) Recently, my cardiologist suggested a coronary artery calcium (CAC) test, and my score was a frightening 1,241! I’m now extremely concerned about my heart health.

I’ve been extremely active all my life, and I routinely work out — about 10 hours per week. My resting heart rate is about 50 bpm, and my blood pressure has long been about 110/70 mm Hg. Once or twice a week, I’ll raise my heart rate to a measured 162 bpm during a HIIT (high-intensity interval training) workout and feel fine afterward. My total cholesterol is 220 mg/dL, with an HDL of 90 mg/dL. I’ve never smoked, and I don’t have a family history of heart disease, chest pain or shortness of breath.

I have a follow-up appointment with my cardiologist soon, and I’m guessing that he may recommend statin treatment. Which additional tests would you suggest before beginning any intervention? Also, what would be the relative and absolute risk reduction as well as the number needed to treat (NNT) with statins?

•J.S.

ANSWER: I’d start with the MESA calculator (tinyurl.com/MESARisk), which combines traditional risk factors with the CAC score. With the information you’ve given me, your high CAC score changed your 10-year risk of a serious cardiovascular event from the 5.5% (predicted by your excellent blood pressure and cholesterol) to a much higher 11.5%. (These numbers are probably overestimates for you because they don’t consider your diligent exercise.)

A good rule of thumb is that statins reduce your relative risk by roughly 20% of your absolute risk. This means that instead of 11.5%, your risk on a statin would be 9.2%. This is an absolute risk reduction of 2.3% or a NNT of 43 people, who’d be treated for 10 years to prevent one heart attack, stroke or death.

I’m struck that your traditional risk factors are low but your CAC is high, so your cardiologist may look for other risk factors, such as a high Lipoprotein(a) level. If your Lp(a) level were very high, your cardiologist might consider a PCSK9 inhibitor instead of or in addition to a statin. New treatments for high Lp(a) levels are in trials now.

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 ToYourGoodHealth@med.cornell.edu.

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