As usual, debates have been swirling in Lipid Land regarding the timing of statin initiation and the utility of CAC as a screening tool for atherosclerosis.  Essentially, the extreme perspectives are as follows:

1. Let’s statinize the entire population to get LDL-C levels down to “physiologic,” which is between 22-44 mg/dL (since that’s what you’re born with).
   1. Or “In general, let’s start statins on everyone in their 30s, just so people don’t accuse us of utter insanity.”
      1. By the way, by age 2 months, average LDL-C is 65-80 and ApoB is 73, since by that time, the fetal liver has had some time to mature.  For what it’s worth.
2. CAC is terrible, useless, and it doesn’t change anything in regards to management!
   1. Right…better just use that awesome Risk Calculator.

So if you are of the School of Thought that “cumulative exposure to atherogenic lipoproteins” will inevitably result in atherosclerosis (this is equating “Plaque Years (LDL Years) to “Pack Years” of cigarette smoking), then it would be reasonable to put everyone on lipid-lowering therapy (except maybe people with genetic hypobetalipoproteinemia…although those folks can STILL GET ATHEROSCLEROSIS…hmm).  Although it’s tough to explain why many people with genetically high cholesterol levels never get any plaque in their arteries or have cardiovascular events despite their “Plaque Years” score being stratospheric.  However, this “Plaque Years” model seems to operate under the assumption that these ApoB-containing lipoproteins are inherently toxic (rather than Mailmen who hopefully are law-abiding citizens but may, in certain situations, “go rogue” and commit Cholesterol Crimes in the arterial wall).

If you are using a Home Security System and Lipid Neighborhood framework, you will recognize that merely living in what appears to be a “rough Lipid Neighborhood” on paper doesn’t necessarily mean that there will be an inevitable “break-in,” as evidenced by a positive CAC score (or identifiable arterial plaque on other imaging techniques).  Perhaps you may have less margin for error, but THIS ARTICLE suggests that the supply of lipoproteins (the number of ApoB Mailmen) is not, by itself, a sufficient explanation for them to, rather than deliver triglyceride “packages” to muscle and fat cells, deliver cholesterol “Plaque-ages” to your arterial wall.  See this quote:

“As the number of retained lipoproteins is several orders of magnitude less than the number of particles that diffuse through the arterial wall, the supply of lipoproteins is not a limiting factor for the retention. The main determinants seem to be the lipoprotein characteristics and the capacity of the vessel wall to bind lipoproteins.”

However, if there is evidence of a “break-in,” it makes sense to utilize the available tools in the lipid-lowering toolbox to “move you to a safer Lipid Neighborhood,” given that many of these tools have, in large randomized controlled trials, reduced cardiovascular events.  And observationally, lipid-lowering therapies in people with CAC=0 don’t really seem to help much.

So here’s one way to view the entire conversation:

We are all RUNNING THE RACE OF LIFE. 

Taking a STATIN is like wearing a HELMET.

Runners typically don’t need to wear HELMETS, and if you are wearing a HELMET while running, you’re probably not going to run quite as efficiently (insert discussion about deleterious effects of statins on glucose metabolism and muscular mitochondrial function).

However, if you have had a CORONARY CONCUSSION because you’ve been running through a dangerous Lipid Neighborhood with volcanic ash-erosclerotic debris falling all around you, you probably ought to wear a helmet and move to a safer community.

Also, if you’ve decided to live F.A.S.T. (Fat, Actively Smoking, Terrible Lifestyle/Diet), then maybe we consider getting you to wear a helmet at a younger age because of your insistence on riding a Motorcycle of Metabolic Mayhem.  Will the helmet prevent a disastrous wreckage?  Maybe, but hopefully you just get off that bike.

And maybe you come from a family of total Kolesterol Klutzes who, despite not necessarily living F.A.S.T., tend to get concussions early in life because they run into mailboxes or fall off of curbs.  Perhaps it’s reasonable to wear a helmet if you “picked the wrong parents” in that regard.

And if you aren’t living F.A.S.T. riding a Motorcycle of Metabolic Mayhem…

And you aren’t a card-carrying member of the Kolesterol Klutz Family…

And there is no evidence of a Coronary Concussion on imaging…

And you aren’t running your race through a modern-day Vesuvius of volcanic atherogenic shrapnel…

Do you need to be “that guy” wearing a helmet as you run the Race of Life?

I’ll always meet you where you’re at if you want me to prescribe you a helmet, and I’ll make sure it’s one that appropriately fits. Just don’t ask me to enroll you in a gene-editing trial or give you a mask to wear while you’re walking or running outside😊