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Dear Dr. Roach: I’m writing to request a second opinion regarding my cholesterol situation. After 20-plus years (I’m 66) on statins, I have become concerned about perceived muscle fatigue. I went off Vytorin for two months and had a blood test. Before going off, my numbers were HDL 56, triglycerides 60 and LDL 111. After being off the statin for two months my numbers were HDL 65, triglycerides 86 and LDL 205.

Because the triglycerides and HDL were still within the reference range, but there was a large increase in the LDL, my doctor recommended that I have a coronary calcium screening done. This score came back a 3. Given that number, my doctor felt I did not need to be on a statin. I might add that none of my other yearly blood and urine screening numbers are ever out of the normal range. I have never smoked, and I exercise four or five times a week. I’m 6 feet tall and weigh 165 pounds. However, I’m now wondering if I am making a mistake by being off the statin, given that the coronary calcium screening is not a standard test for cholesterol.

T.Z.

Dear T.Z.: The most important point is that an LDL of 200 is too high, and it should be treated, normally with a statin. If you had side effects to simvastatin (the statin component of Vytorin), then try atorvastatin (Lipitor), rosuvastatin (Crestor) or even other statins if need be. The evidence is still that the statin class is best to prevent heart attack and death. Rosuvastatin can be taken every other day, which might reduce muscle aches.

The issue with your calcium score is trickier. I enlisted the help of a cardiologist, Dr. Erica Jones, at Cornell. She notes that a low calcium score predicts low risk of heart attack in the next 15 years in people who have not been taking statins. She sometimes will get a calcium score on people when it’s unclear whether a statin is necessary, and will hold off on prescribing statins in people with very low scores, those who are less likely to benefit. In your case, the calcium score of 3 is harder to interpret because of the long time you had been on statins. She agreed that someone in your situation should continue on a statin.

Dr. Roach Writes: In a recent column, I suggested an MRI for a person with longstanding dizziness and a pacemaker. Several astute readers pointed out that MRI scans are not normally done for people with pacemakers, and wanted to know if that had changed.

I admit that I didn’t think through the interaction of pacemakers and MRI scanners when writing the answer, but I’m glad to have a chance to review it now. There have been cases where a person with a permanent pacemaker required an MRI scan, and case series have shown generally minor adverse effects in people with pacemakers after an MRI.

However, the presence of a pacemaker still makes an MRI very risky, and it should not be performed unless the MRI scan is absolutely necessary. Several device makers recently have made MRI-compatible pacemakers, and one of these has been approved by the Food and Drug Administration. I appreciate the careful reading and alertness of my readers.

Email questions to ToYourGoodHealth@med.cornell.edu.

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