When BMJ published a study online that found increased cardiovascular risk among healthy postmenopausal women taking calcium supplementation, I took note as a cardiologist, a women’s health specialist, and a woman with osteoporosis (BMJ. 2008;336:262-266; also available online free of charge at: www.bmj.com/cgi/content/full/336/7638/262, accessed March 10, 2008).
I probably care more about bone health than the average cardiologist. In 1998, while attending a health fair, I casually sat down for a bone screening. I was shocked to learn that at age 38, despite a very athletic past, I had low bone mineral density. My osteopenia progressed to osteoporosis within twoyears. However, with treatment, my T score returned to normal by the time I was 45. I still take my 1,200 mg of calcium supplements and 600 mg of vitamin D every day.
And despite the dilemma the BMJ findings present, I would not give up my calcium, even though I’ve reviewed the study and I’m a cardiologist who is concerned about heart disease. The risk of older women falling and breaking a hip is very real, as are the strong consequences of disability, morbidity, and mortality. And osteoporosis itself can be crippling.
On the other hand, the morbidity and mortality rates associated with heart attack are decreasing, thanks to improved acute interventions. For example, using stents instead of thrombolytics to open arteries can help avoid serious bleeding complications. And keep in mind that many of the women in the BMJ study were smokers, had prehypertension, and were quite sedentary. This was not a low-risk group.
So we need to interpret the BMJ report carefully and decide what is best for our patients—each one of our patients. Regardless of the details and implications of this particular study, we should never lose sight of the fact that we’re always treating an individual patient. I get worried when we try to make blanket statements such as “All men over 50 should take aspirin”—because there are some who shouldn’t. And a study shouldn’t convince you that no women—or all women—should be on calcium after menopause. That’s something each provider and patient need to determine together based on the patient’s personal and family history, risk factors, and individual health goals.
When administering the 64-slice CT for coronary artery calcium score, I would always tell my patients, “Don’t worry; your dietary calcium has nothing to do with the calcium in your arteries.” But as a result of the new study findings, I won’t be able to say that anymore. Instead I’ll tell them, “I believe that taking calcium to keep your bones strong is very important as you get older, but there’s some evidence now that calcium could be adding to your atherosclerotic plaques.
We have to decide what’s more important.” And I will discuss that situation with each woman, taking into consideration her specific health issues and circumstances.
Clinicians have to sit down with each patient and weigh the risk factors for osteoporosis and the risk of falling vs. that particular individual’s cardiovascular risk factors. I’m not ready to completely stop calcium in these patients. But I am very open to the fact that some may need a lower dose as they get older, and I will monitor each case with that in mind.
It all comes down to individual assessment for each and every patient; there are no blanket statements when it comes to the best course of health management.