More on “How Do You Get a Heart of Stone?”
Here is some follow-up on my case report of a lifelong endurance athlete with a CAC score of 2,125 who ultimately was found to have a parathyroid adenoma. I emailed and blogged about his case on March 26th . His calcium (Ca) level was at the upper limits of normal at 10.2 (n=8.4–10.5) as was his parathyroid hormone level (PTH) at 64 (n=14–64). I remarked that I was just a “simple cardiologist”, but referred him to endocrinology for further workup because a Ca level that high should have a lower PTH level. He was ultimately diagnosed as having a parathyroid adenoma.
The March 23/24, 2020 JAMA was delivered on March 28th had a “JAMA Insights” on primary hyperparathyroidism (PHPT) .(1) The article noted that “normohormonal PHPT is a known variant with an elevated Ca level but a normal serum PTH level. There is also a variant of PHPT with a normal Ca and an elevated PTH level. These variants are due to the variability of PTH levels. Patients with normal Ca or PTH levels may develop increased Ca levels over time. My patient subsequently had an abnormal PTH level of 100.
An academic cardiologist wrote that he had developed osteoporosis from steroid therapy and had been prescribed Forteo, a PTH analogue, which he has taken for 11 months years. This treatment increased his bone density, but also produced 9 kidney stones (!) and markedly increased his coronary artery calcification. There are 3 PTH analogues available to treat osteoporosis: Natpara (recombinant PTH), Forteo (teriparatide), and Tymios (abaloparatide). Use of these should go into the differential of a CAC score more severe than expected.
Finally, someone else mentioned that PHPT can also accelerate valvular calcification, (2)so PHPT should be in the differential of early, apparently accelerated mitral or aortic valve calcification.
1. Zhu CY, Sturgeon C, Yeh MW. Diagnosis and management of primary hyperparathyroidism. JAMA. 2020. doi: 10.1001/jama.2020.0538.
2. Brown SJ, Ruppe MD, Tabatabai LS. The parathyroid gland and heart disease. Methodist DeBakey cardiovascular journal. 2017;13(2):49. doi: 10.14797/mdcj-13–2–49.
