Dr John M

Statins are so misunderstood…
Posted: 29 Aug 2010 06:19 PM PDT
The medical assistant who checked the patient in tells me,

“Dr Mandrola, this guy had coronary artery disease since the 1980′s.  He is 90 years-old now, and his only medicines are that statin and aspirin.” 

One of the more common questions that arises in cardiology is whether a person should take a statin drug. Despite the fact that statins are the most widely studied drug in the history of mankind, there remains widespread misinformation on their use.

Such angst was on full display in the comment section of a recent post from the well known medical blog, KevinMD.  Dr Eric Van de Graaff, a cardiologist and blogger, submitted a very informative and well written piece on the use of statins for the prevention of stroke and heart disease.  (A must read for doctors and patients alike.)

Dr Van De Graaff made many salient points. First, he tells us about the enormity of the science behind the use of statins. No drug has been studied more. He correctly said that in high-risk patients, especially those who have already been diagnosed with blood vessel disease, statins are unequivocally beneficial.

Dr Van De Graaff knows that just saying that statins are scientifically proven to benefit high-risk patients will not be enough for the throngs of nay-sayers, especially those who offer their products to sell.  Thus, he goes on to point out how these drugs were proven successful. In easy to understand language, he explains that the studies (of 120,000 patients) proving statin’s benefits were of the highest scientific rigor: they were prospective, randomized, controlled, and double-blinded.

Even after this fair and balanced piece on statins, the comments illustrate the public’s tremendous misinformation on statins. We read that doctors overly rely on medicines, and we under-emphasize prevention. (They should ask my overweight patients.)  Even a doctor commented, “I’ve read much of the evidence and I am not convinced.” In her psychiatry practice, she had three patients with possible statin side effects, so she is dismissing the data from 120,000.  Yet another doctor who had a unrecognized statin related side effect admonishes us to “consider ramifications of the most important enzyme pathways in our bodies.”  

Confusing the public with medical misinformation really fires me up. And even more inflammatory is that many entrepreneurs use such misinformation for personal gain.

I have written about statins in the past, and as long as the shark-cartlage-for-health-dot-com-like sites continue to spread misinformation, or, the anecdotal reports of this side effect or that side effect speak louder than the truth, I will be motivated to write.

In an effort to spread the truth about prevention of heart disease, I give you this list of statin-facts…
Making good lifestyle choices are the most important means of preventing heart disease. Eating well, sleeping well and exercising daily should be a given. Good doctors will tell you this, but they shouldn’t need to.
Drugs, procedures or surgery should never replace good lifestyle choices. Taking a statin to counteract cheetos is utter nonsense.
Statin drugs lower cholesterol levels, but this is not likely the primary mechanism of cardiovascular benefit. They are vascular anti-inflammatory agents that work at the blood vessel wall. 
In patient’s with high a risk of heart disease (those with risk-factors like genetic predisposition, diabetes, high blood pressure or smoking), or in patients who have had a vascular event (stent, heart attack or stroke), statins are scientifically proven to be beneficial. The science behind this is second to none.
Even though science proves the benefit of statins in the secondary prevention of vascular events, it does not mean they are devoid of adverse effects. It just means that the side effects are greatly outweighed by the reduction of events (in 120,000 patients.) 
These same trials showed that the side effects of statins were very similar to those of placebo.  Do the nay-sayers tell patients this?
Adverse effects of statins are rarely if ever life-threatening. However, the disease which statins prevent, heart attack and stroke, are definitely life-threatening.
Statin side effects are real, and they are clearly higher than what is reported in the literature. Sometimes they can be mitigated by changing to a different statin, but more often than not, they are a class effect, and these patients cannot take them.
Whether statins reduce CV risk in patients whose only risk factor is a high cholesterol is not clear. Low risk patients have such low event rates, that is hard to show a benefit of any therapy. Statin-enlightened doctors know this. Patients could ask, “Doc, high cholesterol is my only risk, do you really think a statin will alter my long-term outlook?”
If changes in one’s well being are noted after starting a statin, the drug should be considered as a culprit. This is why there is a doctor-patient relationship, and why doctors should have the time needed to listen to the patient’s story.
When reading about your health consider potential conflicts of interest. We all know about big pharma’s conflicts: they make more money if they sell more statins. To me, such conflicts are self-evident and understood. However, the entrepreneurial nay-sayers are also conflicted. Bashing science-based medicine is a fertile field of business. The statin-bashers will frequently have a newsletter, book, diet or supplement to sell you. Conflicts. Be aware.
Doctors do not financially benefit from prescribing statins. We can’t even use pens with industry logos anymore. Doctors recommend statins because we know that the small risk of an adverse effect is out-weighed by the proven benefit. And as a rule, the higher the risk of an event the more the benefit. 
I believe in patient choice. Patients can choose to forego the benefit of statins, just like they can forego any medical therapy. 
Doctors wish there was no need for drugs.  We wish you hadn’t had a heart attack, but since your endothelium has proven to be susceptible, our goal is to prevent another event.  In addition to good lifestyle choices, a statin drug will clearly decrease your risk.

Sore muscles are unfortunate, but not as much as a heart attack or stroke.

JMM

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