Cochrane Review questioning statins = another shared decision-making moment

A Cochrane Review published last week raises questions about the strength of the evidence for statin drugs to prevent heart problems in people at low risk. The summary states:

“Previous reviews of the effects of statins have highlighted their benefits in people with coronary artery disease. The case for primary prevention, however, is less clear.
…
This current systematic review highlights the shortcomings in the published trials and we recommend that caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.
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Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life. Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.”

(By the way, if you don’t know about Cochrane Reviews, you can learn more here.

TheHeart.org reports (registration required) that this “has provoked controversy.”

• It quotes one expert saying, “the absolute benefits are really rather small–1000 people have to be treated for one year to prevent one death. It is probably a real effect, but it means a lot of people have to be treated to gain this small benefit. As we don’t know the harms, it seems wrong-minded to me to treat everyone with a statin. In these circumstances, lifestyle changes and stopping smoking would be far preferable.”
• Then it quotes another expert saying: “I object to the conclusions they have drawn from their review. They say there is not good evidence of benefit, but their own data show significant reductions in deaths and cardiac events. They didn’t show any increase in adverse events in their review, but they then say the benefit is not worth the risk. That doesn’t make sense.”

The Boston Globe covers the controversy today.

But absent in any of the online reactions I’ve read to the Cochrane statins review is any discussion of what an important moment this is for shared decision-making. This is exactly the kind of issue that demands a deep discussion between patient and physician, and a clear communication of what’s known and isn’t known about the tradeoffs of benefits and harms.

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