Posted by Gary Schwitzer in Journal practices
The Journal of the American Medical Association debuted its “Dueling Viewpoints” feature with “the common clinical question of whether an otherwise healthy middle-aged man with an elevated cholesterol level should begin to take a statin” drug.
Drs. Rita Redberg and Miitchell Katz, editor and deputy editor of the Archives of Internal Medicine, write that “Healthy Men Should Not Take Statins.” Excerpt:
For some clinicians, evidence that statins reduce the risk of recurrent coronary events in patients with documented coronary disease leads to the belief that statins also “must” be beneficial for patients without coronary disease. However, recent history is rife with examples of interventions that are proven to work in patients with serious disease yet are not efficacious when generalized to patients without serious disease. For example, coronary artery bypass graft (CABG) surgery is lifesaving for patients with symptomatic left main disease. However, CABG surgery would not be a good choice for single-vessel coronary artery disease (CAD) because risks would outweigh benefits in less extensive CAD. Similarly, the benefits of carotid endarterectomy in preventing stroke outweigh the risks for symptomatic patients with tight carotid artery stenosis, but not for asymptomatic patients with less critical stenosis. In addition, the use of aspirin is similar to statins for prevention. The data show clear benefit for aspirin in secondary prevention of cardiovascular disease, but not for primary prevention. Practitioners should not be generalizing from other settings when good data indicate that statins are not effective in improving length or quality of life when used for primary prevention.
For every 100 patients with elevated cholesterol levels who take statins for five years, a myocardial infarction will be prevented in one or two patients. Preventing a heart attack is a meaningful outcome. However, by taking statins, one or more patients will develop diabetes and 20% or more will experience disabling symptoms, including muscle weakness, fatigue, and memory loss.
But Drs. Michael Blaha, Khurram Nasir and Roger Blumenthal of Johns Hopkins write a countering viewpoint, addressing some arguments they’ve heard:
Are statins safe? Adverse effects with statin therapy are rare. Approximately 5% of patients will develop muscle-related complaints that are generally reversible after drug discontinuation. Many of these patients can tolerate a different statin. There is no good peer-reviewed evidence that statins lead to cognitive impairment or memory loss, as has been anecdotally reported; one report suggested that statins may improve memory.7 In appropriate middle-aged patients, the risk of type 2 diabetes associated with statins is mainly seen in those with preexisting glucose intolerance and is minimal in comparison with CHD event reduction.
Do statins lead to less adherence with a prudent lifestyle? In fact, there is evidence to the contrary; a recommendation from a physician for statin treatment may motivate overall healthy behaviors. It is incumbent on physicians to refrain from paternalism/maternalism and to encourage sustained motivation for adherence to both lifestyle and medicine.
Is there a durable benefit to statin therapy, or should statins be prescribed only after a myocardial infarction? There is no apparent logic in waiting for a myocardial infarction or a stroke to occur before starting a risk-reducing therapy. A recent meta-analysis of trials confirms that statins retain their benefit after discontinuation of randomized therapy.
Is statin therapy cost-effective? With the emergence of generic high-potency statins like simvastatin (~$4 a month) and atorvastatin, statin therapy is increasingly cost-effective, well below the typical willingness-to-pay threshold. Would it be more cost-effective to spend this money on walking trails, neighborhood renovation, and increased accessibility to fruits and vegetables? This is not likely, despite the critical importance of these approaches.
Do statins only work in men? In the recent meta-analysis by Kostis et al, women derived just as much benefit from statins as men for primary prevention.
Do patients expect medications to prolong survival within 5 years? Most patients do not expect near-term survival benefit from medicine; they are concerned about myocardial infarction, stroke, venous thrombosis, and the resulting chronic disease and disability that may occur. They see their parents, who have vascular dementia and congestive heart failure, and seek safe strategies to reduce their risk. In fact, more than ever, the modern patient is focused on quality of life and not exclusively on longevity.