It’s disconcerting when medical authorities get into a pissing match over potentially life-and-death issues — as they have, very publicly, in the last few days over new guidelines for prescribing cholesterol-lowering statin drugs.
The new guidelines could result in millions more people taking statins. Some see statins as such wonder drugs that they recommend just putting them into the public water supply, or doling them out to just about everyone over 50, but statins can also have very real side effects. The ping-ponging medical opinions in the new recommendations and resulting backlash are likely to leave many confused — me included. So I turned to an authoritative source: Dr. Vikas Saini, president of the Lown Institute, a cardiovascular specialist and a reasoned opponent of over-treatment. Our conversation, lightly edited:
So what are we, the public, to make of this great big loud debate over statins and the new risk calculator?
Firstly, for those with coronary disease or other vascular disease, statins are an essential medication in a program of prevention. Nothing has changed here.
Also, the controversial new risk calculator applies to people who don’t have heart disease and are not at immediate high risk — millions of people — so there is no rush to change our practice today until we are clear on this issue of the right calculator.
To start, I’d like to quote Dr. David Newman of the Mt. Sinai School of Medicine, who has done some calculations: “We need to tell patients the actual numbers. For patients without diabetes or a prior heart attack or stroke who are treated with statins for five years, 98% will see no benefit; 1.6% will be spared a heart attack and 0.4% a stroke — and, importantly, there will be no difference in overall mortality. At the same time, 2% of individuals treated with statins will develop diabetes and 10% will have muscle damage.”
Those numbers, he says, are aggregate numbers from large studies, and, most importantly, assume that “duration of therapy is 5 years, age is about 60, and comorbidities and baseline risks are relatively high.” For lower-risk patients the numbers will be even more unfavorable for statin use.
Aside from risk calculations, what is new in the new guidelines is the general idea that we should treat overall risk, and not target a hard number of the LDL (bad) cholesterol. This is generally a good idea.
Even here, however, there are some problems with the guidelines, in my opinion — particularly for women.
The guidelines basically have four risk groups. There’s very little debate around two of them: people with cardiovascular disease and people with diabetes. Another group is if your LDL (bad) cholesterol is greater than 190 — and if you look at the way it’s laid out, if your LDL is higher than 190, you should be on a statin.
The issue here is that if that’s the only number that’s wrong with you, and you’re a woman and your HDL (good) cholesterol is 80 or 90 — very high and probably protective — these guidelines seem to say you should go on a statin, and yet the evidence that your group would benefit from a statin is practically non-existent. Continue reading