Wednesday, April 15, 2015

Should every man over the age of 65 be on a statin?

If you believe the latest arteriosclerotic cardiovascular risk calculator, the answer is yes.



A previous version seemed to recommend statins for everyone over a certain age. I decided to plug in the optimal values, conveniently stated in a footnote beneath the data entry fields, for a 65-year-old man. Here is what the data entry looks like.



As you can see below, the risk calculator recommends "moderate to high-intensity statin therapy."



Below the recommendation, it says, "Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL with no diabetes and estimated 10-year ASCVD risk ≥7.5% should be treated with moderate to high-intensity statin therapy." This is a apparently high-level (A1) evidence-based recommendation.

What am I not understanding here?

I would very much appreciate it if some cardiologists would comment and explain to me how such a sweeping recommendation came to be.

Is this accepted as gospel? Do all cardiologists recommend statins in the above situation?


24 comments:

Jeffrey Patten said...

Whatever the cardiologists have to say, I will tell you, as a prospective patient, I am the final arbiter of what goes into my mouth. I say that as one who finds out all he can about a situation before taking considered action.
One condition I would place on my cardiologist before taking statins is that he personally be responsible for expenses incurred for treatment of resulting diabetes and/or rhabdomyolysis.

Skeptical Scalpel said...

As the late Sy Syms used to say, "An educated consumer is our best customer." But I don't think you will find too many cardiologists willing to accept your deal.

artiger said...

I think I'll just eat reasonably well, play a lot of tennis and jog, and have an average of two drinks a day. If that isn't as good as a statin, I'd rather be dead anyway.

Skeptical Scalpel said...

I have chosen that path too.

frankbill said...

As with all meds that may extend life question is what will the extended life be like. If you can extend life by 10 years and that 10 years is spent in a nursing is it worth it?

Jeffrey Patten said...

frankbill:
When you're in that boat...
http://opinionator.blogs.nytimes.com/2015/04/08/overruling-my-father/?_r=0

Skeptical Scalpel said...

Jeffrey, I had not seen that article. It was very well-written and mirrors my own experience with my parents at their end-of-life stage. Thank you.

Michael Martinez said...

I have tried all the major statins and I cannot tolerate any of them. Doctors cannot wave magic wands and come up with new drugs but the widespread belief that statins are a miracle treatment is a myth. There is a high cost of intolerance for as many as 20-25% of patients. I don't know what it is about statins or my body that kills the deal but we need more research into new meds. I won't be the only one waiting for them.

Skeptical Scalpel said...

Michael, thanks for adding the perspective of a patient.

frankbill said...

Some of the newer data seems questions how well statins work.

StaphofAesclepius said...

MS-II/III here. It doesn't really answer your question, but we had an endocrine guy lecture during GI about this. His recommendation seemed to be based on comorbidities, targeting LDL >190 or lower for DM. He couldn't give a hard fast rule on what to do about the borderline patients that seemed "healthy", but had a >7.5% chance based on the ASCVD estimator. It seemed to me to very much be a Gestalt and discussion with the patient approach for his practice.

Anonymous said...

Skep, you and Artiger have my votes. I think the problem is we need insurances and the like to pay for more midlevels in education of patients. I function quite well but there are few patients who can traverse UpToDate like it was Facebook. I don't think we need that but we do need something that is geared towards "if I am a patient is this what I would want" with some reliable data to back it up.

Skeptical Scalpel said...

Staph, it's nice to see that even an endocrinologist doesn't know what the right answer is. How would anyone expect a patient to understand it?

Anon, based on my thought above, how are you going to educate a patient if no one really knows what the right answer is?

OldfoolRN said...

When my mother entered hospice care for terminal lung cancer she readily surrendered all treatment modalities with the exception of her Zocor. A testimony to the perverse power of direct to consumer marketing. I think Merck was the first pharmaceutical company to link an NFL figure to it's product. I still remember A post coronary bypass Dan Reeves of the Atlanta Falcons blabbering about the life saving benefits of statins in TV ads. I always thought arteriosclerosis developed over a long period of time. I don't think statins make a huge difference with us oldsters.

Skeptical Scalpel said...

I agree. They tried to start my wife's 88-year-old aunt on Zocor, but my wife and I intervened and said, "no thanks."

frankbill said...

In reply to educating us patients. First bit about uptodate. I did try uptodate for researching hyperaldosteronism. It is one of the many sources I have looked at. I found it to a bit one sided as other ongoing studies have different information then what Dr Young put in uptodate.

This leaves a question does uptodate really have the best information about the latest research?

Now If one is looking information on do statins prevent heart attacks. This is one of the sites that comes up. Is what is stated here fact or is someone just trying to sell something. Maybe a bit of both.

I always try to look at pubmed but many times you need to pay to see the whole paper. Something that many can not afford to do.
http://chriskresser.com/the-diet-heart-myth-statins-dont-save-lives-in-people-without-heart-disease/

Fernando E. Miranda M.D., F.A.C.S. said...

expert said Statins have been proven to substantially reduce fatal and nonfatal cardiovascular events in individuals without known cardiovascular disease, even among men and women with cholesterol levels considered in the normal range,

Skeptical Scalpel said...

Frank, thanks for the interesting link. I find UpToDate invaluable. It's the best resource available.

Fernando, thanks for commenting. Please provide links to the papers that experts have written about the effect of statins on the subjects you mentioned.

frankbill said...

While I have not found other information relating to what is in the chriskresser link. At this time I have to question the source. Maybe someone else has better information.

It what is stated is close to being true that it doesn't make a good case for giving one statins.

If the newer research on hyperaldosteronism is true the all providers need to get up to speed on what it takes to Dx it. Once this is done then it may have a bigger impact on preventing cardiovascular events the statins.

Current research is that 10% or more of us with hypertension is due to hyperaldosteronism. But if you ask most providers how many they have seen with it most will say none. Seems they are still being thought that if they see one case in a lifetime they are lucky.

frankbill said...

From JAMA June 28, 2010, Vol 170, No. 12


Review Article | June 28, 2010

Statins and All-Cause Mortality in High-Risk Primary Prevention

A Meta-analysis of 11 Randomized Controlled Trials Involving 65 229 Participants
.
In part

Background Statins have been shown to reduce the risk of all-cause mortality among individuals with clinical history of coronary heart disease. However, it remains uncertain whether statins have similar mortality benefit in a high-risk primary prevention setting. Notably, all systematic reviews to date included trials that in part incorporated participants with prior cardiovascular disease (CVD) at baseline. Our objective was to reliably determine if statin therapy reduces all-cause mortality among intermediate to high-risk individuals without a history of CVD.

Data Sources Trials were identified through computerized literature searches of MEDLINE and Cochrane databases (January 1970-May 2009) using terms related to statins, clinical trials, and cardiovascular end points and through bibliographies of retrieved studies.

Conclusion This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
.
Statins are now one of the most widely used drugs for the treatment and prevention of cardiovascular disease (CVD) both among individuals with established disease and among high-risk healthy individuals who are at an elevated risk of incident CVD.1There is little debate that, compared with placebo, statin therapy among individuals with established coronary heart disease (CHD) not only prevents complications related to atherosclerosis but also reduces all-cause mortality.2- 4 The benefits of statins on fatal and nonfatal CVD have provided reassurance for the majority of clinicians for use of these agents in high-risk primary prevention settings.1 However, the absence of prior convincing data for all-cause mortality has led some researchers5,6 to question the benefits of statins among individuals without a history of CHD, including Abramson et al5 who stated that “in some subgroups statins cause serious unrecognized harm, which negates the beneficial effects if the benefit is small—ie, most primary prevention settings.”
..
Recently, the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) reported that among individuals with comparatively low levels of low-density lipoprotein cholesterol (LDL-C) (<130 mg/dL) (to convert to millimoles per liter, multiply by 0.0259) and baseline levels of hs-CRP of higher than 2 mg/L (to convert to nanomoles per liter, multiply by 9.524), statins significantly reduced all-cause mortality by 20%.7 Some have questioned these findings as a chance or exaggerated observation.8 Four systematic reviews have been published on the topic thus far, which have either principally attempted to evaluate heterogeneity of effect estimates between statins and thus have not reported combined effect estimates across statin trials9 or have included populations with prevalent CVD10- 12 and/or have included trials with incomplete randomization.11 The most recent systematic review,12 which included results from JUPITER, is also somewhat limited by the inclusion of participants with prior CVD at baseline (n = 3659), as well as the exclusion of smaller statin trials.13,14 Thus, to provide the most robust information to date, we undertook a meta-analysis of published clinical trials (including information previously unpublished by these studies) to assess whether statins reduce all-cause mortality in the setting of high-risk primary prevention populations.

http://archinte.jamanetwork.com/article.aspx?articleid=416105#Abstract

Skeptical Scalpel said...

Thanks for the reference. Interesting that since the paper was published, the indications for statin use have expanded.

frankbill said...

I believe this is called follow the money.

Jeffrey Patten said...

To frankbill:
http://www.ncbi.nlm.nih.gov/pubmed/25891981?dopt=Abstract

frankbill said...

Jeffrey Patten

Wish I didn't have to pay to see full paper. Think this part of discussion needs to be moved to
http://skepticalscalpel.blogspot.com/2014/10/1-in-20-americans-are-misdiagnosed.html#comment-form

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