Statins for everyone – more puzzling evidence!
A recent study published in The Journal of the American Medical Association (July 2020) suggested that cholesterol lowering statins are safe and very effective in people over the age of 75. While I do not dispute the results of this very extensive study, I certainly believe this needs to be put into effect. perspective.
This was an observational trial (not the landmark randomized controlled clinical trial) involving just under 327,000 white veterans over 75 years of age. The average age was 81, 97% were male, 90% white and, most importantly, 72% were veterans. current smokers. It was a seven-year trial and the results showed a 32% reduction in all-cause deaths at two years, a 21% reduction at four years and 13% at six years, all results being statistically significant. There was a concomitant reduction in cardiovascular deaths with numbers similar to those above.
Therefore, is this a done deal? Should we all take statins for prevention, not only against cardiovascular disease, but also against all forms of death? If you believe a lot of members of the medical profession and especially those of us in cardiology, it certainly is. I have heard many world leaders in this field say that they take statins daily for disease prevention only, regardless of the risk factor profile. Over the past two decades, many people in cardiology have pushed strongly for the use of a polypill, which includes a dose of statins and BP therapies and sometimes there have been some suggestions for low-dose aspirin, contained in this a pill.
The problem with this is that the “one size fits all” approach usually doesn’t work. Older white males who were primarily former smokers are generally at much higher risk of disease than the rest of the population. In my clinical experience of over 40 years of practicing medicine, statins are not harmless and sometimes have quite severe side effects. And at other times, very subtle side effects that affect a person’s quality of life.
I can present two interesting cases from my recent medical practice that address this problem. I was recently referred to a 77 year old man with high cholesterol. His GP wanted to put him on a statin, despite the fact that he had no history of cardiovascular disease. He had also suffered from long-term hypertension and was taking medication for this problem. Rather than automatically starting it on statin therapy, I ran a coronary calcium score (the most accurate predictive test for cardiovascular risk) and its score was just over 1000. Any score above 100 is significant and a score greater than 400 is in the upper-risk category. So I felt justified in starting this man on moderate dose statins and, more importantly, reinforcing the need for continuous targeted BP therapy aimed at a resting BP of around 120/80.
That same day I saw a 41 year old woman whose father is one of my patients and had suffered one. coronary bypass surgery 20 years ago, now in his 70s and doing very well. Her daughter had no history of heart disease, but her cholesterol level was high and her GP strongly encouraged her to start statin therapy.
I organized a coronary calcium score and in her case was 0, placing her at low risk. I measured his arterial stiffness parameters and these were all very adequate and stable from the levels I had measured four years before. So I felt there was no justification for her starting statins at such a young age. Even though she inherited the heart genes from her father, women tend to develop coronary artery disease 10 years later than men and I fully agree that if there were signs of early atherosclerosis as seen sees on coronary calcium score and arterial stiffness measurements, then statins would be warranted.
What I mean about all of this is that each person needs to be individually assessed and carefully monitored, whether or not pharmaceutical therapies are used. In a person with a coronary calcium score below 100, it is warranted to repeat the test in five years to assess disease progression. In a person with a score well over 100, especially when the scores are over 400, there is no rationale for a repeated coronary calcium score, but certainly a strong rationale for aggressive cholesterol lowering, management. appropriate blood pressure and with higher scores, low dose aspirin as well. . Of course, other risk factors must be taken into account, such as smoking and people with diabetes.
While this major new study suggests that statin therapy should be considered in what I believe to be a higher risk group, I don’t think this justifies this knee-jerk “high cholesterol – prescribe pill” reaction. occurs far too often in medicine. As I have mentioned in recent articles, the future of medicine is personalized therapy, not a one-size-fits-all solution.