Statin research

[Martha]

Business Week's lead article for this week is about cholesterol lowering drugs and their effectiveness. Do Cholesterol Drugs Do Any Good?

Rich, Meadh, others, any thoughts? The article states that the number of people you need to treat with statins for just one to benefit (not have a heart attack) is 100. To break this down a bit, for people who have had a prior heart attack or signs of heart disease 16-23 people need to be treated to prevent one heart attack. However, if the treated people have no signs of heart disease, but risk factors, you need to treat somewhere between 70 and 250 people to prevent one heart attack or stroke.

Based on these figures, I can't help but wonder why I have taken a low dose statin for a number of years when all I have are risk factors.

I also have read that once you start on a statin, you are stuck on it for life, but the Business Week article doesn't address the issue.

 

[dlhanson]

Here is one doctor's opinion about who should take statins:

The McDougall Newsletter - Who Should Take Statins?

 

[Rustic23]

The New Low Carb Way of Life - Home Page

I read this book about three years ago. Dr. Thompson's opinion is Statins are a miracle drug. That along with weight loss and exercise he says has made a great difference in his practice. Later I talked with my own doctor and he confirmed much of what was brought out in the book. I recommend you read it. It is different from most diet books. No recipes. In fact it is more medical advice than diet advice.

 

[Rich_by_the_Bay]

Here's a brief summary. My numbers are approximate but in the ballpark of of plausibility. This is gonna get boring if you're not really interested, so be forewarned.

• The number of patients you need to treat to prevent one bad outcome (e.g. heart attack) is one way of expressing how effective a drug is - it's called the NNT for number needed to treat.
• Statins cut the risk of a heart attack by about a third; it is less effective if your baseline (untreated risk) is low and more effective if your baseline risk is high.
• Now, say your baseline risk is 1% a year or 10% over 10 years. This is the risk that a middle aged man with moderate cholesterol elevation might have. These risks can be calculated using family history, cholesterol, blood pressure, etc. For any given year, the risk is very low -- almost negligible. But, alas, the risk is cumulative so you really don't want to ignore it.
• You also have to consider that statins have both cost and side-effects. Ignoring trivial side effects, the risk of serious problems (permanent muscle damage, liver damage) is about 1 in 500 or higher. If you do all the math, you can figure out the point at which the harm and benefits cancel each other out. Any one whose risks exceed a certain number gets a net gain from taking statins; anyone whose risks are lower is better off not taking statins.

Of course on any individual basis you may win or lose (and sometimes a royal flush loses or a pair of twos wins), but at least you can know what the best bet is. By the way, statins also reduce the risk of stroke by a bit, so that tilts a bit toward taking them if things are a close call.

If there is a problem with statin prescribing in North America, it is failure to restrict it to those whose annual risk is greater than about 1%. You can calculate that here if you know the information. Also, let's assume that lifestyle and diet are either optimized or hopeless.

Sorry for being so tedious, but you really need to understand those point if you want to explain the gist of the article you referenced. I believe doing what I explained above is good advice, but every patient needs to make that choice, and needs the pertinent information with which to make it.

 

[simple girl]

If there is a problem with statin prescribing in North America, it is failure to restrict it to those whose annual risk is greater than about 1%. You can calculate that here if you know the information. Also, let's assume that lifestyle and diet are either optimized or hopeless.

So Rich, the calculator gives you your 10 year risk. So does that mean if you are over 10% you should consider statins? (Just making sure I understand what you said correctly.)

Thanks for the info, very helpful! My 10 year risk is < 1%, DH's is 2%.

 

[Martha]

Rich, I think I get your point with cumulative risk. Thanks. Given that I seem not to suffer side effects from the statins, that my dose is pretty low, and given my horrendous family history, it seems to continue to make sense to continue the statins. Which my doc thinks I should do.

 

[Rich_by_the_Bay]

So Rich, the calculator gives you your 10 year risk. So does that mean if you are over 10% you should consider statins? (Just making sure I understand what you said correctly.)

Yes, I would say it means you should consider statins, but there are always so many individual factors to consider. For example, diabetics should take statins at the hint of a risk; marathon runners whose parents lived to their 90s should probably wait for a stronger risk, etc. But generally speaking, I would say that at higher than 1% per year, the discussion should be had.

 

[Dawg52]

Rich, I think I get your point with cumulative risk. Thanks. Given that I seem not to suffer side effects from the statins, that my dose is pretty low, and given my horrendous family history, it seems to continue to make sense to continue the statins. Which my doc thinks I should do.

I'll probably stay with them too. All my numbers were pretty good prior to taking Mevacor, except my LDL level was border line high. The drug brought that number down to the optimal range and all my other numbers improved.

No side effects and it only cost $4/mo. Might as well continue.

 

[Nords]

If you do all the math, you can figure out the point at which the harm and benefits cancel each other out.

I must have been going to the wrong doctors for the last three decades or so. I've never ever seen one whip out a calculator, let alone do math...

 

[dumpster56]

If there is a problem with statin prescribing in North America, it is failure to restrict it to those whose annual risk is greater than about 1%. You can calculate that here if you know the information. Also, let's assume that lifestyle and diet are either optimized or hopeless.

RICH

So what you are really saying is most everyone SHOULD be on cholesterol lowering drugs.

My number is 3%

Total Cholesterol 189 HDL 58 LDL runs near 140 at times Trigly 50 on BP meds small dose though 5 lisinopril 50 Metoperal XL which has BP in the 115/65 range 51 years old had a cardiac cath 6 years ago for viral pericarditis saw no blockages in my coronary arteries. Never smoked, run 60 miles a week and have been running for almost 40 years. Marathons, track races etc. Great diet 6 feet tall and 170 to 178 depending on the time of the year. Family history dad still living but with heart diease, however he smoked for 40+ years stress to the max etc. I have had nuclear stress tests etc over the past 6 years echos all that I still will not take statins. My cardiologist says fine and has me on baby asprin and 3 grams pharma Fish Oil.

 

[Rich_by_the_Bay]

So what you are really saying is most everyone SHOULD be on cholesterol lowering drugs.

No, I'm not "really" saying that. I'm just saying what I said .

That is, each case should be assessed individually and decisions made accordingly. A high cholesterol or low HDL alone is but one factor in that decision. A recent normal cath and extensive exercise regimen would certainly raise my threshold for starting statins very high. As I said, individual variations are important.

At 1% or above annual risk, you should definitely talk with your doctor about ths + and - of statins.

 

[Zoocat]

Regarding the calculator, Rich. I entered several random numbers to see where the line crosses 1% and was surprised that a woman with total colesterol of 160, HDL of 58, nonsmoker, systolic BP of 114 and no medication would still be judged 1% at risk. This seems to be a healthy person and with no other indications I would think the risk of statins would be greater than the risk of heart attack.

I realize that standards for LDL ratio have been lowered recently, but something seems screwy with this scenario. I think that's why NewGuy888 assumed that doctors think everyone should be on statins.

I also would like to add this additional point. All the statins apparently work the best if you change your diet. My experience has told me that many on statins do not change their diet, in fact, believe that now that they are on the statin they can eat whatever they want. Also, I have noticed that people on statins have gained weight on the drug and complain that they can't lose it either.

I wonder if clinical evidence of weight gain as a side effect has caught up to the research yet?

 

[Nords]

Regarding the calculator, Rich. I entered several random numbers to see where the line crosses 1% and was surprised that a woman with total colesterol of 160, HDL of 58, nonsmoker, systolic BP of 114 and no medication would still be judged 1% at risk. This seems to be a healthy person and with no other indications I would think the risk of statins would be greater than the risk of heart attack.

Age: 47
Gender: male
Total Cholesterol: 212 mg/dL
HDL Cholesterol: 48 mg/dL
Smoker: No
Systolic Blood Pressure: 120 mm/Hg
On medication for HBP: No
Risk Score* 3%

3%?!? Where's the extra credit for a low-fat diet, almost zero red meat, high veggies/fruit/fiber, martial arts 3x/week, heavy yardwork, and a low-stress surf-bum ER lifestyle?

3% per year means that my chance of surviving a cardiac-free decade is only one out of four.* But life is miserable enough without daily ice cream, and I draw the line at cutting chocolate.

I still have a problem with any doctor who looks at the latest numbers for total cholesterol, HDL, & TGL and says, in the absence of any other questions or data, "You're gonna have to get those down or we're gonna have to put you on statins."

[-]By the way, if FIRECalc gave my ER portfolio a 3% chance of having a heart attack, we'd be ecstatic[/-]**...

*If the chance of a heart attack in a year is 3% then the chance of no heart attack is 97%. The chance of 10 heart-attack-free years in a row is 97% to the 10th power, or 73.7%. So the chance of having at least one heart attack during that time is 26.3%.

**Of course the Framingham study is assessing the risk in any particular year while FIRECalc is looking at much longer cumulative periods. So if FIRECalc was revised to examine one-year periods and coughed up numbers like 3% then perhaps we wouldn't be so happy after all.

 

[dumpster56]

Rich have you read the studies on the ratio of HDL to Triyglicerides?

Basically saying that the higher the HDL and lower Tryglicerides which something like my numbers of 58HDL and 50 Tryglicerides would give a ratio of < than 1 which would say that the LDL particals no matter what the number would be of the large fluffy kind and not be able to deposit on the walls of coronary arteries?



From Dr Barry Sears Omega Zone.

 

[dumpster56]

Age: 47
Gender: male
Total Cholesterol: 212 mg/dL
HDL Cholesterol: 48 mg/dL
Smoker: No
Systolic Blood Pressure: 120 mm/Hg
On medication for HBP: No
Risk Score* 3%

3%?!? Where's the extra credit for a low-fat diet, almost zero red meat, high veggies/fruit/fiber, martial arts 3x/week, heavy yardwork, and a low-stress surf-bum ER lifestyle?

I still have a problem with any doctor who looks at the latest numbers for total cholesterol, HDL, & TGL and says, in the absence of any other data, "You're gonna have to get those down or we're gonna have to put you on statins."

By the way, if FIRECalc gave my ER portfolio a 3% chance of having a heart attack, we'd be ecstatic...

Thats just it Nords the business week article tells people like us with the 3% risk that it really is a waste to take them, that the doctors are really playing the game on defense meaning they better use them in their patients because everyone says they should prescribe them or risk malpractice?

 

[dlhanson]

Excerpts from Dr. McDougall article on stanins:
Cholesterol-lowering medications, commonly referred to as statins, are considered so beneficial that some enthusiastic doctors declare, “they should be put into the drinking water.” The pharmaceutical companies and their sales staff (most medical doctors) would like you to believe that simply lowering your cholesterol number is the major solution to your health problems. And that is untrue.
Statins do reduce cholesterol measured in the blood, but what is unclear is the real benefit for the patient—will the patient live longer and/or healthier? Or will he or she simply have a fatal heart attack the same day (as would have occurred without the medication), but with a lower blood cholesterol level? The decision to take these medications should not be made lightly.
...
The risk of future tragedies is predicted by observing signs, called risk factors. These include high blood pressure, cholesterol, triglycerides, uric acid, and blood sugar, as well as, being overweight. Information on family history, alcohol use, exercise, and smoking is also important. An even more reliable predictor of future problems is a person’s history of having problems with his or her arteries. Thus, people with a history of a heart attack, stroke, bypass surgery, and/or angioplasty are at the highest risk and the ones most likely to benefit from statin therapy.
....
A no-cholesterol, low-fat diet is the first step to lowering elevated cholesterol and cleaning out the arteries. You can expect a reduction in cholesterol by 20% to 45% with strict adherence.
...
Regardless of the patient’s chances of benefits and risk from medications, diet and lifestyle changes should be the first and most enthusiastic prescription made by all doctors for their patients. Only then, as a last resort, the patient and the doctor should look into medications.

 

[Rich_by_the_Bay]

Regarding the calculator, Rich. I entered several random numbers to see where the line crosses 1% and was surprised that a woman with total colesterol of 160, HDL of 58, nonsmoker, systolic BP of 114 and no medication would still be judged 1% at risk. This seems to be a healthy person and with no other indications I would think the risk of statins would be greater than the risk of heart attack.

Well, the results are what they are. Some surprising results are artifact - a 10 year forward risk is probably too long for people approaching 60 because most of the risk is back-loaded toward the end of the 10 year bracket, and this is not reflected in the over-simplified results. Not that many events occur at age 60 compared to age 70.

The more sophisticated models define the treatment threshold as a relative risk compared to your age-adjusted peers. I would not treat the example you gave unless there were other risks.

But note that in cultures with very low incidence of heart attacks, normal cholesterols often range in the low 100s or less. So maybe our "normal" is set too high. That's not to say everyone needs statins, just that what we consider normal may in fact carry some excessive risk.

Interestingly, we don't know what will be the results of treating older people with only mild risk. There is a hint that it reduces risk of stroke (more fearsome than a heart attack to many) and Alzheimers. If either of those is proven convincingly, the recommendations may change.

So, the facts are what they are. It's what to do with those facts that's tricky.

 

[Rich_by_the_Bay]

Age: 47
Gender: male
Total Cholesterol: 212 mg/dL
HDL Cholesterol: 48 mg/dL
Smoker: No
Systolic Blood Pressure: 120 mm/Hg
On medication for HBP: No
Risk Score* 3%

3%?!? Where's the extra credit for a low-fat diet, almost zero red meat, high veggies/fruit/fiber, martial arts 3x/week, heavy yardwork, and a low-stress surf-bum ER lifestyle?

NORDS! Come to your senses <slap upside the head>: your risk is 3% for TEN years.

Wanna trade?

 

[kaneohe]

[*] You also have to consider that statins have both cost and side-effects. Ignoring trivial side effects, the risk of serious problems (permanent muscle damage, liver damage) is about 1 in 500 or higher. .

Can these serious problems be detected before they do permanent harm?
What tests and at what time intervals should they be done in the startup
period and at what point can you monitor only annually?

 

[Eagle43]

Since we're confessing.
Age: 64
Total Cholesterol: 212
HDL: 74
Triglycerides: 91
CHOL/hdl: 2.86
Systolic: 120
BP meds: yes
Risk: 9% during next 10 years.
Due to bad press, I just switched from zetia to zocor. If zetia sucks and statins suck, and I tried eating carefully, what else? I can't change my genes. Next lipid panel evaluation in late March to see what if any effect the statin has on my liver. BTW: my cholesterol used to stay around 220 without ANY drugs and my HDL was always good. Unfortunately, my dad passed at age 67 and that is not far off.

 

[Rich_by_the_Bay]

Can these serious problems be detected before they do permanent harm?
What tests and at what time intervals should they be done in the startup
period and at what point can you monitor only annually?

Blood tests can detect liver and muscle problems early, while they are highly reversible. There are rare cases where such problems arise seemingly suddenly and irreversibly. I have not seen such a case ever. Liver problems usually occur within the first 3 months.

Once stable, annual follow-ups are what I do.

 

[Rich_by_the_Bay]

If zetia sucks and statins suck...

Heart attacks suck.

 

[Zoocat]

But note that in cultures with very low incidence of heart attacks, normal cholesterols often range in the low 100s or less. So maybe our "normal" is set too high. That's not to say everyone needs statins, just that what we consider normal may in fact carry some excessive risk.

IMHO, our "normal" --whatever that is - is what it is because of our diets. People in those countries, assuming you are talking primarily about Asia, eat a primarily vegetarian/fish diet and are quite lean. The question remains for me: is a statin-lowered cholesterol number really preventative if the person doesn't change his/her diet and continues to be overweight?

I realized this is a question that research hasn't answered yet, which is part of the delimma. I think that our medical culture tends to throw pharmaceuticals at medical problems to mask the symptoms when the only "cure" is to change the fundamental cause, if it can be determined.

But I also realize that physicians can't very often take the time to guide a patient through drastic lifestyle changes.

 

[Nords]

NORDS! Come to your senses <slap upside the head>: your risk is 3% for TEN years.
Wanna trade?

Phew, OK, I read the full text. I got sidetracked by that one-year statistic. Thanks for the well-deserved percussive recalibration.

Whatta relief. [Gilda Radner]"Oh. Never mind!!"[/Gilda Radner]

See you guys later; I'll be surfing... with chocolate ice cream to follow.

 

[FinanceDude]

Heart attacks suck.

I'll take YOUR word for it.........I prefer not to experience that first-hand..........