Click above to enlarge and read.

By Paul Goldfinger, MD, FACC

Physicians have known for years that statin drugs such as Lipitor (atorvastatin)  will reduce cardiac complications in those who already have coronary heart disease. This is called secondary prevention. Many patients who were given this therapy have, by now, been on them for over 20 years.  A report on Blogfinger discussed the long term risks (see link below)

https://blogfinger.net/2011/11/25/medical-long-term-statin-use-may-be-safe/

But many questions have been asked in recent years about these drugs including regarding their use in primary prevention, i.e. to prevent coronary disease in individuals who have no evident heart disease,  but who do have  coronary  risk factors, particularly high cholesterol, as well as others including smoking, family history, diabetes, diet, obesity, high blood pressure and lack of exercise.  Physicians have learned from research trials that primary prevention in high risk cases can save lives.

But the agencies that make recommendations regarding who should get treated with statins, what doses to use, and what end-points in terms of LDL cholesterol levels should be achieved, have varied in their guidelines over the years.

This month, the US Preventive Services Task Force (USPSTF) released their final recommendations and evidence summary in the Journal of the American Medical Association (JAMA)  for the use of statins for the primary prevention of cardiovascular disease (CVD) in adults.*

The main points are:

—–Adults aged 40-75 years, who do not have CVD, but do have one or more CVD risk factors and who have a 10% or more risk of having a heart attack or stroke over the next 10 years, should be treated with low to moderate dose statins. Doctors have access to equations which help them assess risk.  (American Heart Association)

—–For those who have the criteria above but whose risk is somewhat lower at 7.5%-10%, doctors have more discretion in individual cases.

—–The evidence is insufficient as to the benefits and harms of starting statins in those who are 76 years and older.

These guidelines have caused controversy among experts (“a contentious debate”*)  because there are “research gaps” in the evidence regarding precise recommendations about when to initiate treatment and what doses and end points to use for primary prevention.  They also differ regarding risks. Some risks are still controversial such as the possible increased risk of diabetes and cognitive dysfunction.

Then there is the concern of when to treat those who are at risk under age 40. Cardiologists tend to be aggressive when it comes to young people with high risk. Sometimes physicians have to use their best judgement when making therapeutic decisions about questions  that remain unproven.

Many of the research trials were paid for by pharmaceutical companies, so those studies contain potential conflicts of interest. In my experience, the funding by Big Pharm is the only way to get large expensive studies done, and the pharmaceutical companies and research teams usually act  with integrity.

These prevention issues have evolved into a tangle of questions, answers and controversies.  About 20 years ago, as some of the data began to evolve, some of us working in the field would joke that perhaps we should add statins to the water.   When it comes to prevention, doctors should follow the guidelines, but some will still resist using statins for primary prevention.

Physicians should individualize care, but, as many of us have noticed, the trend in healthcare now is to treat patients like cogs in a wheel rather than as individuals.

*Source: Medscape.com regarding the data reported in the Journal of the American Medical Association

AL MARTINO   “I Have But One Heart”  (From the soundtrack of The Godfather)