The father of the eternal fiancee’ of the skeptical cardiologist (FOEFOSC, let’s call him “Geo”) is a typical 61 year old white male. A year ago his primary care physician informed him that he needed to start taking a statin drug because his cholesterol was high. The note accompanying this recommendation also stated “work harder on diet and exercise to get LDL<130.” No particulars on how to change his current diet and exercise program were provided.
Neither of Geo’s parents and none of his siblings have had heart problems at an early age and Geo is very active without any symptoms. His diet is reasonably free of processed food and added sugar, he is not overweight and his blood pressures are fine. Due to concern about side effects he had read about on the internet and because he doesn’t like taking medications , Geo balked at taking the recommended statin,
Reluctance to start a new and likely life-long drug is understandable especially when combined with a constant stream of internet-based bashing of statins.
My advice was sought and I suggested a few things that would be helpful in making a more informed decision:
-Calculate Geo’s 10 year risk of heart attack and stroke using the ACC ASCVD Risk estimator app.
-Assess for early or advanced build-up of atherosclerotic or fatty plaque in the carotid arteries (vascular ultrasound) and coronary arteries (coronary calcium scan).
As I’ve pointed out before (here), the vast majority of men over the age of 60 move into a 10 year risk category >7.5%, no matter how great their lifestyle is, and Geo was no exception with a risk of 8.4%. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.
The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18, putting him at the 63rd percentile. This is slightly higher than average white men his age.
When Geo presented these findings to his PCP, he seemed unaware of the ASCVD risk estimator (recommended by AHA/ACC guidelines first published in 2013), which no longer suggests LDL levels as goals. His PCP also seemed miffed that he had gotten the coronary calcium scan. Geo felt like the PCP’s attitude was “shut up and do what I tell you.”
Geo’s PCP’s approach exemplifies a not-uncommon traditional doctor-patient relationship, but a better approach is shared decision-making (see here). Geo, like many patients, welcomes more information on the risks and benefits of any recommended treatment so that he can participate in deciding the best course of action.
I steer patients who want more complete information towards my evidence-based blog posts on statins (see here for discussion on statin side effects and here for statin benefits beyond cholesterol lowering.)
By giving patients more information on the risks, side effects, and benefits of the statin drugs along with a better understanding of their overall risk of heart disease and stroke, we can hopefully move more patients “off the fence” and onto the most appropriate treatment.
Stay tuned to find out what The Skeptical Cardiologist Recommended for Geo. (Read about “A compromise approach we worked out for Geo here.)(Read more about what happened with Geo here)
For more discussion on the value of coronary artery calcification (CAC) and the value of statin in lower risk patients see this recent paper entitled “Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions”(PDF refining-statin-prescribing-in-lower-risk-individuals-informing-riskbenefit-decisions)
If you’d like to read the recently published recommendations of the US Preventive Services Task Force on statins for primary prevention of cardiovascular disease see here. Importantly this panel of unbiased experts concluded that statin therapy significantly reduced overall mortality and cardiovascular mortality. In addition, the review found no increased risk of diabetes overall with statin therapy. The only trial that identified an increased risk was using high intensity statin therapy (Crestor (rosuvastatin) >20 mg).
And, since the internet is jammed with people who believe statins robbed them of their brain power, I would advise noting that the writers concluded “These findings are consistent with those from a recent systematic review of randomized trials and observational studies that found no adverse associations of statins with incidence of Alzheimer disease, dementia, or decreased scores on tests of cognitive performance.”
Addendum. I ha