Recently, the American Heart Association and the American College of Cardiology issued new guidelines on the management of cholesterol. The idea that individuals should be treated on the basis of their LDL-cholesterol level has been significantly relaxed. What this means, is that some individuals with ‘raised’ cholesterol but who are deemed to be at low risk of cardiovascular disease may now reconsider the appropriateness of statins.
However, while this rule has been relaxed, others have been tightened. Specifically, the new guidelines recommend expanding treatment to those at lower risk of cardiovascular disease than was previously advised. In the past, guidelines urgedtreatment for individuals for whom risk of developing cardiovascular disease was calculated to be between 10-20 per cent over the next 10 years. Now that threshold has been set at 7.5 per cent. Also, every middle-aged person with type 2 diabetes will be advised to take a statin – irrespective of risk. Overall, the number of people taking medication for cholesterol is set to rise by about 70 per cent.
Each time cholesterol guidelines are issued they expand the numbers of people eligible for treatment. In the past, I feel there’s been a natural tendency for doctors to accept these recommendations and act on them dutifully and, perhaps, without thinking. However, this time, I sense the mood is somewhat different. There has been vocal public opposition to the guidelines from some quarters, some of which has even made its way into the mainstream press.
An example is this opinion piece published in The New York Times written by Professor Rita Redberg (cardiologist and editor of the journal JAMA Internal Medicine) and Dr John Abramson (lecturer at Harvard Medical School). In reference to the expansion of those eligible for treatment, the authors say this: “This may sound like good news for patients, and it would be — if statins actually offered meaningful protection from our No. 1 killer, heart disease; if they helped people live longer or better; and if they had minimal adverse side effects. However, none of these are the case.”
They reference a recent piece co-authored by Dr Abramson and published in the British Medical Journal [1] that shows that 140 low-risk individuals would need to be treated to prevent one heart attack or stroke, and there would be no overall reduction in death or serious illness. At the same time, though, 18 percent or more of this group would experience side effects such as muscle pain or weakness, decreased brain function, increased risk of diabetes, cataracts or sexual dysfunction.
The New York Times piece also draws our attention to the fact that ‘popping a pill’ may give some a false sense of security, who may benefit far more from lifestyle interventions around, say, diet, exercise and smoking cessation.
The authors also highlight the potential conflicts of interest that may drive recommendations that are unsupported by the evidence, writing:
The process by which these latest guidelines were developed gives rise to further skepticism. The group that wrote the recommendations was not sufficiently free of conflicts of interest; several of the experts on the panel have recent or current financial ties to drug makers. In addition, both the American Heart Association and the American College of Cardiology, while nonprofit entities, are heavily supported by drug companies.
The American people deserve to have important medical guidelines developed by doctors and scientists on whom they can confidently rely to make judgments free frominfluence, conscious or unconscious, by the industries that stand to gain or lose.
The authors conclude that:
Patients should be skeptical about the guidelines, and have a meaningful dialogue with their doctors about statins, including what the evidence does and does not show, before deciding what is best for them.
I think Professor Redberg and Dr Abramson have done a great job of highlighting the issues with cholesterol management and the new guidelines. The reality is, statins are already probably massively over-hyped and over-prescribed, and it’s gratifying that Professor Redberg and Dr Abramson are seemingly able to see that by looking at the data and thinking for themselves. Many doctors, I think, could learn a lot from them.
References:
1. Abramson JD, et al. Should people at low risk of cardiovascular disease take a statin?
BMJ 2013;347:f6123
Well, some people might be grateful :-), see how Tom Naughton reacts to new guidelines:
http://www.fathead-movie.com/index.php/2013/11/18/why-im-grateful-for-the-new-statin-guidelines/
Shame the article requires a sub…
I took the AHA test and now have been advised to take a statin! The test doesn’t ask about exercise, sleep or actual levels of HDL or triglycerides.
Who would ask their GP for statins on the base of an on line test? The same ones that would ask their GP for statins after watching a TV advertisement for them.
BTW, I haven’t seen an ad for statins here in NZ, even though they are allowed.
Over-hyped, over-prescribed, and unfortunately as true over here as over there.
I am in the US and my doctor didn’t exactly twist my arm, but offered a statin prescription at every visit for several years. I am T2 diabetic and have treated it by changing my lifestyle because I’m skeptical of mainstream medicine. Luckily, I’ve been healthier since my diagnosis than ever before!
Dr Malcolm Kendrick is having a great deal of fun pointing to the risk calculator (for heart disease) and the notion of a statin-by-date, which is no more than a thought experiment to poke fun.
Allegedly people are entering their data and parameters into the fields required by these calculators and the calculator is returning the result that they died several years ago! I cannot vouch for the truth in these allegations. But clearly there are people (many of them lay-people) that are becoming knowledgeable enough and confident enough to poke fun at the most disastrous medical hypothesis of all time. Public acceptance of the notion of torture-by-statin is a minority concern but willingness to see statins as a public health disaster is growing.
Kems mention of sleep is pertinent, Dr Briffa, for poor sleep and exposure to extended levels of light is taken (by progressives) to have influence over the hormonal cascade, bearing first upon cortisol, and then raising insulin, and chronically so.
If you think about it the supposedly multi-factorial risk factors for CVD must converge to some common physiological pathway, and the cortisol connection links with insulin. In effect, diet and emotional stress of various kinds can create a state of hyperinsulinaemia, and hyperinsulinaemia then destabilises serotonin and melatonin. Quite what about insulin actually results in CVD remains patchy to me, meaning; is it insulin itself, insulin resistance, glycosilation, or other consequence that follows? More study and contemplation needed.
Wiley and Formby, (‘Lights Out’, a book) do present a case that does read true, but with my qualifications being confined to LGV; C+E, I cannot endorse it critically.
Did you get around to reading ‘Lights Out’ and do it’s propositions stand up to scrutiny, or do mock the sense in medical science?
I, too, have had the experience of every visit to the GP being accompanied by a less than subtle suggestion that I take statins.
What has shocked me in the nearly three years since I was diagnosed as a Type 2 diabetic is how unscientific and incurious virtually all medical staff seem to be. I am always wryly amused when medical articles suggest having a meaningful conversation about risks and benefits of XYZ treatment before committing. In my ever-widening experience, such conversations simply do not happen even if I try to initiate them.
For fun, try these simple questions the next time you are sitting opposite your GP or other medical consultant:
01. Why are you asking me to take X?
02. What studies support your recommendation?
03. Who funded those studies?
04. What were the parameters of those studies – were they perhaps too narrowly focussed?
05. Are there any studies which contra-indicate the studies you (have failed to) quote?
06. Have you read the studies for yourself or just the prepared summaries published by the proponents of treatment X?
07. Do you have your own analysis of these studies – perhaps you have published them on the website of your medical practice?
08. If I take treatment X, will it benefit me as an individual or are we talking about a wider ‘herd’ effect such that I could even be worse off when considered in isolation?
If anyone ever, ever gets anything more than a brush-off and a hastily concluded session, please do let me know. I remain confident I will never hear from any of you to say that you have!
I have been poking around the calculator. Contrary to an earlier post, it does factor in HDL. It also takes into account systolic blood pressure. Together with non-HDL cholesterol, there is a decent basis for using those factors to identify risk. An Ohio clinician named Dr. William Feeman has used a formula based on these or similar factors and claims that for non-smokers it is highly predictive (smokers are at high risk regardless).
However, anything good about using those factors for a risk assessment is completely negated, however, by the way the calculator trumps everything with age. The calculator shows a percentage risk of heart disease within ten years. Any risk of 7.5% or higher triggers a high-dose statin prescription under the new guidelines (unless your doctor uses her or his own brain). With “optimal” factors (as deemed by the calculator) — systolic BP of 110, HDL of 50, non-HDL of 120 (this could be trigs of 100 and LDL of 100 under the standard formula, which would be an OK trigs number and a quite low LDL number), non-smoking, non-diabetic — a white man of 63 has a 7.5% risk (higher with each additional year of age). Same for an African American man of 66, an African American woman of 70, or a white woman of 71. Upon reaching these ages, virtually everybody will have been told that the guidelines call for them to be taking statins for the rest of their life.
Never mind the fact that the 7.5% risk factor seems ridiculously high as a stated ten-year risk for a 63 year old white maile with pretty good risk factors.
Of course, the number of people that can put up all the so-called optimal factors (untreated cholestoral numbers and BP in particular) cannot be 20%, and is probably less than 10% of the population. For them, the magic age of being told to take statins will be even earlier than the ages I list above.
Some further controversy has erupted in the US about the calculator and its overestimating of risk. Noted statin promoting Dr. Paul Ridker (who brought us the distorted and questionable Jupiter study) publicly attacked the calculator and called for a do-over on it.
Gibsongirl: Me too! T2 male, used low carb eating to lose 30 pounds and greatly lower A1C but GP still tells me being T2 “is the same as having had a heart attack” in assessing need for statins! Yet no family history of heart disease whatsoever long before advent of statins but lots of dementia which statins may exacerbate. Family snd medical history no longer matter? GP harangues me about statins but almost no mention of dietary and lifestyle changes….just take the statin. If I challenge statin use he literally yells at me. What in the world is going on here?!? Doctors just drug salesmen now spouting marketing nonsense and puffery like used car salesmen? Seems like it…
It was not long before puppies were given prozac to calm them down, I wonder how long it will be they are looking to sell more Statins so they sell them via vets for dogs? They have to sell them somewhere.
I too have the benefit of being fitter since being diagnosed T2 a few years back and simply because I did a little web research and applied a little common sense. This meant ignoring GP pressure to take statins and not to forget those carbs – most important apparently. Is it really too much to expect these professionals to apply a little science before spewing out the pharmaceutical rhetoric with which surely they too have become sceptical? There is a serious ethical question here and it is nothing to do with being over-worked. I cost the NHS far less than those with ever thickening waists who attend diabetes clinic run by my GP who is the practice lead partner on diabetes. He must have more science than me and he should be asking questions in professional circles. Let’s have more GPS rocking the boat to protect our health. Thank you, John.