On both sides of the Atlantic moves are afoot which will mean that many more individuals will be considered as good candidates for statin therapy. This will inevitably mean that more individuals are going to have the prospect of statin therapy raised by their doctors. In this situation, doctors can talk about ‘guidelines’ and ‘protocols’, but none of this matters much. What patients generally want to know is what the likely benefits are, as well as the risks.
So, how should likely benefits to be communicated? One approach to say that statins will reduce the risk of heart attack, say, by a third. But this can be very misleading, as the true benefit here is dependent on general risk (if risk is actually very low, then reducing it by a third does not help someone much).
I was interested to read a recent piece here written by Professor Henry Ting, professor of medicine at Mayo Clinic in the US. In the piece, Professor Ting talks about how doctors and their patients should use ‘shared decision making tools’. He states:
Rather than routinely prescribing statins to the millions of adults who have ≥7.5 percent risk of having a heart attack or stroke within 10 years, there is an opportunity for clinicians and patients to discuss the potential benefits, harm and burdens of statins in order to arrive at a choice that reflects the existing research and the values and context of each patient.
And that is extremely good advice, I think. But Professor Ting goes further by using an example of how the likelihood of benefits might be expressed to someone in a way that I think allows them to make a truly informed decision. Here’s how he puts it:
If a patient has a 10-year cardiovascular risk of 8 percent, then taking statins for a decade will lower his/her risk to 6 percent – in natural frequencies, that means for every 100 patients with comparable risk who agree and adhere to statins for a decade, 2 patients will avoid a heart attack or stroke, 6 will still have a heart attack or stroke, and 92 will not have a heart attack or stroke regardless if they took a statin.
This is accompanied by the figure below.
So, from this figure we can see that at 8 per cent risk (risk above the new threshold recommended in the US), 8 out of 100 people will have a heart attack or stroke over the next 10 years. However, even if someone is destined to have a problem, their chances of benefitting by taking a statin are only one in four.
What isn’t mentioned in this article, though, is the risk of harm. It’s very difficult to know what the true incidence of adverse effects such as fatigue, muscle pain, liver damage and mental symptoms are, because historically these have not been documented well in studies, or simply haven’t been disclosed. Plus, studies are often conducted in a way that effectively gets rid of people who are prone to problem before the study starts in earnest.
However, the best guestimates are that adverse events affect about 20 per cent of people. So, for someone at relatively low risk, the chances of harm are about 10 x the chances of benefitting. In my experience, these are the sort of plain facts people really appreciate when being counselled on the risk:benefit of statins.
I’ve known lots of people who have apparently been put on a lot of pressure by their doctors to ‘go on statins’. When I have enquired, though, it seems doctors have often presented statins as a no-brainer. As we can from the figures above, even for people at higher risk of cardiovascular disease, statins are most certainly not a no-brainer, and some people may actually want to educate their doctor about why this is.
Some doctors won’t like their patients questioning their judgement and perhaps having key statistics presented to them (that they should perhaps have quoted themselves). But, I think this is a situation we doctors are going to have to get increasingly familiar with, now that individuals are able to access information on the internet.
Besides, as I sometimes remind people, it’s not we doctors who decide treatment for the most part. This may be the case when someone is admitted unconscious to a casualty department, but whether someone takes prescription medication or not is ultimately determined by that person (not their doctor).
And while we’re on this subject, I think some of us doctor would do well to remember the respect the concerns and wishes of our patients. Not so long ago I wrote a piece which highlighted advice given by the regulatory body for UK doctors (the General Medical Council) regarding this. Here’s a couple of reminders from the GMC that I feel have relevance here:
Doctors must listen to you and respond to your questions and concerns.
[A doctor] may recommend one treatment option, but it is up to you to decide which option you want and you can decide not to have treatment.