Thursday, June 17, 2010

Are Statins for Everyone?

There is some discussion amongst health care professionals in regards to the use of statin (i.e. Lipitor, Zocor, Cresor, Vytorin, Simcor) medications to lower cholesterol. A panel is considering making the recommendations more personalized which could add people to the list of medicated and also remove them. You can read more about these recommendations and why they are being suggested elsewhere. My post today is more general.

I can’t remember the exact date or year that cholesterol numbers and medication became a household subject, but they are now. My first memories are of my father mixing up some powdered medication that he had to drink two or three times a day because he had high cholesterol levels. This may have been before his first heart attack, but certainly after. I don’t remember my primary care doctor talking about cholesterol levels before the year 2000. It is around then however, that health fairs began to offer cholesterol screenings on a pretty routine basis as did employee wellness programs. In fact, most personal wellness profiles or risk assessments include them now.

It also seems to me that at first the only thing they had us focus on was the ratio of good to bad cholesterol and that is discussed less often now. Then there was the whole thing about the good cholesterol or HDL and how to get it higher. Oh yes, and the great egg debate and whether cholesterol in food was the evil or if saturated fat led to cholesterol in the blood and was the real bad guy. Ah – nostalgic isn’t it?

Of course, the drug companies have blessed us with many more options for lowering our cholesterol – no more messy, yucky-tasting powders! And as the drugs have improved, it seems the target numbers, especially for that pesky LDL, have been lowered and lowered again. People with no additional risk factors get one goal number and people with any variety of other risk factors get others. It has even been proposed that everyone get on the statin medications regardless of their cholesterol status. Ah but you see – these medications are not without side effects and do require routine blood work to check for damage to other body systems.

What I like to ponder and hope that you will as well is the outcome question. This has come up in the public health discourse with more frequency in the last few years and that is a good thing. It is not enough for a medication to limit or reverse a condition that leads to a more serious disease or disease outcome; it also needs to reduce the number of those adverse events. (You can think this through with many a risk factor or condition and a disease)

So let us take high cholesterol. The reason we want to lower cholesterol in the body is because too much of it can lead to atherosclerosis or plaque build up in the arteries. This makes the walls of the arteries thicker and they can become so thick that blood won’t pass through them. Pieces of plaque can also come off the wall and clog the artery. Sometimes clots travel through and clog veins as well. The outcome of these scenarios is a heart attack or stroke and possibly death. So the question is – regardless of whether the medicine lowers the cholesterol number- do these drugs stop heart attacks?

I am sure that the information to my research question below is available to some extent, however, I do not have the liberty, i.e. time, to explore that and will just offer it as food for thought. If someone were suggesting that I take one of these medications, however, I WOULD make the time to find the answer.

Question: Which of the following interventions reduces the number of heart attacks, strokes, surgeries, death – etc in patients with high cholesterol?

Statins alone
Statins with low fat calorie controlled diet and daily exercise
Low fat calorie controlled diet and daily exercise alone

And yes, you already know what I think the answer is – though it may depend on other factors of a particular set of people as well.

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