45 million Americans “should” take statins. Are you one of them?
It may surprise you to find out that you might be. When your doctor plugs your information into a cardiac risk calculator, he or she may tell you that you should to take a statin.
You may not feel bad. You may not have many other cardiovascular risk factors. Yet you may be labelled with the “disease” of elevated cholesterol.
“New” Guidelines- Questionable Sources, Questionable Guidelines
Why are so many more previously healthy Americans now being treated for high cholesterol? We can thank the 2013 ACC/AHA guidelines, which increased the intensity with which physicians prescribe statins.
Interestingly, these were not based on any new data. Instead, they were based on new interpretations of old data, much of which has not been made available for third party reviewers. None the less, it is now recommended that physicians consider prescribing a statin to anyone with a 5% 10-year risk of cardiac disease (increased from a previous 20% risk).
To me it seems that a recommendation to dramatically increase the use of these drugs should save lives left and right and have almost no down side. Unfortunately, that is not the case.
Don’t get me wrong. Statins are not useless. They can reduce the incidence of heart attacks and strokes. For someone who has never had a heart attack (referred to as primary prevention) we need to treat between 60 and 104 people for 5 years to prevent one heart attack without any significant difference in the risk of dying.
That’s a little underwhelming, is it not? That seems like a “shotgun” approach where you send a hundred bullets out knowing that one will hit the right person (in this case getting hit by a bullet is a good thing). It doesn’t have to be this way.
In addition, statins are not perfect drugs. For every 50 people treated over five years there will be one new case of diabetes. There will also be at least 10% risk of muscle aches and pains with potential damage to the mitochondria (the energy producing part of the cell), and may even be linked to onset of dementia and memory dysfunction.
A system that potentially harms more people than it helps doesn’t seem like a viable solution to me. We can do better.
Better Define Your Risk
The problem is that our medical culture emphasizes prescribing drugs more than further defining your risk, and more than exploring alternatives to reducing your risk.
The current cardiac risk calculator uses:
- Total cholesterol
- Blood pressure or previous diagnosis of hypertension
- Diagnosis of diabetes
- Smoking status
Those are all reasonable initial risk factors to evaluate. But doesn’t it make sense that if we are using a drug that will only benefit one in 100, maybe we should try to further define those at high risk? To me that is a no-brainer.
For instance, one study showed that by measuring a coronary calcium score on statin eligible individuals, we could reclassify 50% of them so that they no longer “qualify” for statin treatment. We can avoid an enormous number of statin prescriptions with one simple test. A test that is readily available now. A test that has minimal risk (very low radiation dose, and a small chance of incidental findings), and is relatively low cost (about $100).
And we don’t have to stop there.
The Scripps Research Institute has developed an app to allow people to use their genetic information to better define their risks. This could potentially be used to define those who are not at high genetic risk for heart disease and therefore would likely not benefit from statin therapy.
Now we are starting to get somewhere. What if we could better define cardiac risk so that one in 5 people benefit from a statin, as opposed to the current 1 in 100? That is an admirable goal.
Even Better Than A Statin
Once we better define our risk, let’s not forget all the alternative to statins.
One recent study demonstrated that even those at the highest genetic risk for heart disease can cut their risk in half with healthy lifestyle habits (eating healthy, getting regular physical activity, not smoking and not being overweight). And that was the highest risk group! That’s likely just as good as, if not better than, a statin could do.
So why don’t we write prescriptions for intensive healthy lifestyle education programs instead of drugs?
Lifestyle changes are “harder.” Lifestyle changes take longer to see results. Lifestyle changes require more education, encouragement and follow up.
Do you know what else is associated with healthy lifestyle changes? Decreased risk of heart attack, strokes and death. Decreased risk of diabetes, high blood pressure and depression. And the only side effects are feeling better, having more energy, and being in control of your health.
That sounds like something that is well worth the extra work, the needed patience, and the more vigorous follow-up. Don’t you agree?
Start Asking Questions
So, what should you do if your doctor recommends a statin? Start asking questions. Lots of them.
- How high is your calculated cardiovascular risk?
- How much will a statin reduce that risk?
- What else can be done to better define your risk (i.e. coronary calcium score)?
- What else can be done to lower your risk (i.e. intensive lifestyle modifications)?
Ask yourself questions as well.
- How can I improve my nutrition to focus on a vegetable based, real food, Mediterranean style eating that focuses on healthy fats and appropriate proportions of high quality animal products?
- How can I improve my daily physical activities in addition to increasing my weekly exercise?
- How can I improve my stress management and sleep habits?
Remember, the benefits of statins are small. Not zero, but small.
Also, remember that statins have not been directly compared to healthy lifestyle habits. We don’t know if they add anything to a comprehensive lifestyle modification program. In fact, I would wager that if you have healthy eating habits, you get regular physical activity, you exercise regularly, and you practice regular stress management, then statins will not reduce your cardiovascular risk at all.
It may seem like a bold prediction, but to me it seems obvious.
Unfortunately we will likely never see a head-to-head study between statins and healthy lifestyle interventions (I discuss the specifics of the study I would like to see in my prior blog post here).
We can do better than a drug
In the end, remember that we can do better than drugs. We can be in control of our health. We can achieve real health that is not dependent on blood tests or medications.
So, don’t blindly accept a prescription for a statin (or any drug for that matter) without further defining your risk, and without further exploring your alternatives. You and your health deserve at least that much.
Thanks for reading.
Bret Scher, MD FACC
Cardiologist, author, founder of Boundless Health
If you are on a statin, or any drug for that matter, make sure you ask your doctor why you are on it, exactly what benefit you should expect, and what the potential short- and long-term side effects are. Also, ask what the alternatives are, specifically regarding your lifestyle and healthy habits. If you aren’t getting adequate answers, ask me! firstname.lastname@example.org. I welcome your emails.