Medical Mondays 2

Dr. Patricia Yarberry Allen is a collaborative physician. This week, she asks cardiologist Timothy C. Dutta to advise a 51-year-old who is highly wary of taking statin drug, although her family doctor believes she needs to do so.

 

 

 

Dear Dr. Pat:

“I am a 51-year-old woman with great health habits. I exercise almost every day. I am 5-foot-6 and weigh what I weighed in college: 130 pounds. I eat lots of salads, fish, vegetables, and some fruit. I avoid processed foods and red meat. No one in my family had any early heart disease or strokes. But everyone in my father’s large family had elevated cholesterol. My last period was two years ago, and my cholesterol shot up! My total cholesterol is 264, with bad cholesterol of 120 and good cholesterol of 144. My triglycerides are normal. My family doctor is pushing me to take a statin, but so many of my friends have had bad experiences with these drugs, I really don’t want to start on this drug path. I don’t take any prescription medications. I take Vitamin D and a multi-vitamin for women that has no iron. Do women with my history have to take a statin? What about the side effects?

Peggy

 

Dr. Pat Responds:

Dear Peggy:

Patients ask me this question all the time. Many have more significant cardiac risk factors than you do and still try to avoid statins by becoming vegans, exercising, and weight loss.  Women tell me that they want more proof that they are at risk before taking statins, and they fear that once they start these medications, they will need to stay on them for life. I recommend that they see a cardiologist and get additional testing if they are unhappy with the recommendation of their general-practice doctor. I have asked Dr.Timothy C. Dutta, the cardiologist who is a member of Women’s Voices’ Medical Advisory Board, to answer this important question.

Dr. Pat

 

Dr. Dutta Responds:

Dear Peggy:

Do you need to take a statin?  Some people seem to say that everyone should be on a statin (statins are one of the most commonly prescribed chronic medications), while others some seem to say that no one should be on one.

Statins, which lower the LDL “bad” cholesterol, can have a favorable effect on the other cholesterol particles, and seem to have other beneficial qualities as well. They may be the safest and most effective group of medications to prevent vascular disease. And vascular disease—primarily heart attacks and strokes—is the most common cause of death for Americans. It is consistently shown that statins can cut the risk of heart attack and stroke by more than 30%; that is an enormous benefit.  Most people do well on statins and do not have problems taking them; it is no wonder that there is a great push to get people at risk to take them.

As medications go, the statins do have a good safety profile, but they are not perfect. While half of Americans will have a heart attack or stroke, half of them won’t. Whether it is worth taking a statin comes down to how much risk you are at and what side effects you might experience.

If your risk of a heart attack or stroke is high, then you should try to take a statin.  Certain groups of patients are agreed upon to be at high risk, and there is little controversy that they should be on medication. Patients who have already had a heart attack or stroke, or who have a stent, a bypass, or a known blocked coronary artery, should be on a statin. Patients who have blockages of other arteries or an aortic aneurysm should be on a statin. Most patients with diabetes should be on a statin. All of these patients have a high enough risk that taking a statin is worthwhile.

For patients at lower risk, there are controversies. Some patients, even some with high cholesterol, may be at low enough risk that a statin may not be worth it.  These patients may be able to lower their risk through diet and exercise. Consider the following table:

dutta

All of these women have lowered their risk of a heart attack by 30%, but based on what risk they started with, the size of the reduction is different. The 75-year-old woman has an almost 1 in 3 chance of having a heart attack. Her risk is still high even on a statin, but is reduced a lot. The 65-year-old woman has a 1 in 20 chance of having a heart attack. The statin lowers her risk, but not by nearly as much. The 55-year-old woman has only a 1 in 100 chance of having a heart attack. Her risk is so low to begin with that the statin lowers her risk very little.  

Aside from preventing a heart attack in the short run, statins also slow or even stop the gradual formation of plaque that narrows the coronary arteries over a span of decades.  Since there is almost no chance of getting rid of plaque once it is there, why not get a head start on prevention by starting the medication earlier, before the plaque forms? For the 55- and 65-year-olds in the example above, their risk will go up as they age. Since we can’t take away their coronary disease at age 75, why not stop it from forming in the first place? This is a compelling argument, and one that I believe in. Others question whether is it a good idea to take something for so long to prevent something that won’t be apparent until decades from now.

Dr. Dutta

In this article, I have discussed reducing the risk of vascular disease from statins, but what are the downsides and side effects of taking statins? I will discuss this in a future article.