Comments on: Can statins prevent my head from exploding?

By: Dr. Pinna

Dr. Pinna — Tue, 26 Nov 2013 21:02:55 +0000

[…] Can statins prevent my head from exploding? […]

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By: Dr. Pinna

Dr. Pinna — Mon, 25 Nov 2013 15:51:27 +0000

[…] Heart Sisters: “Can statins prevent my head from exploding?” […]

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By: markmcc1985

markmcc1985 — Wed, 20 Nov 2013 16:46:15 +0000

Yes, check out the “CARDS” trial (Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004).

And the answer is: the same as most trials….statins lower risk of events. Again, the KEY question is: “what is our best guess of YOUR risk without statins and what is the magnitude of risk reduction with a statin. I would recommend you get a ($10) subscription to MyStudies.org where you can look at actual data from all such trials and decide for yourself if the magnitude of benefit is worth it to you, as an individual.

As an aside, if all readers of this excellent blog would simply take data from MyStudies.org to their doctors and ask questions, both patients and doctors would be better educated and make more informed decisions.

And if your doctor doesn’t want to look at data, you really might want to find a different doctor.

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By: Carolyn Thomas

Carolyn Thomas — Wed, 20 Nov 2013 03:32:53 +0000

I agree with you. Yet I’m also hearing from other docs (already feeling overburdened and time-crunched during patient visits) who doubt whether these shared decision-making discussions will realistically be more successful than just pulling out the prescription pad. If physicians themselves cannot seem to come to an agreement over whether statins are recommended for primary prevention, what hope do confused patients have? And the issues with that risk calculator are just plain embarrassing . . .

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By: Mark

Mark — Wed, 20 Nov 2013 01:21:19 +0000

Here is a rather simple take on this issue:
Let’s FORGET about cholesterol. How about we focus on 3 things:
1. What is your baseline risk of a CV event?
2. How much…in absolute numbers…does a statin reduce that risk?
3. Once YOU see those numbers, is taking a statin worth it to YOU?

I love your piece. But the whole dialog is easily side-tracked by fiddling with whether or not statins work. They do. (and they DO have risk of harm!). The question for each patient (not their doctor or some regulatory agency which pays doctors for metrics) is: Does the Absolute reduction in YOUR risk seem worth it to YOU?

This is why it’s best to TRY (with imperfect tools) to estimate an individual patient’s risk and then show them what OLD studies (we don’t have new ones) reveal to us about absolute risk reduction. Dr. Ridker’s comments (as with Dr. Stone’s) should be taken with a grain of salt. He is a proponent of High sensitivity CRP (or CRAP) as a test which, in the JUPITER trial tried to expand the group of patients who “should” take statins.

The only “should” in the conversation is that we, as docs, SHOULD try to present to patients absolute risk and absolute risk reduction and harms. And then humbly wait as patients individually decide what is important to them.

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By: cave76

cave76 — Wed, 20 Nov 2013 01:09:18 +0000

Have you seen this comic strip about statins?
https://mail.google.com/mail/u/0/?shva=1#inbox/1426be2c6abef54f

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By: Carolyn Thomas

Carolyn Thomas — Tue, 19 Nov 2013 22:40:05 +0000

Hi Michael – thanks for sharing your perspective here. I’m now going to go embroider this on a pillow: “You have nothing to offer her. I have Crestor to offer her!” I get what you’re saying – but your wife’s story seems actually one of shared decision-making between doctor and patient (yes! even when we don’t like the results of that decision!) Also, from a patient’s perspective, it can feel scary seeing those high LDL numbers, and then equally reassuring to see those numbers plummet, as they are very likely to do with Crestor. Whether plummeting LDL numbers (a surrogate endpoint) are predictors of a good outcome is, of course, The Question. I’m aware of a few statin studies on patients living with diabetes. For example, in the Heart Protection Study, 5,963 patients with diabetes were randomized to 40 mg simvastatin (Zocor) or placebo regardless of their baseline LDL or prior cardiovascular disease. Conclusion: a significant 22% reduction in the first event rate of major coronary event, stroke, or revascularization was noted. PS Check to see if Merck funded that study. FYI, here’s a table on other comparable studies.

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By: Michael Wosnick, PhD

Michael Wosnick, PhD — Tue, 19 Nov 2013 21:48:10 +0000

Thank you for this Carolyn. I have been having a running feud with my wife’s doc (and she is an endocrinologist not even a cardiologist – so the koolaid they are drinking goes well beyond the heart doc!) about this.

She insisted on putting my wife on Crestor (her LDL was admittedly high) but acc’d to my read of the data she was in line to receive no benefit in terms of cardiac event or mortality (yes her LDL numbers would go down but so?).

When I protested and said she would be better off to do a diet intervention the doc looked me in the eye and said “You have nothing to offer her. I have Crestor to offer her”.

I vowed never to return and have kept that promise but my wife likes her and continues to see her. At least I got them to agree to go down to the lowest possible dosage (5 mg). She has had no adverse effects (yet?) and her LDL numbers are indeed very good now, but I am convinced she is courting harm for no good reason.

I was playing around last night with the online risk calculator and have a question for you: Are you aware of ANY trials that looked at statin use solely in diabetics. If you have no other risk factors other than diabetes the new guidelines say go on statins. But unless statins have been tested on diabetics with NO cholesterol problems, how could we possible conclude that. I can’t see why any such trial would ever be done, but just wondered if you have any knowledge.

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By: Carolyn Thomas

Carolyn Thomas — Tue, 19 Nov 2013 20:03:33 +0000

*Sigh* is right. Glad you kept reading right to the bitter end, Cave… 😉

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By: cave76

cave76 — Tue, 19 Nov 2013 17:59:13 +0000

Thank you for presenting facts in a simple way. Although I did read your entire article, I was tempted to stop after reading this in the third paragraph:
” …our doctors not to obsess quite so much on those target LDL numbers in favour of expanding the pool of potential statin-users out there.”

Bazinga! and Sigh.

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By: Carolyn Thomas

Carolyn Thomas — Tue, 19 Nov 2013 17:18:45 +0000

Hello Kathleen – so glad you mentioned the NNT website. It’s now my ‘go-to’ resource for almost all questions on drug/treatment options.

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