Ok, so maybe I’ve been too hard on statins. Just because they suck at preventing a first heart attack is no reason to throw the baby out with the bath water.
The list of side effects continues to grow, with diabetes being the most concerning (unless of course, it is you personally who happens to die from a fatal rhabdomyolosis, in which case you’re probably less worried about diabetes….), because for every 11 heart attacks avoided 8 new cases of diabetes will be created.
I have argued less against the use of statins in secondary prevention (those who have already had a heart attack and are now trying to prevent a second heart attack) because the data is a little stronger. In general, though, statins will do very little to protect against a first heart attack. The only real benefit is seen in those who have a greater risk. In other words, the otherwise healthy, lean body weight, low blood pressure 45-year-old male with an isolated, elevated cholesterol will have ZERO benefit from taking a statin. This doesn’t stop him from getting prescribed a statin by some overzealous primary care doctor who just got back from a conference sponsored by Pfizer, however.
As I have mentioned before, only 1 out of every 100 people will see a benefit from taking a statin. My point has always been that lifestyle changes will blow the effectiveness of statins out of the water every single time with lower cost and no side effects.
But what if we could identify a (very) small subset of patients who have not had a heart attack and yet would most likely be that ONE person out of 100 that benefits from taking a statin? Turns out we may be closer to this answer with this particular study.
I have, for a long time, been a vocal advocate for the “heart test,” or calcium artery scoring (CAC) using an ultra fast CT scan. Overall, the studies and subsequent data on the use of the EBCT (electron-beam CT) continues to improve and radiation doses have continued to drop to the point where the radiation exposure can be less than a dental X-ray (as opposed to standard CT scans, which we hand out like candy in the ER, which have a much higher radiation dose and have been linked to some 29,000 cancers per YEAR).
In the study, researchers looked at the benefits of statins through the lens of those having high calcium scores, indicating a higher likelihood of having a blockage in the coronary arteries. Specifically, they looked at the relationship between the CAC, statin use and outcomes (heart attack, chest pain leading to stents being put in, resuscitated cardiac arrest, stroke, cardiovascular death). Here’s the specifics:
- Researchers looked for those with Ultra fast CT scores over 100 (21% of participants with CAC 100 or higher).
- They then looked at those with abnormal cholesterol levels: LDL > 130 mg/dL, HDL < 40 mg/dL for men (50 mg/dL for women) and triglycerides > 150 mg/dL.
With these two factors in mind, here’s how the study data played out:
- More than half of events (55%) occurred in the 21% of participants with CAC ≥100 (the CT scan group bore the brunt of the heart events).
- Conversely, 65% of events occurred in participants with 0 or 1 lipid abnormality (in other words, heart events are happening to those with normal cholesterol)
- In those with CAC ≥100, event rates were as high as 29.5 per 1000 person-years, regardless of lipid / cholesterol numbers.
- On the other hand, when the CAC was a big fat zero, cardiac event rates were 5 times lower at 5.9 per 1000 person-years regardless of lipid / cholesterol numbers.
To summarize, those with higher CAC scores were at a much greater risk of a cardiac event, regardless of where his or her lipid numbers were at. Medicine has been locked into using the blinders of cholesterol (sounds like some D & D special armor…) despite the fact that it just wasn’t making sense when we looked at current research. While there has been some move away from cholesterol, it hasn’t been with a logical head. The most recent guidelines on statin use have indeed thrown cholesterol levels out the window, but instead of replacing them with something smarter like the CAC, the blanket recommendation was just to give everyone a statin.
The smarter approach, based on this study, would be to use treatment for those at the highest risk based on CAC scores, NOT on cholesterol levels. Let me point out though, that nothing in this study actually looked at whether or not statins could lower cardiac events in those with higher CAC scores, although this is an excellent question to ask.
Maybe, just maybe, one of these decades medicine will actually catch up to the research.