Medical experts have many views about the use of statins, so a decision to start
a statin or other lipid-lowering drug that will likely be taken for a lifetime is not
straightforward and deserves a considerable discussion with your health care provider.
In 2013 the American College of Cardiology and the American Heart Association
(ACC/AHA) published a Guideline on the Treatment of Blood Cholesterol
to Reduce Atherosclerotic Cardiovascular Risk in Adults. The guideline
endorsed use of statins because, among lipid-lowering medications, statins had the
strongest evidence of improved patient health. One estimate is that the treatment
of 10,000 patients for five years with statins would cause one case of serious muscle
injury (rhabdomyolysis), five cases of muscle inflammation (myopathy), 75 new
cases of diabetes, and seven hemorrhagic strokes while averting about 1,000 heart
attacks and other serious cardiovascular events among those with preexisting CVD,
and averting 500 CVD events among those with elevated risk but without preexisting
disease.
The 2013 AHA/ACC guidelines have an appropriate emphasis on lifestyle changes
to prevent CVDs. However, the recommendation called for abandoning specific
goals for a healthy level of LDL-C and basing the decision to use statins on a 10-
year risk assessment of heart attack or stroke. This was a change that many medical
experts (including me) do not agree with.
In summary, the 2013 ACC/AHA guidelines recommended statins for the following
groups:
• People age 40 to 75 with a 7.5% or higher risk of heart attack or stroke within
ten years based on an online arteriosclerotic cardiovascular disease (ASCVD)
risk estimator at http://tools.acc.org/ASCVD-Risk-Estimator/, and, http://
www.cvriskcalculator.com
• People with a history of cardiovascular disease
• People age 21 or older with very high LDL-C, i.e., a LDL-C level of 190 mg/dl
or higher
• People ages 40 to 75 with type 1 or type 2 diabetes
The Mayo Clinic also offers an online decision guide at https://statindecisionaid.
mayoclinic.org
One study estimated that according to the 2013 ACC/AHA guideline, statins should
now be prescribed for 56 million Americans. The AHA estimates that 33 million
of these individuals would be without overt cardiovascular disease but are over the
10-year 7.5% risk threshold. Some experts postulate that perhaps all of the more
than 73 million adults in the United States who have elevated LDL-C should be
considered for statin therapy. An article in Lancet, “Statins for all by the age of
50 years?” suggests that adoption of a 10% or more cardiovascular risk threshold
would classify 83% of men older than 50 years and 56% of women older than 60
years in Britain as needing a statin based on a 2003 Health Survey for England.
Many medical experts were supportive of the 2013 guidelines and assert that the
benefits of statins outweigh any conceivable serious adverse effects. But immediately
after their release, articles appeared in the medical literature questioning their
appropriateness. The question that was most frequently asked was: Would the new
guidelines lead to the unjustified treatment of millions of people?
Articles were published in the JAMA titled, “More than a Billion People Taking
Statins?” and “Healthy Men Should Not Take Statins.” Their main arguments
were that the decrease in mortality would be small, the formula overestimates risk,
that the adverse side effects of statin use are significant, and that individuals with
the highest risk have the most to gain. Commentators also expressed concern
that both doctors and their patients will be lulled into thinking that taking
statins is all that is necessary to avoid CVD when adopting a healthy lifestyle is the
most important way to prevent CVD.
Although some experts said the new guidelines were problematic because they
overestimate risk, other critics argued that they underestimate risk because some
(especially young) people with only moderately elevated LDL levels and no other
risk factors would have a low short-term (10-year) risk and not be recommended
to take statins even though they would be at a high lifetime risk of CVD. Some
experts advocated a return to target-based lipid guidelines. The University of
California, Berkeley, Wellness Letter noted, “We are hesitant to endorse the new
guidelines. It is not clear that this approach—especially its emphasis on the risk
calculator—will actually be more effective than the previous target-based guidelines.”
This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel.
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