A commentary from Navar and Peterson in the JAMA advocates use of statins but
also expresses concern about sole reliance on a risk assessment formula to decide
about use of statins for primary prevention. They point out problems with the
USPSTF recommendation guidelines with the example of a theoretical Mr. Young
a 41-year-old man with hypertension and an unhealthy blood lipid profile: a total
cholesterol level of 245 mg/dL; a LDL-C of 155 mg/dL; and a HDL-C of 50 mg/dL.
According to the risk assessment formula, his estimated 10-year cardiovascular disease
(CVD) risk is 2%, with an estimated lifetime CVD risk of 50%. Mr. Young has
a high cholesterol and hypertension but is only at a relatively low risk in the short
term from cardiac events because of his young age.
Another example, Mr. Smith is a 63-year-old man with a lifetime risk factor profile similar to that of Mr. Young,
except that his cholesterol levels indicate low risk, his total cholesterol is 160 mg/
dL; LDL-C, 80 mg/dL; and HDL-C, 50 mg/dL. His estimated 10-year CVD risk is
10%, and his estimated lifetime CVD risk is 50%.
Based on these patients’ respective 10-year CVD risk estimates, the USPSTF recommendation
statement would not suggest statin treatment for Mr. Young despite
his elevated LDL-C level but would recommend therapy for Mr. Smith despite his
“normal” or healthy LDL-C level. There is compelling evidence that early treatment
can delay the onset of CVD later in life among adults with elevated cholesterol
levels. So waiting to treat Mr. Young until he is old enough to reach a 7.5% or
higher 10-year CVD risk would be likely to expose him to many years of unhealthy
elevated cholesterol levels. And it is entirely plausible that prolonged reductions
in LDL-C with statin use would reduce the long-term risk of CVD.
Navar and Peterson also note that in almost every trial to date, statins have been found efficacious
in reducing CVD risk, so it is reasonable to consider offering statin therapy to
younger populations. They suggest that clinicians “… practice the art of medicine
and engage with patients in shared decision making regarding strategies for CVD
prevention.”
One consideration about low targets for LDL-C and triglycerides is some evidence
that low LDL-C levels are associated with an increased risk of hemorrhagic stroke.
In a study among women, those with LDL-C lower than 70 mg/dl and in the lowest
quarter of triglyceride levels were at twice the risk of hemorrhagic stroke compared
to women with LDL-C of 100 to 129.9 mg/dl. This finding must be balanced
against the evidence that among patients with a prior ischemic stroke or transient
ischemic attacks, use of high dose statins to lower HDL-C to a target of 70 mg/
dl had a lower risk of a subsequent ischemic stroke and no statistically significant
increased risk of hemorrhagic stroke.
Commentators on the study that found that low HDL-C increased hemorrhagic
stroke pointed out that it is important to consider the clinical relevance of the
study. Although the absolute hemorrhagic stroke risk per year in the highest
risk group category was 0.04% per year (on average 0.02% per year higher), the
reduction in risk of other CVDs from statin use may be greater. The Cholesterol
Treatment Trialists’ Collaboration showed that every 10 mg/dL lowering of LDL-C
reduces the annual CVD-risk by 1.03%. As always, keep in mind that twice the
risk of a rare event, such as a hemorrhagic stroke compared to an ischemic stroke
and other CVDs, is still a rare event.
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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