Growing doubt on statin drugs — the problem of drug-lifestyle interaction

My mind is changing about statins. I’m growing increasingly worried about the irrational exuberance over these drugs, especially when used for prevention of heart disease that is yet to happen.

An elderly patient called my office last week to tell me thank you…not for a successful procedure or surgery, but rather, for helping with a problem that had dogged her for a decade. How did an electrophysiologist help a patient without doing a procedure?

I stopped her statin.

A few weeks later, the patient said, her muscle and joint pain were gone. “I thought it was arthritis. I’m walking now. I haven’t felt this good in years. I’ve even lost 5 pounds.”

So why was this elderly patient on a statin?

It was being used to lower cholesterol in the hopes that it would lower the risk of a future heart attack or stroke. This is called primary prevention. The patient had no vascular disease but had a high cholesterol level.

The problem of course is that statins have not been well-studied in elderly women. Her doctor, and the medical establishment writ large, have extrapolated findings of clinical trials on younger mostly male patients to all patients with high cholesterol levels. This is a striking jump to make given that low cholesterol levels in the elderly associate with higher death rates.

Anecdotes are not evidence but this one moved me to review some of the statin evidence. And to think (again) about treating people versus disease.

As always, let’s start with the truth–absolute not relative values. Then I will move on to some new revelations about statins, and then an interesting theory of why potent cholesterol-lowering drugs have such painfully small effects on overall cardiovascular outcomes.

The Truths:

When statins are used in low-risk patients without heart disease (primary prevention) there is no mortality benefit. That’s right. Your chance of dying are the same on or off the drug, regardless of how much the statin lowers the cholesterol level.

When statins are used for primary prevention there is a small lowering of future vascular events (stroke/heart attack) over 5-10 years. The absolute risk reduction is in the range of 7 per 1000. That means you have to treat 140 patients with a statin (for five years) to prevent one event. Or this: for 99.3% of statin-treated patients, there is no benefit. I like to call this the PSR or percent same result.

There is also general agreement that statins increase the risk of developing diabetes, especially in women, and that risk is about the same as preventing a stroke or heart attack, approximately 1%.

Another fact is that patient-level (raw) data from the industry-sponsored cholesterol trials have not been independently analyzed. Systematic reviews from the Cochrane group have analyzed only published data rather than the raw data. There is likely a difference.

There is great debate about the incidence of statin side effects, such as muscle pain, cognitive issues, decreased energy, sexual problems, kidney and liver injury, among others. In the industry-sponsored randomized controlled clinical trials, discontinuation of statins was not significantly different from placebo. Observational data, and the observations of any clinician, provide a different picture.

No statin drug has ever been compared to lifestyle interventions for the prevention of cardiovascular disease.

New Revelations:

A study presented in April 2014 at the Society of General Internal Medicine Meeting in San Diego showed that individuals prescribed statin therapy for high cholesterol consumed more calories and more fat than non-statin users. And, not surprisingly, this increase in calories paralleled an increase in BMI (Body Mass Index) in statin users.

An analysis of a prospective cohort study of men (published in JAMA-IM) revealed that physical-activity levels were “modestly” lower among statin users compared with nonusers independent of other cardiac medications and of medical history.

Possible Connecting Theory: Drug-Lifestyle Interaction

These two recent studies are troublesome. As pointed out in the excellent coverage from heartwire journalist Michael O’Riordan, there may be an interaction between medication and lifestyle. Namely, if statin users consume more calories, gain weight and exercise less it becomes easy to see why cardiovascular benefits are so small.

It’s been really hard to explain why the striking reductions in bad cholesterol (LDL)–up to 30-50%–from statins hasn’t translated into significant future benefit.

One possibility is that cholesterol levels are a lousy surrogate for outcomes. That surely seems true in the elderly, but what about in younger patients and those with familial high cholesterol? These patients are definitely at increased cardio-vascular (CV) risk. So cholesterol levels are surely not unimportant. There is convincing data, for instance, that higher HDL (good cholesterol) levels associate with lower CV risk.

Another possibility for lack of statin benefit is analogous to AF rhythm-control and high blood pressure issues. As in, yes, it’s better to be in regular sinus rhythm and have normal blood pressure, but getting to those goals with pills isn’t the same as being there naturally. With rhythm-control and blood pressure drugs the achievement of the desired outcome is muted by side effects from the drugs. Perhaps it’s the same with statin drugs?

You don’t have to posit malfeasance on the part of big pharma here. All you have to do is think past the disease-specific mindset of modern-day medicine. We are much more than our cholesterol level. A statin drug, like so many drugs which block enzyme pathways far upstream in major cellular pathways, is going to have much more biologic action than just moving an easily measured cholesterol level.

When you step back and look at medications as chemical modifiers of cellular processes in complex biologic systems like our body it’s easy to understand that health comes not from pills. Not even statins.

JMM

References:

Should people at low risk of cardiovascular disease take a statin? BMJ 2013;347:f6123

The above authors reply to criticism: http://www.bmj.com/content/347/bmj.f6123/rr/678736

The Cholesterol Myth | YouTube video of Australian TV investigative journalism piece: http://youtu.be/F0kIC-dbW2g

Comments

  1. says

    This is why I am beating the drum for treating cholesterol as a risk factor, not a disease (and hence, the treatment of cholesterol as a risk-reduction tactic). Far too many are treated who are not at increased risk. My tactic is to treat the high risk people, not treat the low risk folks, and get a coronary calcium score on those in between. This may not meet everyone’s scientific criteria (as treatment of a calcium score of 200 may not equate to treatment of someone with angina or those who’ve had an MI), but it focuses on the main goal: lower risk of death or harm. Obviously, when focused on risk one must consider the risk of the medication you are using, as well as its impact on quality of life. It’s our job to educate patients on these things when we start any medication: why the medication is being started, what the risk of the medication is, potential negative effects, and how this medication either reduces risk or improves quality of life. In other words, we must do our job and not cut corners.

  2. Pete says

    I am so glad you addressed this topic.

    Using he risk estimator at http://tools.cardiosource.org/ASCVD-Risk-Estimator/ that follows the new guidelines for statin use, a 65 year old white male with cholesterol of 146 and HDL of 50, no diabetes, non smoker, 110 systolic pressure, not treated for hypertension has a 10 year risk of 7.9% and therefore is recommended to take statins (over 7.5% 10 year risk).

    Those are my numbers. I would have to have an HDL level of 56 to not be on statins. I’m not sure there are many 65 year old males with numbers as good as that. Even if my cholesterol was 160 and my HDLs were 60 (that’s the “protective” threshold), I would still have a 7.5% 10 year risk. Sounds like practically every 65 year old white male needs to be on statins.

    Okay, so then comes the issue of determining how vascular disease is diagnosed. In your example, the following statement was made: “The patient had no vascular disease but had a high cholesterol level.” How was that determined? I presume you are talking about heart disease… EKGs, stress tests, nuclear stress tests, listening and imaging carotid arteries, and ankle-brachial index, family history, etc. Did you include coronary calcium score?

    The reason I ask, is that I had all the tests except the coronary calcium test and was not diagnosed. Enter the coronary calcium test. I scored 34. That is not zero. The test indicates that 65% of the men my age have higher scores. That doesn’t sound too bad. But I’m told it isn’t zero and I need to take action. Statins! Remember, my cholesterol is 146 and has been in the 150s for decades, and my HDLs have always been in the 50s. So now I’m wondering what I should be looking for in my cholesterol score to see I have reduced my risk. Mind you I eat a Mediterranean diet, a really unusually strict heart healthy diet and exercise daily. So should I look for a cholesterol level of 99? Is that even healthy or possible? Or how about cholesterol 99 and HDLs 60?

    It seems to me that maybe the cholesterol numbers aren’t the reason I have some calcification (low btw) and that lowering my cholesterol might not change anything and might harm. I don’t have the answer. But it doesn’t sound logical. I can convince myself internally that taking statins might help, but the acid test is explaining it to my wife. We’ve all been there. “Honey, I was late because a meteor hit the car in front of me and…” Sounds like a plan till I get home. Then my story falls apart. If it sounds dumb when I’m explaining it to my wife, it probably is. If it sounds unbelievable, it probably is. My wife would come back with ” All the obsessive running you’ve done since High School probably gave you some calcium and, btw, I read about it on http://www.drjohn.org that you always quote”.

  3. DoctorSH says

    DrJ

    I have read and enjoyed your blog for some time now, even though I often disagree on many points you make.

    I am happy to say I am in total agreement with you on statins.

    I am in FP, 2/3 of my practice is wellness and prevention with diet and lifestyle first and meds next if needed.

    Statins will go down in history as a huge scam and the sooner physicians see this and reverse course the better. Continued use of statins with such a terrible NNT (number needed to treat) is ridiculous.

    Physicians treat individuals, not populations. Statin use should be reserved for those with known high risk and even then we should calculate the true NNT.

    I think we would find statins rarely used if true numbers ever came out.

    Bravo for taking off your statin blinders. Your one patient has been replicated by a hundred or more in my practice over the years.

    At some point anecdotal becomes real.

    DrH

    • says

      I agree completely with DrH. There can be benefit from statins – but depends on the clinical scenario – and IF most patients were told NNT numbers – and that if NNT equals 100 – or 50 – or whatever the number is (let’s use 100) – this simply means that 99 patients get NO benefit. Not “a little benefit” – but NO benefit. And those 99 patients all pay for the drug and for monitoring (though fortunately new Cholesterol Guidelines recently out suggest at least between the lines less need for ongoing monitoring once on a drug). And those 99 patients are then all subject to potential for developing side effects. Discrepancy in number and frequency of side effects from statins is large – and all I know is that many patients I had treated had disappearance of those vague-hard-to-put-a-finger-on-symptoms shortly after stopping the statin. Hard to sort out how much of the general recommendations for statins in drinking water for patients without underlying heart disease is about $$$ – which is frustrating indeed ….

  4. says

    A 2013 JACC artivle (http://www.ncbi.nlm.nih.gov/pubmed/23583255) suggesting that simvastatin impairs exercise adaptation really got me concerned about this particular downside of statin therapy. I took myself completely off the statin I was intermittently taking after reading it.
    I utilize vascular ultrasound to asess carotid IMT and carotid plaque to assess the actual presence of atherosclerosis to guide my statin prescribing (http://theskepticalcardiologist.com/2014/04/16/searching-for-subclinical-atherosclerosis-vascular-screening/) and with this approach I have found myself taking more patients off inappropriately prescribed statins, especially in the elderly. As you have found it, can be very gratifying when you can simplify the patient’s medical regimen and make them feel substantially better at the same time.

  5. Verted says

    John, this has me in a tailspin, as I finally recently agreed to go on a statin, based in part on your blogs over the years (statins inflammatory benefits, etc).

    Now, I might be in the group that statins could help. My total cholesterol being over 200, my LDL too high, and my HDL too low. On atorvastatin, my total got knocked down to 150, and my LDL reduced, but my HDL remains stubbornly at 39, where it’s been forever, despite prior statin trials, heavy exercise and great diet.

    I did have a stent a few years ago after a cath revealed a 70% blockage in one artery, but my lifestyle has changed radically since then (better diet, excercise, 40 pounds lighter0 and my episodes with afib. With better diet and exercise, I’ve been afib free for a long time without any meds. My GP has been after me to go on a statin, so I finally agreed, although using the risk calculator, I found not that big a benefit. I worry about side effects. I had a rough time with Zocor, but so far the new statin has had no side effects I’ve noticed.

    Another thing that convinced me to try again was a recent article i read concerning statins and lowering of visual field defect progression from glaucoma – the theorybeing that lowering lipids increased blood flow to the optic nerve.

    So, we shall see. You had a great point about those taking statins and their diets/lifestyle. I’ve found that it’s all too easy to say to myself – “Oh well, eat that steak, you ARE taking a protective statin”. i have a friend I worry about who eats like there’s no tomorrow, is tremendously overweight and his mantra is “better living through chemistry” bp meds, statins and endless NSAIDS and pain killers for his joint problems. I can’t convince him.

    Nice, well rounded blog regarding statins. Thanks. The latest recommendations that came out suggesting practically everyone should be on a statin were totally off base in my opinion.

  6. Don L says

    It seems hard to believe now, but there were once serious proposals to put statins into the water supply.

  7. Dr J Younger says

    I enjoyed the post but think it is worth making some points in support of statin therapy.

    There is good evidence that statin therapy DOES save lives in primary prevention.
    Two recent meta-analyses unequivocally support statin therapy for primary prevention. The Cholesterol Treatment Trialists’ Collaborators demonstrated a 9% decrease in all-cause mortality and a 25% decrease in cardiovascular (CV) events for every 1.0 mmol/l reduction in LDL cholesterol, even among low-risk patients. The 2013 Cochrane review support these findings showing a 14% reduction in all-cause mortality and a 25% reduction in CV events with statin therapy.
    I totally agree that people at very low CV risk probably won’t benefit from statin therapy, at least in the first 5 years. Even those with a high cholesterol level may not benefit if they don’t have evidence of vascular disease and their global risk score is low. I would not recommend a statin just because of a high cholesterol level (although familial hypercholesterlaemia is an exception, as this group of people certainly die young unless they are treated).
    However CV disease kills more people than all cancers combined. In other words, you are more likely to die from CV disease than any other single cause, so your lifetime risk of dying from CV disease is about 40%. Definitions of high risk therefore can be quite variable, depending on the length of your time scale. Once your risk goes up, the number needed to treat, for one to benefit in the first 10 years, is around 6. It your life goes on for more than 10 years, the number needed to treat will be smaller (i.e. there is more chance that you will benefit). This is explained here
    http://www.medicine.ox.ac.uk/bandolier/booth/cardiac/statcalc.html

    Also it is worth noting that one of the references used for the main blog article above is a program from the ABC in Australia. ABC were forced to remove the program from their website after an independent review found that it was biased and inaccurate. The other reference, a BMJ article, was arguing against statin use in low risk patients. The arguments don’t apply to those at higher risk.
    So if you are at more than low risk, and a statin tablet does not annoy you, why not reduce your chances of dying from something preventable?

  8. Pete says

    Dr. Pearson: If you found ANY plaque in the carotid of a 65 year old male (assuming no soft plaque discovered that was unstable), would that be enough to prescribe statins?

    Dr. Younger: You reference “low” risk and “very low” risk in your post. How do you differentiate the two? Do you prescribe statins for all 65 year old males with risk scores of 7.5% or greater, with no additional risk factors?

    Would one of you doctors please comment on your assessment of the reliability of coronary calcium scores and gene expression tests?

    It seems virtually all males 65 or older have other than zero (0) coronary calcium scores. Also, as I mentioned above, it would be hard for a 65 year old male not to score 7.5% 10 year risk if you play with the numbers/factors :

    http://tools.cardiosource.org/ASCVD-Risk-Estimator/

    The Corus Gene Expression Test website is at: http://www.cardiodx.com/media-and-events/press-releases/the-corus-cad-gene-expression-test-significantly-correlates-with-plaque-burden-and-obstructive-coronary-artery-disease-as-validated-by-ct-angiography

    Thanks.

  9. says

    Pete asks a very good question which gets to the heart of the controversy over the new cholesterol guidelines. If you punch in to the ASCVD calculator what I would consider to be reasonably good numbers for cholesterol (total 180, HDL 45) and BP (systolic 135) and no risk factors, the risk for a 65 year old white male comes up 13.7% compared to 8.8% for that same age male with “optimal risk factors”. Both are over 7.5% and thus statin therapy would be recommended. Almost all males >65 years of age using this approach would be taking statins.

    This where I feel the search for subclinical atherosclerosis can be helpful in guiding the decision. The patient with advanced carotid plaque and calcium score I would strongly advise statin therapy. The patient with no carotid plaque and calcium score <50th percentile for age I would not advise statin therapy. In all decisions I engage in a discussions with the patient about risks/benefits but in those not in one of the two categories above I strongly rely on patient preference.

    The 50th percentile calcium score for a 65 year old white male (you can check it at http://www.mesa-nhlbi.org/Calcium/input.aspx) is 71.

    I don't have any experience with the Corus Gene Expression Test but what I have read indicates that it is useful in patients presenting with chest pain to decide if they have obstructive coronary artery disease and need a catheterization and is not being touted for prevention.

  10. Pete says

    Dr. Pearson:

    Thanks so much for your direct answer. I’ve posed the question various places and it seems many doctors run from the question. I looked on the calculator and I am in the 39th percentile. The doctor I saw prescribed Ravastatin 10 mg as a “compromise”, a less aggressive approach.

    My 10 Year Risk:

    65 year old white male with cholesterol of 146, LDL of 80, and HDL of 50, no diabetes, non smoker, 110 systolic pressure, not treated for hypertension, 10 year risk of 7.9%, recommended to take statins (over 7.5% 10 year risk).

    I’m wondering what my cholesterol will drop to on the statin. If my HDLs went up, I wouldn’t mind that. Last time around, they checked my VLDL and it was really low.

    One last thought. I noticed the coronary calcium score adds up numbers from various locations. I was wondering if it would be better to have low numbers in more places than everything in one location.

    Thanks again.

    • Dr J Younger says

      Pete raises some very valid points. I agree with Anthony Pearson. I’m not aware of gene expressions tests being used clinically to guide preventative therapy at present. The use of imaging tests is important to guide therapy for individual patients who are at low or intermediate risk. In recent years I believe that CT calcium scoring has demonstrated superiority over carotid intima media thickness. I use calcium scoring regularly. Any calcium score above zero is evidence of atherosclerosis. However there is still debate about what level of coronary calcium mandates treatment and percentile levels can he helpful in this situation.
      It is not just about the total number. If a 45 year old had a score of 34 this would represent severe premature atherosclerosis (above the 90th percentile) and they ought to be aggressively treated. However for a 65 year old this is only at the 39th percentile and therefore not at high risk.
      The SHAPE Task Force guidelines from 2006 (Naghavi et al), although a little dated now, provide some expert opinion. They suggest target LDL levels based upon risk. For someone with a calcium score less than 100 AND below the 75th percentile, the suggested LDL level is less than 130mg/dl (with 10% 5 year event risk and the low risk category applies to individuals with a SCORE less than or equal to 1%
      and free of qualifiers that would put them at moderate risk, such as diabetes, kidney disease, severe hypertension, etc. My comments on low vs. very low risk were based on an earlier system which regarded 5% and below as low risk and < 1 % as very low risk. Almost no-one in the "very-low " category has an event within 5 years.
      Having said all this, the decision to start a statin needs to be individualised and involve a discussion between doctor and patient.
      There is no doubt that statin therapy saves lives and reduces cardiovascular events like heart attack and stroke. However not everyone will have a heart attack or stroke in their lifetime, so not everyone will benefit from a statin. Too often in modern medicine we can just follow guidelines and forget how to be a physician.

  11. Verted says

    CT Scans are being advertised non-stop here on radio and TV. Is that a worthwhile test (not covered by insurance) that would be of real benefit in addition to lipids analysis?

  12. Dr J Younger says

    Good question about when CT may be useful. I think the answer is that it depends!
    Having a CT scan alone won’t save anybody’s life. The benefit comes from the action taken based on the CT results. In order to be useful, a CT needs to re-classify the person from one risk level to a higher level at which the treatment would be different. The evidence is that CT is most useful for patients who are at intermediate risk when assessed by the usual criteria of age, gender, smoking, cholesterol, BP, etc. The CT helps reclassify this group as either high or low risk.
    You would have to perform CT on 50 to 100 low risk individuals to find one person who would be reclassified as high risk. You could also argue that all high risk patients should be on treatment already, so the CT would not make any difference. In my practice I believe that calcium scoring is useful for asymptomatic males older than 40 years and females older than 50 years who are at intermediate risk. However the only reason to have the scan is if your treatment will be adjusted based on the result.

  13. Verted says

    Excellent explanation Dr. Younger. Thank you.

    One of the local ads even suggested giving a scan to your mom as a mother’s day present “so she would know you care”.

    Irrational exuberance indeed.

  14. says

    Verted, I am curious: Where do you live? I don’t see a lot of calcium score advertising here in St. Louis. My hospital doesn’t really promote it although we have set up what I believe to be a very low charge of 125$ .
    Dr Younger, I agree. Coronary calcium is more predictive than carotid IMT. I find value in the CIMT in the lower risk who have not developed plaque. The very low risk patient based on standard risk criteria who has a particularly worrisome family history for CAD are the patients I am most aggressive with in searching for subclinical atherosclerosis (http://theskepticalcardiologist.com/tag/atherosclerosis/)

    • Pete says

      Dr. Younger and Dr. Pearson: Thanks for your replies. I noticed the group, SHAPE, didn’t adjust the calcium score for age. Which brings me to the next question… why is it okay for an older person to have a certain calcium score that would be bad for a younger person? Because they will die earlier? I’m slow. I like things spelled out. I was watching an ad for an assisted living center called “A Place for Mom”. I asked my wife, what about a place for Dad, where is that? She just looked at me than looked down at the ground, and I said “Oh-h-h-h-h-h…”. so sometimes it takes me longer to catch on to things.

      BTW, the CT scans are advertised in Maryland and New Jersey too.

      • Jeff Patten says

        I’m with you on this question, Pete. (Anyone??)

        As a seventy-year-old, I’d like to know if I’m being given up on as a losing statistical entity.

        I’d like to point out that the older you get, the greater your life expectancy becomes. (To a point.)

        I’d also like to point out that no one dies of “old age”. Everyone dies of a particular vital failure.

        Everyone is healthy… until they’re not.

        There IS the fact that young persons have not had nearly the opportunity to neglect their Lifestyles that we more mature ones have had.

        Is THAT a reason to treat all maturity superior persons so differently??

        A substantial number of us have always taken lifestyle to heart.

        OK. I hope I’ve contributed enough outrage here to stimulate thought and elicit an answer or two.

        Thanks, Dr John

    • Verted says

      The radio ads I catch here are primarily from one scanning center. There may be others, but these ads are heard on my drive to and from work.

      Typically, they start out with a woman’s worried sounding voice and a message Luke “I eat right and exercise almost every day. I was SHOCKED when my doctor told me my cholesterol was a little high. Now I worry, could I have heart disease?”

      It’s followed by the announcer droning stats about every 30 seconds in America someone has a heart attack, and the rest of the pitch talks about “peace of mind” and how the test is quick, painless and noninvasive.

      And, oh yes, “this month we’re running a special price for (name the occasion)”.

      The opening pitch might vary, but the message is the same.

      What I find interesting, is that the ads I catch seem to always target women. I wonder if they are counting on the women persuading their significant others to get checked as well.

      • says

        @ Verted – You accurate description is defined as “marketing” (and NOT as provision of medically relevant information in proper perspective). Sole purpose of those doing the marketing is to make money (regardless of the sensationalist pleading upon consumer vulnerabilities that the marketers choose to go after). In my humble opinion – it is deplorable.

        • Verted says

          Of course it’s marketing, Ken. I’m intimately familiar with marketing, and see right through that layer. I just wanted to give Dr. Pearson a proper account of what’s being presented. The marketing involving many medical situations and drugs these days is deplorable and often misleading. The information presented in this commercial is “accurate”, but presented in a way to hook you into purchasing a scan product, perhaps even without first seeing your PCP or cardiologist. The fact that they run ads for special pricing for “mother’s day” and “father’s day” are a dead giveaway.

          Do you remember the statin ad a few years ago showing two lovely women admiring a muscular, obviously in shape, middle age man at a pool. They were all smiles, until suddenly his total cholesterol number flashed on the screen (don’t remember what they were) and their smiles turned to frowns and they turned away from him as if in disgust? Then came the pitch for one of the brand name statins. The marketing message was you’d never get the babes if you had high cholesterol, although they were supposedly saying that even if you thought you were healthy, you ought to get your cholesterol checked and buy our product. That was a double male ego whammy to try and hook you.

          • Pete says

            Verted:

            Since Dr. John’s blog has totally been hijacked, I thought I would add something to the discussion. Heck, he probably still has jetlag from the CardioStim gathering in Nice and won’t notice. :-)

            I was just thinking about that advertisement you mentioned with the guy standing by the pool and the high cholesterol numbers. I took it upon myself to write a dating site ad that would be sensitive to what women really want in a man:

            “I love life and I love living life. I enjoy the outdoors, traveling, healthy restaurants, laughing, cultural events, and socializing with people. Non-smoker and non-drinker. My cholesterol numbers are good, although under the new guidelines, I should be on a low dose statin. I have resisted taking a statin as I am against drugs. I do eat mayonnaise and spreads with plant sterols. My HDL level is protective. I have taken extensive testing, not ordered by my doctor, but I just wanted to know. My coronary calcium score is 10. That means that 95% of people my age have a higher score, and therefore, they have more atherosclerosis. Although the nuclear stress test has little value in detecting blockages below 50%, I took it anyway as I just wanted to know (again). Other tests revealed nothing other than a small mitral valve leak that is so common, most doctors don’t mention it to patients to eliminate unnecessary anxiety. Luckily, I’m not a hypochondriac, so I’m handling it well (Don’t listen to what my ex-wife says about me being a hypochondriac). I must mention I have a very good health plan with very low deductibles. For the heck of it, I took genetic and gene expression tests to identify any possible risk factors. You never can be too careful. Particularly when the health plan pays for some of it. I have had every blood test conceivable and MRIs, x-rays, and sonograms of almost every body part. My CRP level, although it doesn’t matter to doctors this year, is perfect. My PSA is also good. As an aside, I scored a 1600 on the SATs. All other tests, including blood pressure, are perfect. I exercise the exact right amount- enough to provide cardiovascular benefits, but not so much that I risk getting an arrhythmia. Please note I adjust my exercise routine to fit whatever changing amounts of exercise doctors recommend. I have no family history of cancer or cardiovascular problems. Everyone in my family has died of unfortunate shooting accidents in restaurants in New Jersey while eating rigatoni or penne. I watch Dr. Oz on Oprah regularly. I am looking for someone of similar interests and health level that can provide medical documentation to substantiate their health. I’m a Capricorn and love walks along the beach in the rain, as long as I’m protected from excess moisture and cold. Please, no life insurance appraisers or medical researchers involved with drug company sponsored trials need respond. Felix.”

            • Verted says

              LOL Pete! Great job . . . .

              I’m having a double cheeseburger and a 6 pack while reading.

              Oscar

  15. Verted says

    And one additional question, since we’ve seriously hijacked Dr. M’s thread.

    If the test is valuable, why doesn’t insurance cover it?

    • says

      Not “going there” for the case of cholesterol – my observations have been that the correlation between what “should” be covered vs what “is” covered is not always good (and not always based on clinically relevant data ….).

  16. UGA Prof says

    It’s being assumed that people who are on statins eat more because they think their diet no longer matters.

    Here are 2 more possibilities:

    (1) They are feeling a vague malaise or myopathy which they perceive as hunger. Basic instinct — you feel weak — you eat.

    (2) The statins are having a metabolic effect related to the way they raise the risk of diabetes.

    Has anyone looked into these possibilities? I am one who cannot take statins due to severe muscle aches and also a symptom that I can only describe as an intuitive feeling that something awful is wrong with my whole body. I want someone to discover how statins actually work and invent a better way of getting the same benefits.

    • Verted says

      Great points. I’ll see how my body responds as my adventure with a statin proceeds.

  17. says

    Some really good questions raised.
    The coronary calcium score is closely related to age in normal individuals. This confirms the fact that some atherosclerosis develops in the vast majority of individuals over the age of 70. As the MESA calculator phrases it “the estimated probability of a non-zero calcium score for a white male of age 70 is 83%”. For a white female it is 59%.
    We are more concerned about those individuals who have more coronary calcium (and “atherosclerotic burden”) than the normal for their age and the cut-off for this is usually considered >70th or 75th percentile. These are at higher risk, more likely to die or have significant morbidity from complications of atherosclerosis and more likely to benefit from intervention.
    The inexorable build up of calcium and atherosclerosis with aging has led some overenthusiastic researchers to recommend statin therapy for all.
    On the issue of insurance coverage-I get asked this by patients a lot. As Dr. Grauer indicated, coverage doesn’t always correspond to state of the art medicine. In this case, insurers are looking for evidence that performing coronary calcium changes outcomes. When that becomes available and national guidelines list it as a Class I indication it will be covered.
    Marketing to women-common in the world of cardiology although men are at much higher risk for CAD.

    • Jeff Patten says

      Is there possibly a confusion between what’s “normal” at some sign-post and what’s “typical”?

      Respectfully, Dr., in this country, at this time, a degree of obesity is typical for men of your age.
      Does that mean obesity is normal?
      Inevitable?
      Vascular calcium is different?

  18. Verted says

    One last hijack.

    I sincerely love this blog, especially because of the spirited participation from both professionals and patients.

    I started following it back in the day when doing research about my afib (hopefully behind me now), and I continue following it (not quite so often as I did) because I’ve learned a lot, and it gives me some real insight and knowledge for discussion when I do see my GP or cardiologist.

    Thank you all, and especially Dr. M for starting it.

    Now back to your regularly scheduled program, which is already in progress.