I am hoping for some input with this case because I really don’t know the right answer.
A 52 year-old male endurance athlete seeks my opinion about whether to continue taking statins. His primary care doctor says yes. He is not so sure. Neither am I.
He exercises regularly, maintains both a high level of fitness and a normal body mass index. And none of this is new; he has been like this for decades. (Also, he’s not an Ironman or multi-marathoner.) He is a non-smoker with a normal blood sugar and his BP consistently measures below 120/80. Neither his Mom or Dad had premature heart disease.
Off statin treatment: LDL = 196, HDL = 70, TG = 113.
On treatment: LDL = 128, HDL = 72, TG = 110.
One last fact: He has taken a statin drug for a couple of years without adverse effects. There have been no reports of muscle pain, cognitive issues or diabetes signal.
What to do?
Plugging this data into the AHA’s Heart Attack Risk calculator reveals an off-statin 10-year risk of heart attack of 6%. Using the statin-aided lower LDL, the 10 year risk drops to 3%.
Here are some questions that I came up with:
1.) Is it worth it to take a drug for that long to reduce your risk in absolute terms by .03?
2.) What is the risk of taking the drug over that period? Statins have risks: Diabetes, cognitive decline and muscle effects. The risks of any drug is surely not .00. Considering some finite drug risk, what’s the realized gain?
3.) There are other life factors that aren’t counted in the calculator. For instance, we know fitness confers major health benefits, and this man has been fit for years. How does that affect the .03 delta?
4.) How much could a strict diet change the numbers? And how much could said strictness be expected to help a fit athlete with a normal body weight?
5.) He has been on statins without trouble. Does this mean they will be tolerated over the long-term?
6.) Would a coronary calcium score help in this case? It’s hard for me to believe that it would change a .03 delta.
How about this paradigm-changer?
Should we even be measuring cholesterol in middle-aged patients at very low-risk for heart disease?
Please feel free to chime in.
If nothing else, I hope this case helps shows how difficult it would be to practice primary care.