I am hoping for some input with this case because I really don’t know the right answer.
The case:
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.
JMM
29 replies on “Struggling with a tough statin case…”
John,
Would consider using simvastatin 20 mg–there is no signal for diabetes at this dose. It might not get his LDL to 100, but it may be the right compromise, assuming changes in diet are not helpful (likely). Would not do a calcium score!
Thanks so much for commenting Eric. I really appreciate that you did. Very nice.
Low-dose simvastatin is great suggestion, as it deals with a concerning LDL number, while creating the lowest possible risk.
Sounds to me that this is a decision that he (not his doctor) should make based on all of the risks/benefits that you have explained so clearly. At some point, a person has to take responsibility for their own medical decisions. My decision was no statins–my primary care doctor was concerned, my cardiologist and EP didn’t even bring it up.
Hello Dr. John – it does my heart good (sorry about that!) to even have you ask these questions. They illustrate a profound willingness that I wish other health care professionals shared – a willingness to consider the whole person, not just the intermediate endpoints as happily dispensed by many (industry-funded) statin trials.
The most important question here seems to be: what does the patient want to do?
regards,
C.
Whether to take a statin for primary prevention is a personal decision. I don’t think there is a right answer. That being said, 196 is a high LDL level, and if it were me I would take at least a low dose of a statin.
“Should we even be measuring cholesterol in middle-aged patients at very low-risk for heart disease?”
In my opinion, the answer is yes. If you don’t check cholesterol you can’t calculate baseline risk and therefore you can’t estimate the benefit of taking a statin.
So noted. I appreciate your well-informed view. Thanks.
To my mind this is an easy one. I would recommend against statin therapy. His risk is lower than the calculator indicates. The benefit of primary prevention in patients like this is infinitesimal. Putting a patient on a drug makes a healthy person into a sick person with periodic office visits, lab tests, anxiety about numbers, and so on. I agree with letting the patient decide after considering all of this, but many of my patients come to me because they want my opinion.
Good point. Thanks for taking the time to comment, and for reiterating the important concept of letting the patient decide.
Dr. John –
As a layperson, I don’t have anything beneficial to add to the discussion. But I’m curious about whether you view coronary calcium scoring as a beneficial test in terms of predicting heart attack risk? And, if so, how does it fit into a cardiologist’s “toolbox” in terms of predicting risk for a “normal” person? Thanks.
Trey
Trey…Your question is hard to answer briefly, Generally speaking, coronary calcium scoring is most useful in patients who fall into the ‘moderate risk’ category, say 5-20% 10 year risk. This patient falls slightly below that level.
In a low risk situation like this, I’m more worried about acts of commission than acts of omission.
I like Dr. Topol’s advice. Low dose statin and aggressive lifestyle modifications. Don’t worry about getting to target.
Jay
hmmmm……… at 73 and having creeped out at just the thought of going to a doctor ( never did for 40 years ). after an incident 3 years ago i’ve become a believer. makes me think how better off i’d be if i had been taking meds. reducing risk by 3% from 6% ( a 50% reduction ) sounds good to me. i’m fellow that asked about the watchman device. hint to a good link is appreciated. of course your opinion is always most valued. thanks
Thanks for being a regular reader Frank. I appreciate your comments. Yes, the watchman deserves comment. In short, I have left the topic alone because it is a long way from being ready for prime time.
John –
My father in law, now over age 80 and with normal weight for decades and regular stair climbing and gym use, refused to take a statin and lowered his cholesterol from numbers like these into the mid 150’s using essentially the portfolio diet – nuts, benachol spread, oatmeal, no sugar. Not a whole lot of soy, but lots of high fiber and fruit and veggies.
Peggy
Thanks Peggy. I don’t really know how ‘clean’ this patient’s diet is (was), but agree with you that what we eat makes more difference than most think.
Having noted the previous comments, in particular the perspective of a man ~ 20 years older than the man who consulted you:
I’d still just give the patient the facts, and let him decide. At his age, he may not wish to make aggressive lifestyle changes when he’s already fit, has low genetic risk (pretty significant, in my book), and has good values for CV health (except for his LDL). Then again, maybe his situation is such that he would opt for every ounce of prevention he can get, including a low simvastatin dose and nutritional therapy, and perhaps adding resistance workouts to his endurance activities. — Any extended-family tendencies toward T2DM? Even if yes, a high fasting glucose after continued statin use could be double-checked with a baseline GTT and regular BG checks, if you or a PCP felt this was indicated.
If this person were to expand his exercise regimen, any c/o muscle pain would of course need evaluation to differentiate, say, muscle microtears from long-term statin-related damage.
Another strategy might be to use a moderate dose of simv. along with ER nicotinic acid, with the possibility of a fairly lengthy drug holiday if that combo and any lifestyle changes can get a significant reduction in the LDL. For what it’s worth, as a student I’ve followed a pt. who’s had good results from that combo plus ezetimibe — though if I could, I’d get him off that (a specialist put him on it, but labs revealed good results p/ being on Niaspan ER and a/ starting Zetia. Lawsuits against Zetia for rhabdomyolysis duly noted by pt., but the specialist’s word carries the most weight for him.)
So, again, this individual should weigh the facts and choose whether he wants to be more high-maintenance as a patient, for whatever reason; or if he’d rather not take on a different role than what he already has.
I’d also like to add my kudos to you for looking at the whole picture. My own PCP occasionally misses the forest for the trees. (We’re all human.)
John – Given that the patient has taken statins for several years without adverse effects and with successful lowering of his LDL – there is NO WAY for you to come out as “correct” if it is “you” who takes him off of his statin and the patient then suffers a cardiovascular event … That said – his overall risk seems very low given his level of fitness, negative family history, and normal body weight, BP and blood sugar – as well as his baseline excellent HDL & TG readings. So, the decision MUST be HIS as to whether or not he wants to continue his statins – reduce the dose of his statins – or stop them entirely.
Given the above – I feel the reduction from 6% 10-year risk of MI to a 3% 10-year risk is an overestimation (I bet at most it is a 1-2% risk reduction, despite whatever the AHA Heart Attack Risk Calculator says …) – but even IF it was a “50%” reduction (from 6%-to-3%) – IF you explained the pros and cons of continuing treatment to this patient in terms of NNT (number-needed-to-treat) vs NNH (number-needed-to-harm) – his answer might very well be verey different … That is – 100 patients must take the expensive statin each day for the next 10 years in order for 3 patients to benefit (that is, 97 patients will get NO benefit at all despite taking the statin daily for 10 years). However – all 100 patients will have to pay for the expensive statin – AND – all patients will have to continue with several-times-yearly visits to their physician for blood tests to check on their values – AND – all 100 patients remain at risk of developing adverse effects from statin therapy. BOTTOM LINE: The choice about whether or not to continue the statin is HIS – and your role is simply to support whatever decision your patient makes given that he has full informed consent, since there simply is no “right” or “wrong” answer – Ken Grauer, MD
Thanks Ken. Great points. I have little to add.
Another question that occurs to me, in light of the patient’s exemplary lifestyle, is whether his high LDL is due to genetic factors. If so, he may have had high LDL for many more years than the average person whose cholesterol numbers worsen in middle age due to weight gain, inactivity, etc. The reason this is important is that risk calculators such as the one you used are not designed for patients with genetic dyslipidemias. If he had an LDL that high even as a young man, his arteries have been exposed to high LDL levels for many years. I would try to find out whether his LDL was that high when he was in his 20s and 30s, if he knows. If so, that is an argument for taking a statin.
A coronary artery calcium scan would give you more information but would expose him to radiation so doesn’t seem justified in this situation.
This patient sounds like he could be you in 12 years or so. One question I’ve often asked doctors is “What if it was you?” As a regular reader of your blogs, I think I know the answer … stay off the statin & monitor the cholesterol levels closely. See what a stricter diet might do.
I am a patient, but I know that the basic cholesterol panel misses a number of problems.
What about measuring the LDL particle size or count using one of the advanced lipid test?
How does one get their HDL up? I’ve tried everything!
Interesting article today in the NYT titled “Do Statins Make it Tough to Exercise?” Seems like the patient you describe in this blog post fits the mold of the patients described in the article.
http://well.blogs.nytimes.com/2012/03/14/do-statins-make-it-tough-to-exercise/?ref=health
You are right on, John. There are no studies looking at people who are this low in risk. I had the same struggle when pediatricians started checking lipids on kids. What do you do with the result?? The only benefit is a little more weaponry in the guilt trip barrage. I’d consider coronary imaging in this guy hoping I would get an excuse to stop the drug.
One of my partners has a similar profile. He just scheduled a coronary calcium scan, for the same reasoning you suggest. He’s also a runner and is worried about the runners-coronary calcium association. Thx for adding to the conversation.
Good comment Rob – but what if you did coronary imaging (that your patient will pay for) and it showed an “equivocal result” …. The issue of checking lipids on kids opens another “can of worms” …. Far better (in my opinion) than turning children into “patients” is instilling in them a healthy lifestyle toward making good food choices (which CAN be taught) rather than starting them on statins before puberty …
Thanks Ken. Agree with your comments on the children.
John – Hopefully your friend has a normal coronary calcium scan! – which would clearly simplify his course. If it is less than normal – we’re then left with accepting results of these surrogate markers with the hope that taking the statin will lower his LDL (thereby lowering his risk) – albeit without real “proof” of beneficial patient-oriented outcome effect …
There is much evidence to indicate INFLAMMATION; not CHOLESTEROL is the primary culprit in CVIs, and that Statins can cause serious physical and emotional damage. I am a prior statin user who has been so affected. I went from an robust, athletic condition to a recliner in just over three years. The first two years didn’t cause me any difficulty, but the third year they doubled my dosage to 40 Mg. Within six months I began a slow decline marked by leg pain, cramps, disorientation, sleep disorders, and susceptibility to infection. My PCP could not determine the cause oof my difficulties so I went to a physician friend who pointed out the AEs of Statin medication. I stopped the drugs and recovered about 30% of my lost abilities over the next five years, but I have not been able to recover to my previous baseline and am starting to decline again – slowly. Of course I consider Statins a dangerous category of drugs and avoid them. There is also a genetic marker: SLCO1B1 (slco1b1-5) that may indicate an innate susceptibility to Statin damage; there is plenty of information in online medical journals on the subject. I AM NOT a physician.
Best,
Brooks