?Statins use in Healthy Male with Raised Cholesterol

From Heartwire

Should Statins Be Used in Primary Prevention? JAMA Gets in on the Debate

Michael O’Riordan

April 10, 2012 (Baltimore, Maryland and San Francisco, California)— Differing opinions on the use of statins in primary prevention make the pages of one of the leading medical journals this week, with the Journal of the American Medical Association (JAMA) the latest in a line of professional and mainstream media outlets getting in on the contentious topic. Introduced by the JAMA editors to encourage discussion and debate, the inaugural "dueling viewpoints" kicks off its new series by considering the clinical question of whether or not a healthy 55-year-old male with elevated cholesterol levels should begin taking the lipid-lowering medication.

The two "combatants" in the clinical duel will also be familiar, having previously debated the topic in the pages of the Wall Street Journal, as well as on theheart.org. For Drs Rita Redberg and William Katz (University of San Francisco, California), who argue that healthy men should not take statins, there are other effective means to reduce cardiovascular risk, including dietary changes, weight loss, and increased exercise.

"These strategies are effective in increasing longevity and also result in other positive benefits, including improved mood and sexual function and fewer fractures," they write. "Although these strategies are challenging, prescribing a statin may undermine them. For example, some patients derive a false sense of security that because they are taking a statin they can eat whatever they want and do not have to exercise."

In their counterpoint, Drs Michael Blaha, Khurram Nasir, and Roger Blumenthal (Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD) agree that the cornerstone of treatment for patients with elevated cholesterol levels will always be diet and exercise but that statins can be a "critical adjunct for those identified to be at increased coronary heart disease risk." The Johns Hopkins physicians argue that there is no logic in waiting for an MI to occur before starting statin therapy and that if clinicians are unsure of the risk of seemingly healthy patients with elevated cholesterol levels, the use of coronary artery calcium (CAC) screening can help.

"The CAC scan is a helpful tool that enables clinicians to direct statin treatment at the disease (coronary atherosclerosis) that they propose to treat and illustrates the concept of risk-based, individualized decision making," write Blaha, Nasir, and Blumenthal. "Statin therapy would not be recommended if a CAC scan revealed a score of 0."

In their viewpoint, they point to data from WOSCOPS and AFCAPS/TexCAPS showing reductions in MI and other coronary events in the primary-prevention setting. However, they argue that the debate over cholesterol therapy needs to be rephrased, because doctors should never treat elevated cholesterol levels in isolation but instead aim to provide therapy to the highest-risk patients most likely to benefit.

For Redberg and Katz, however, the data simply do not support the use of statins in the 55-year male patient with normal blood pressure and no family history of disease but with elevated cholesterol levels. They point to a recent meta-analysis in healthy but high-risk men and women showing no reduction in mortality with statin therapy, as well as a recent Cochrane review showing similar results. Moreover, Redberg and Katz highlight the adverse effects associated with statins, including cognitive defects and diabetes.

"For every 100 patients with elevated cholesterol levels who take statins for five years, a myocardial infarction will be prevented in one or two patients," they write. "Preventing a heart attack is a meaningful outcome. However, by taking statins, one or more patients will develop diabetes and 20% or more will experience disabling symptoms, including muscle weakness, fatigue, and memory loss."