Statins: a simple proposal
I am the simple life.
I have but one winning formula: Set the bar low; pull the target close; paint the bull's eye big.
But I struggle to keep medicine simple. I believe, ultimately, a doctor’s decision should empower and enable you, not enslave, and sometimes it just might take a whole visit to get one simple thing straight – like cholesterol.
Screening cholesterol for heart and stroke risks, we focus on two values: HDL and LDL (the levels are mostly determined by genes). LDL is bad; it carries cholesterol to arterial walls. HDL is good, it removes the cholesterol from them.
To improve your cholesterol level, first do: exercise, eat the right fats, increase fiber, decrease sugar and starch, lose weight and quit smoking.
I divide dietary fats into the good, the not-so-bad, and the ugly. The good: certain vegetable oils (olive, corn, sunflower), nuts, fish and milk. The not-so-bad: coconut and palm oils, animal fat, eggs and butter. They can raise both good and bad cholesterol; moderation is the key. The evil: partially hydrogenated oil, a processed vegetable oil found in shortening. It raises the bad cholesterol and lowers the good.
Then there are statins (e.g. atorvastatin, lovastatin), a class of drugs that targets LDL. These drugs work, winningly. In patients with heart attacks or strokes, statins reduce the risk of a second event and improves mortality. There’s no other cholesterol drug like a statin.
What’s not so clear – and here is where the smart pens squirt ink – is how aggressively we should push statins to prevent the first heart attack or stroke.
In healthy people, we screen cholesterol between the age of 40 and 75. If your LDL is over 190, we recommend that you go on a statin. Below that, your statin need is determined by a risk calculator that includes: age, sex, ethnicity, smoking, blood pressure, cholesterol and diabetes.
The American College of Cardiology/American Heart Association recommends starting statins if your 10-year risk is over 7.5 percent; the U.S. Preventive Service Task Force says 10 percent. The Europeans and Canadians use different risk calculators. Meanwhile, many experts are concerned (and rightfully so) that these calculations overestimate the risk of heart attack and that statins’ benefits may be too trumped up.
To toe the guideline, around 40 percent of Americans without clinical heart disease will need to take statins for life. What does that achieve? Based on a Cochrane Library analysis: if we put 100 people on statins for five years, we can potentially avert two heart or stroke events.
I agree with all the talking points, but for a solution? I go to the one with the answer – you.
Statins lower the risk of heart and vascular diseases beyond the ability to lower cholesterol, yet who’s to say you and I are the two percent who’d benefit from it.
For whatever it’s worth, for most of us, the duration of taking statins will outlast the average duration of marriage in the U.S.