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Tuesday, May 13, 2014

Europe's take on America's statins guidelines

In November 2013 the American Heart Association released new recommendations on who should be taking “statins” (drugs like Lipitor/atorvastatin), the most common medicines we use to control cholesterol levels. High cholesterol levels are associated with higher risk of heart attacks and strokes, and taking statins, which lower cholesterol, can reduce those risks. The drugs have pretty significant side effects, though, and not everyone with high cholesterol or other cardiac risks will actually have a heart attack or stroke, so it seems clear to most of us that not everyone should take statins.

The American Heart Association’s 2013 guidelines

The new recommendations departed from prior ones in saying that we should prescribe statin drugs to patients with higher risk of heart attacks rather than just patients with high cholesterol. I wrote about the new recommendations here. It actually kind of makes sense, since even patients with relatively normal cholesterol levels may have lower risk of heart attacks when they take statins, and patients who have high cholesterol but no other risk factors may be vanishingly unlikely to have a heart attack regardless of whether they take the drugs. So, theoretically, the new recommendations would allow some people who have been taking statins entirely because of high cholesterol levels to stop taking them, which would be nice.

More statins: good idea or bad idea?

There has been considerable debate since these recommendations were released since they actually significantly increase the number of people who doctors may encourage to take statins. The data on whether giving statins to patients who have never had heart attacks will reduce their risk of heart attack or stroke is pretty weak, and it appears that statin therapy in this group of people does not reduce the risk of death or other disability. (Check out the audio discussion by Dr. John Abramson of Harvard University at The British Medical Journal online since the printed version costs money to read.) Statins appear to be significantly more effective in preventing heart attacks in patients who have already had coronary artery disease, including heart attacks or angina (“secondary prevention”).

Almost all of the data we have on how effective statins might be has been financed, at least in part, by the manufacturers of the drugs, whose primary responsibility is to make money for their shareholders by selling statins, not to make patients live longer and healthier lives. The new recommendations would result in many patients without medical illnesses being starting on medications, what we call “primary prevention.” Patients who are calculated (using a risk calculator) to have a 10-year risk of heart attack or stroke that is greater than 7.5% would be encouraged to take statin drugs.

How many Dutch people would be on statins?

A group of physicians from the department of epidemiology at Erasmus University in Rotterdam, the Netherlands, did a very clever study to look at what effect implementing these new recommendations might have had on a group of random Dutch people (average age 65 or so) they have been following since 1997. Using the data they had collected they found that 100% of the men and 65% of the women would have been recommended to take statins based on risk level.

On average the men were calculated to have a 21.5% 10 year risk of heart attack or stroke based on the calculator and the women 11.6%. They were able to actually look at who had these events, and it turned out, at least for this population, the calculator seriously overestimated the risks. Only 12.7% of the men and 7.9% of the women actually had a heart attack or stroke. (Perhaps Dutch people have lower risk of heart attacks because they ride bicycles more. Physical activity is not entered into the risk calculator.) The authors conclude that using the risk calculator to determine whether to prescribe statins is inaccurate in their population and basically unnecessary over the age of 65 since nearly everyone would receive qualifying scores. They ask if the present guidelines are really advocating a blanket prescription for statins based on age.

Putting it all together

Statins may or may not make us live longer. If they do, it is a pretty small effect unless we have had prior heart attacks or coronary artery disease. They do have side effects. About 1 in 5 people who take them develop some problem, often just muscle pains and weakness but sometimes diabetes and probably thinking and memory problems. The new recommendations released in 2013 by the American Heart Association would have us encourage the majority of people over the age of 65 to take these drugs, as well as quite a few healthy younger people.

Since drug companies are major players in funding research on statins, we may never get truly unbiased information about their risks and benefits. Healthy diet, regular exercise and not smoking are far more powerful ways to reduce risk of heart attack and overall death and disability due to all causes, but advertising this makes nobody any money. It is possible that guidelines that increase the use of statins will also make us just a little weaker, achier, stupid, and diabetic.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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