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Statin use: miracle or deception?

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I can guarantee you this, if you are 45 or older and you have four family members or friends who are also 45 or older, then you or one of them is on a statin.

I can tell you another fact: if the American College of Cardiology's new recommendations on statin use get implemented to their fullest scale, then the odds of the above “prediction” are even higher, moving from one in five to one in three.

However, and despite those figures, the controversy in the past two years over statin use has dominated medical literature, with more people wondering whether they should stop taking statins to lower their cholesterol, and more doctors supporting, or at least condoning, this decision.

But before making such a choice, it is important to look at what the trials say.

What did the studies show?

Most major trials for statins have been funded by the pharmaceutical industry. Having said that, they were rigorously examined by leading experts in the cardiovascular field and by independent organisations before their approval.

As an example, a collaboration funded by multiple British health bodies brought together data from 26 trials involving 170,000 patients to better understand what the studies found.

They discovered that the results were remarkably consistent: statins reduce the risk of heart attacks or strokes by 20 per cent. This is true whether someone had a cardiac event or a stroke in the past or not. There were fewer women in the trials, so the data on women is less precise, but is approximately the same.

The above figure translates as follows: if one's risk of having a heart attack or stroke over the next ten years is 30 per cent, taking statins will reduce it to 24 per cent. If it were 5 per cent, that risk would be reduced to 4 per cent. So the benefit is greater if one's initial risk is higher. Another way to look at it is if one takes a low-risk population, between 100 to 200 people would need to be treated with a statin to prevent one cardiovascular event, and that may not even offset the 1 per cent to 2 per cent side-effect risk.

On the other hand, only about 30 high-risk patients would need to be on a statin to prevent one such outcome. And if one takes into account that heart attacks and strokes are serious events, then there is clear evidence that statins reduce the chance of having these.

But, like all drugs, statins have side effects and it is becoming more evident that they were probably underestimated in trials.

Trials often exclude elderly patients and people with some medical conditions, such as kidney or liver disease.

Trials exclude patients with early side effects, and if these adverse effects were too early, then the “dropped-out” patients might not have been included in the final analyses.

It is possible that trials that showed a high rate of side effects might not have been published, thinking the high adverse rate might have been related to chance, a “fluke”, or they were never submitted for publication (deliberate data “hiding”).

Having mentioned that, the side effects of statins have been investigated in many postmarketing analyses and they were not significantly different than the trials.

The most common side effects are fatigue, muscle achiness, exercise intolerance, cataracts, memory loss and increased risk of diabetes. The most serious, but rare, are liver and muscle damage.

Who should take statins?

The decision to take statins should not be based on someone's cholesterol level alone, unless it is quite high.

Instead, it should be made based on their risk. The risk of heart attack or stroke is calculated by using scoring systems, such as the Framingham risk score, that incorporate major factors including age, gender, blood pressure, diabetes, smoking and lipid levels.

Medication may be considered for people at moderate risk (10 per cent) or higher, or if they have a strong family history of heart disease.

The advantage of this approach is that people at high risk for heart attack or stroke who have normal cholesterol levels can still reduce it by taking statins. At the same time, people with mildly elevated cholesterol levels who have no other risk factors, and are therefore unlikely to benefit from statins, do not need to take them.

Despite being the most used drug class in the history of medicine, statins are not miracle pills, though they were dubbed so.

People who take them may still have a heart attack or stroke, even though the chances are reduced. On the other hand, statins are not deceptive pills as they are being portrayed in some uneducated outlets. They are part of the answer to a complex problem in very different at-risk populations.

•Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women's Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients' care recognition awards. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article.

Joe Yammine
How they work: statins are a group of medicines that can help to lower the level of low-density lipoprotein (LDL) cholesterol in the blood. LDL cholesterol is often referred to as “bad cholesterol”, and statins reduce the production of it inside the liver

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Published January 12, 2016 at 8:00 am (Updated January 12, 2016 at 1:55 am)

Statin use: miracle or deception?

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