Statin therapy for healthy people with high cholesterol?

bohm2

I thought this was interesting commentary in a fairly recent issue of JAMA arguing for the 2 different viewpoints. To prescrtibe or not to prescribe statins for healthy people with high cholesterol?

Healthy Men Should Not Take Statins
http://jama.jamanetwork.com/article....icleid=1148381

Statin Therapy for Healthy Men Identified as “Increased Risk”
http://jama.jamanetwork.com/article....icleid=1148380

mazinse

I suppose you would also have individualize base on a person's BMI, assuming they dont have any risk factors which the people in the article were.

bohm2

So are you saying that statins should be recommended even for primary prevention when cholesterol is elevated (but without documented coronary heart disease) but only when BMI is high? But if BMI is not high, one shouldn't recommend statins in such patients?

bohm2

This recent meta-analysis is interesting because it suggests that statins may not even be effective (at least with respect to increasing longevity) in women with coronary heart disease (e.g. secondary prevention):
Statin Therapy in the Prevention of Recurrent Cardiovascular Events-A Sex-Based Meta-analysis
http://archinte.jamanetwork.com/arti...icleid=1195535

So basically, if I'm understanding these studies, then:
1. statins aren't likely to prolong life in women with/without a history of coronary heart disease
2. statins are not likely to prolong life in men without coronary heart disease

So, the only group that appears to derive benefits are men with history of coronary heart disease.

Monique

Isn't it more important to figure out why the healthy individuals are having a high cholesterol and tackle the problem at the root?

bohm2

That would be a good approach assuming that cholesterol (or at least the small, dense LDL part acording to some studies) is the problem, particularly for men and it isn't something else correlated/confounding. Kind of like fever and infections. It's the bugs that is the problem, not the fever unless fever gets exceptionally high. Thus, if you get rid of the bugs, you get rid of the problem. Anti-fever meds are not getting at the heart of the problem. Some have suggested that cholesterol may be like that and even questioned the "LDL cholesterol drives atherosclerosis" model but such views are in the minority. For an interesting paper on this critical view see:

The mainstream hypothesis that LDL cholesterol drives atherosclerosis may have been falsified by non-invasive imaging of coronary artery plaque burden and progression
http://thrivewithdiabetes.com/doc/Me...holesterol.pdf

Monique

Well, I think using statins to lower cholesterol is metaphorically lowering the "fever" thus not tackling the real problem. My question would be: why is the cholesterol high, poor diet or other factors?

I also heard that the "bad" LDL hypothesis has been taken into doubt, how accepted is that position?

bohm2

Genetics and diet determine cholesterol level. As far as I know every major professional health organization supports the LDL hypothesis and recommends some type of treatment based on reaching certain LDL target but type of therapy varies depending on cardiovascular risk potential.
For instance, the Canadian guidelines that doctors, pharmacists, etc. use (See p. 575 for the summary):

Canadian Cholesterol Guidelines 2009: Summary of recommendations
http://www.ccs.ca/download/consensus...Guidelines.pdf

Having said that, there are some health professionals who question some of these guidelines. The most vocal group are the The International Network of Cholesterol Skeptics but again, they are still in the minority. Some have even argued that some of statin's beneficial effects in some patients may be due to anti-inflammatory properties?

SW VandeCarr

Progression of atherosclerosis (and how such progression is measured) and the correlation of serum LDL cholesterol levels with fatal myocardial infarction (MI or heart attacks) are two different questions. As was mentioned, the anti-inflammatory and anti-thrombotic effects of statins may play a role. Abnormal levels of other lipid fractions as well as high serum triglyceride levels are also considered risk factors for fatal MI. Inflammation associated with the rupture of the coronary arterial (endothelial) lining by the underlying atheroma seems to be the precipitating event in the case of MIs, at least according to some studies. This article summarizes situation as of 2002. This is not a new idea.

http://qjmed.oxfordjournals.org/content/95/6/397.full

bohm2

The author of that article (Uffe Ravnskov) is or was the spokesman for The International Network of Cholesterol Skeptics (THINCS), I mentioned above. Most experts in the field do not interpret the balance of studies in the same way as that organization; nevertheless, many have questioned the need for using statins in so many individuals especially given the small benefits in all-cause mortality outcomes.

SW VandeCarr

There's nothing wrong with a healthy level of skepticism. The fact is, the science, as judged by regulatory agencies, only justifies the use of statins for secondary prevention of fatal MI (that is in MI survivors) afaik. Any other use of statins, such as in primary prevention, would be considered "off label". The effect of statin therapy on serum LDL cholesterol levels or other lipid fractions is not the critical end point.

EDIT: One statin (rosuvastatin) has been approved for the primary prevention of MI, stroke, cardiovascular related death and other outcomes in patients who have have certain risk factors for cardiovascular disease.

http://www.ccmdweb.org/dsl/middle.as...738&Catid=1036

mazinse

the people who have hereditary hyper lipidemia still benefit from statins

feihong47

Diet and exercise ARE still first line therapy before any statins are recommended in most cases. Only if the individual still maintains a high LDL above the threshold after a certain period of time despite diet and exercise, are then recommended for drug therapy

http://www.uptodate.com/contents/hig...ond-the-basics

ApplePion

By definition of "healthy" there is nothing wrong with a "healthy" dose of skepticism, but empirically it is just about always the case that people who label themselves with that word, as did that cholesterol "skeptic", are wrong and seriously unreasonable. I'd challenge anyone to come up with more than one counter-example to my claim. (I do not want to call my self a skeptic about skeptics, though!)

I also note that after telling us that skepticism can be healthy, you unskeptically post some official guidelines. Guidelines are merely opinions.

The relationship between LDL cholesterol and heart disease is clearly causal. The correlation between LDL and heart disease is very strong. And it is biologically plausible. A correlation between wearing red socks and heart disease is less plausible because red socks are not found lining the coronary arteries. And regardless of the reason for the elevated LDL any group with elevated LDL has increased heart disease risk.

People with Familial Hypercholesterimia (FH) lack a full set cholesterol receptors in their livers leading to very elevated cholesterol lervels, and very high risk of heart attack. People with Apo E2 have lower cholesterol levels than average and people with Apo E4 have higher levels, and the heart attack risk is just about exactly numerically explained by the cholesterol levels. The mechanism for Apo E affecting cholesterol is quite different from FH, yet we see the same cholesterol dependence on heart attack risk. Indeed, the reason why Apo E 2 reduces LDL is because there is a defect in the conversion of triglyceride carriers to LDL. And so despite elevated triglycerides people with Apo E2 have lower heart attack rates. And the relationship is even stronger. People with two Apo E2 genes can sometimes develop a cholesterol abnormality (hyperlipoproteinemia type III ) and those people are then, unlike other people with Apo E2 at increased risk of heart disease. And people with high LDL due to diet are at increased risk of heart disease. If it was not LDL directly causing heart disease you would not see the relationship among groups having increased LDL for so many different reasons.

And just about any method to lower LDL decreases the risk of heart disease--diet, most or all medications, and in the case of people with FH, actually sending their blood through devices to remove cholesterol. Again the diversity argues that the LDL relationship is causal.

SW VandeCarr

No. Guidelines for the use of prescription drugs are based on data, or the lack of data, from randomized clinical trials.

I challenge you to post a link to a qualified source that says that statistical correlations can establish causality. We can interpret strong associations as possibly causal to some high probability but no responsible scientist would say that a statistical association establishes causality. Do you know what a confounding variable is? Randomization helps control confounding, but most of the data in risk analysis comes from prospective and retrospective observational studies.

The topic is statin therapy for healthy people with high cholesterol. Do you consider people with FH healthy? No one is questioning the fact that statins lower LDL-C. The question is: Are you treating the patient or the laboratory value? Besides, I've not found any evidence that lowering LDL-C in FH significantly improves survival. Perhaps you could find something?

http://www.nejm.org/doi/full/10.1056/nejmoa0800742

I believe elevated LDL-C is a predisposing factor for MI, but is it a necessary cause? If so, how do you explain MI's in people with normal or low LDL-C? They are not uncommon. Are you aware of the Jupiter trial? You should be if you are making these kinds of arguments in these forums. The rules require that you post links to qualified sources to back up what you say. Just posting your opinions is only allowed in the General Discussion forums.

http://www.diabetesincontrol.com/art...ith-normal-ldl

www.nejm.org/doi/pdf/10.1056/NEJMoa0807646

http://jcem.endojournals.org/content/88/6/2445.full

bohm2

Some might this summary of lipid trials interesting. Note:

1. Primary vs Secondary prevention
2. All-cause mortality when comparing drug vs placebo
3. The # of people and # of years of treatment needed to save 1 life (and it's not clear for how much longer that person may survive?)

And also keep in mind that published studies tend to over-represent positive trials (e.g. publication bias) as pointed out in many reviews. I think one can make a good argument that such funds can be used elsewhere for greater health benefits.

All-cause mortality outcomes from major lipid trials
http://www.midtownclinic.ca/rx7/14-C...ajortrials.pdf

The source is Rxfiles, a summary used by Canadian doctors and pharmacists to help guide drug therapy decisions.
http://www.rxfiles.ca/rxfiles/module.../druginfo.aspx

ApplePion

SW VandeCarr writes the following and then provides us with a link to a study in a prominent medical:

Yes, I can find something--the very article you linked! You very seriously misundersood it. It actually says the opposite of what you thought it said. It did not say that statins were not beneficial in people with FH. It says they are. What it said that confused you was that adding a second drug gave no additional benefits over the benefits statins gave.

I would very strongly urge people interested in this discussion to read the article SW VandeCarr adduced, and see what it actually said. Here it is again:

http://www.nejm.org/doi/full/10.1056/nejmoa0800742

.

I would explain the situation as beiong analogous to the situation whereby some people who were not driving drunk die in car crashes. Drunk driving makes one more likely to die in a car crash, and elevated cholesterol makes one more likely to die from a heart attack. In both cases the correlation is causal.

I'm not sure what you mean by "predisposing factor"--I was under the impression that previously you cited approvingly that skeptic group which claimed elevated cholesterol does not increase the risk of heart attacks.

Responding to me saying that guidelines are opinions, SW VandeCarr responds:

Obviously the guidelineswes have some relationship to the data, but that does not make them not be opinions. They are the opinions of certain people about the data. Indeed, all opinions have some factual motivation (unless they are really unreasonable), but opinions are still opinions.

But what I find puzzling is that you keep using "appeal to authority" while saying how proud you are to be a "skeptic" and while taking a view on cholesterol that respected authorities strongly reject. The group you cite "The International Network of Cholesterol Skeptics" is not considered a mainstrean scientific group, while the American Heart Association, the National Institutes of Health and the Surgeon General, all of which disagree with you, are considered authorities. It is fine for you to have a non-standard view if you can argue it with facts and logic, but it makes no sense to use appeal to authority when you are taking a position at odds with authority.

Indeed I do. And in my vey first post in this thread I, in great detail explained how we know that the correlation is not due to confounding, so perhaps you should ask yourself the question you just asked me. I will summarize it for you.

If there was just one way that high cholesterol was linked to increased risk of heart attack, then confounding should be a concern. So, for example, if studies found that people who ate red meat had higher cholesterol and higher rates of heart attack then we could wonder if maybe, for example, the real culprit was iron in red meat. But there are many disparate unrelated modes of getting cholesterol--diet, genetic deficiency of cholesterol receptors to remove cholesterol from the blood, genetic predisposition to have increased conversion of triglycerides to LDL cholesterol, and all of them lead to increased risk of heart attack. Furthermore, there are many ways to lower cholesterol--diet, statins, blood filtration, and almost all lead to lower rates of heart attack. So it is not some confounding that is going on--the risk is fundamentally from the cholesterol itself.

It seems that you might be thinking that a correlation must be strong in order for it to be causal. That is not mathematically correct. While, everything else being equal, a stronger correlation argues more strongly for causation, it is not always necessary.

Suppose one flipped a coin "in a fair way" (i.e. the flipper has set things up correctly, but the coin itself might be defective) and got heads 55 percent of the time. There is only a weak correlation between flipping and getting a head. But it this was over, let's say 10^90 fair coin flips the effect would clearly be causal--we could determine that the coin itself was not fair.

I find this very strange from someone who posts stuff from that "International Network of Cholesterol Skeptics" group. I don't know what you want from me--I've posted quite a bit about the science. Do you want me to cite authorities--sometimes you engage in "appeal to authority" but sometimes you tell us you are a skeptic and you post views clearly at odds with mainstream medicine. So what do you want?

But most puzzling is that in a post that was rude, condescending, and now threatening, you claim I am breaking some message board rule. You need to check the rules for yourself.